[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.

[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 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 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.

[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.

[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.

[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.

[Urodynamics of urethral valve resection]. / Zur Urodynamik der Urethralklappenresektion.

Basing on the cases of 8 children with urethral valves who were diagnosed and treated during the first year of life we report on the urodynamic results. It is concluded that after valve resection enhanced pressure levels may still exist during micturition for some time even if the flow of urine has become normal. A morphologically and functionally satisfactory treatment result (separate lasix clearance on both sides) can be expected only after the pressure has dropped, a phenomenon that often occurs spontaneously.

[Urinary incontinence in the female over 60 years of age--urodynamic findings]. / Die harninkontinente Frau über 60--urodynamische Befunde.

A group of 20 urinary continent postmenopausal women and two stress incontinent groups in the age of 60-69 and 70-79 years have been examined concerning standardized conditions without and with stress. The measurements using the pneumatic-hydraulic pump perfusion were recorded under standardized conditions. The whole pressure profile without stress decreased with increasing age and with stress incontinence. The maximum urethra closure pressure has been displaced in the distal part of the urethra. The stress profile demonstrated a shortening of the continence zone, a clear decrease of the urethra closure pressure and a bad pressure transmission in the whole urethra, especially in its distal part. These fluctuations make us expect, that there are only a few promising possibilities of conservative treatment in stress incontinent postmenopausal women over 70 years.

[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.

[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.

[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.

[Compartment pressure measurements with a wick catheter]. / Kompartmentdruckmessungen mit einem Dochtkatheter.

There is no generally accepted method for compartmental pressure measurement, as yet. Substantial disadvantages are implied in methods based on outflow resistance measurement, and, above all, these methods are hardly suitable for long-time pressure measurement nor for objectivation of dynamic pressure alterations. Described in this paper is the authors' own method, using a wick catheter. It is highly reproducible and is characterised by high measuring dynamics. A comparatively large amount of hardware is required. Evidence is produced to the impact of differentiated conditions of examination on measuring results. Values measured by means of this method in the anterotibial compartment of the lower leg did not normally exceed a pressure level of 2.0 kPa.

[Effect of local estriol therapy on the urethral pressure profile in the postmenopausal period]. / Zum Einfluss einer lokalen Estrioltherapie auf das Urethradruckprofil in der Postmenopause.

Measurements of the pressure in the urethra were performed under standardized conditions with the aid of perfused catheters in 20 fertile and 20 postmenopausal women, from it 12 women after local estrogen therapy by means of Ostriol-Ovula. Hormone-cytological swabs from the urethra, vagina and from the urinary cells were done. Proliferation of the urogenital epithelialia under the estriol-therapy and an ascent of the MUP and MUCP in the urethra pressure profile under resting conditions could be achieved. The maximum of the pressure profile could be displaced proximaly. In the urethra pressure profile the distal pressure transmission increased. Estriol therapy was without secondary effects and is suitable for the conservative therapy of the stress incontinence type I to III.

[Manometry studies in the evaluation of anal continence]. / Manometrische Untersuchungen zur Beurteilung der analen Kontinenz.

In a complex measuring program performing anorectal perfusion manometry a great number of parameters were determined in incontinent patients, patients after continence improving operations and in healthy persons. In this way, we were able to select 20 parameters in which healthy persons differ from incontinent patients, the difference occurring with a security of 99.0 to 99.9%. Our investigations were carried out with test persons at rest, after distension of the rectal ampulla, during abdominal straining and coughing. Rectoanal resting profiles and stress profiles were recorded and the measuring values obtained compared with an anamnestic score.

[Manometry studies of continence performance in patients following gracilisplasty]. / Manometrische Untersuchungen zur Kontinenzleistung bei Patienten nach Grazilisplastik.

Out of a total of 10 patients who had undergone a Pickrell-procedure of the gracilis muscle from 1970-1980, 6 were now followed-up by clinical examination and perfusion manometry of the anal canal. The manometric parameters were compared with an anamnestic score. For anal continence the degree of resting activity of the transposed gracilis muscle is in our opinion not decisive. For that reason, there is no necessity for a permanent contraction.