X-ray generation by fs-laser processing of biological material.

The use of ultrashort pulse lasers in medical treatments is increasing and is already an essential tool, particularly in the treatment of eyes, bones and skin. One of the main advantages of laser treatment is that it is fast and minimally invasive. Due to the interaction of ultrashort laser pulses with matter, X-rays can be generated during the laser ablation process. This is important not only for the safety of the patient, but also for the practitioner to ensure that the legally permissible dose is not exceeded. Although our results do not raise safety concerns for existing clinical applications, they might impact future developments at higher peak powers. In order to provide guidance to laser users in the medical field, this paper examines the X-ray emission spectra and dose of several biological materials and describes their dependence on the laser pulse energy.

[Promoting young academics in anesthesiology: factors for an attractive internship]. / Nachwuchsförderung in der Anästhesiologie: attraktive Gestaltung der Famulatur.

BACKGROUND: Practical experiences in clinical traineeships can shape the later specialty choice of medical students. KEY QUESTION: The following study aimed to find factors in anesthesiological clinical traineeship that encourage students to specialize in the field. MATERIAL AND METHODS: As part of a nationwide online survey conducted by the working group for education of the German Association for Orthopedics and Trauma Surgery (Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, DGOU), study participants (n = 479) answered questions about their minimum 4­week traineeship in anesthesiology. The information on items was analyzed in six content categories: 1) integration into the team, 2) acquisition of skills, 3) teachers, 4) quality of teaching, 5) structure of teaching and 6) satisfaction with the clinical internship. The respondents were subdivided into 4 groups by answering the question "Could you imagine an elective in anesthesiology during the final year (PJ)" with "Yes, I have made this decision after the clinical traineeship" (JdF, n = 212, 44%), "No I have decided against an elective during the final year after the traineeship" (NdF, n = 56, 12%), "Yes I have decided for an elective in anesthesiology before the internship" (JvF Yes: n = 144, 30%) and "No, I have decided against an elective in anesthesiology before the internship" (NvF: n = 67, 14%). Answers of the participants regarding the six content categories were compared between the four groups. RESULTS: The survey reached all medical faculties in Germany and included participants with an average age of 25.8 years and a balanced gender ratio. There were significant differences between satisfied and dissatisfied students in all four subgroups. Of the 479 respondents, 211 (44%) were already set regarding their decision of choosing anesthesiology as an elective during the final year before the clinical traineeship. Of the respondents 268 (56%) were influenced by the internship, 212 (44%) of them positively. In total, 81% of the trainees rated the internship as "satisfying". Students who were satisfied with the overall internship and who spoke in favor of the PJ elective in anesthesiology differed significantly from the other groups in the categories of team integration, skills acquisition, structure and quality of teaching. The teaching of practical skills and specialist knowledge as well as the integration into diagnostics and treatment planning promoted the recruitment of young people. DISCUSSION: The positively evaluated anesthesiology internship promotes later specialty choice, with quality and structure of the teaching affecting student satisfaction. Trainees who were attracted by anesthesiology gave better overall ratings and acquired more skills during the course of the internship. In order to win aspiring doctors for anesthesiology, the medical team has to integrate trainees well and support the acquisition of practical skills and specialist knowledge. In addition, didactics and practical relevance should be given high priority.

[Informed consent for surgery: clearly regulated by the patient rights law-significant uncertainty among medical students : Legal analysis and inventory of over 2500 medical students in Berlin as part of the Progress Test Medicine]. / Chirurgische Aufklärung: Klar geregelt durch das Patientenrechtegesetz ­ deutliche Unsicherheit bei Medizinstudierenden : Rechtsanalyse und Bestandsaufnahme bei über 2500 Berliner Medizinstudierenden im Rahmen des Progress Test Medizin.

BACKGROUND: Obtaining informed consent is a challenging task and is part of the educational objectives in the German NKLM. Teaching formats are inconsistent and time-consuming, with little emphasis on legal aspects, although they have moved into the focus of attention since the implementation of patient rights laws and play an important role in legal proceedings. OBJECTIVES: The aim of this study was the evaluation of medical students' knowledge about the legal aspects of obtaining informed consent. A legal analysis was performed, and the patient rights laws were reviewed with reference to implications for undergraduate medical education. MATERIALS AND METHODS: After the analysis of laws and jurisdiction, multiple-choice questions regarding the legal aspects of obtaining informed consent were created and placed in the Progress Test Medicine (PTM). A statistical analysis of the results of Berlin medical students was performed descriptively. RESULTS: The answers of 2625 (winter semester 2018/19) and 2409 (summer semester 2019) medical students in Berlin were analyzed. The rate of students who answered the questions about the procedures requiring informed consent and adequate time for consideration increased over time but did not reach comparable values to all PTM questions. Questions about required content were answered correctly by 30 to 60% of the students, regardless of their level of training; we did not see an increase along with the time of study. CONCLUSION: In our study, we were able to show that medical students of all educational levels show tentativeness when it comes to the legal aspects of obtaining informed consent. Yet, the legal framework offers room for new teaching formats like "Co-Action", introduced in this paper for the first time, where students acquire informed consent while being supervised by the medical doctor in charge.

[Physician Shortage: How to Prevent Generation Y From Staying Away - Results of a Nationwide Survey]. / Ärztemangel: Was tun, bevor Generation Y ausbleibt? Ergebnisse einer bundesweiten Befragung.

BACKGROUND: Medical students' attitudes and expectations about their future working life are changing. To hire the best talents from Generation Y, hospitals must pay attention to these factors to make working in patient care more attractive. However, little detailed knowledge about the professional and career expectations of today's medical students is available to date. METHOD: In a nationwide online survey, a total of 9079 medical students from all German medical faculties returned the questionnaire. Twenty-one questions related to future career choices and work satisfaction, followed by 21 questions dealing with reasons for not working in patient care. RESULTS: Factor analysis yielded five factors: work-life balance, career, professional needs, working atmosphere, and prestige. A correlation analysis between these factors and respondents' socio-demographic data revealed significant correlations with sex, specialty choice, and marital/parental status. A correlation analysis with "reasons for not working in patient care" revealed that work-life balance, career, professional needs, and working atmosphere had high priority for both sexes. DISCUSSION: It is crucial to collect data on the work satisfaction of Generation Y, whose members are motivated and willing to perform in today's highly demanding work environment. However, sex-dependent/independent expectations must be met to make the medical profession more attractive, to overcome the Germany-wide shortage of physicians, and to attract young doctors to the hospitals.

Predictors of outcome in decompensated liver disease: validation of the SOFA-L score.

A growing number of patients with liver disease are being referred for critical care support. We have recently shown that a combination of lactate and SOFA score (SOFA-L score) may provide an accurate, objective measurement of prognosis in a group of patients admitted to ICU with alcoholic liver disease. This score has not been validated in an independent patient cohort. A retrospective study was performed where patients admitted to our ICU with decompensated liver disease (any cause) were included. The SOFA-L score accurately predicted in-hospital mortality in this group of patients with an area under the ROC curve of 0.83. Sensitivity and specificity were 65% and 87% respectively SOFA-L performed superior to SOFA, MELD and MELD-Na scores. This study validates the use of the SOFA-L score in the initial 24 hours of ICU admission as an accurate predictor of mortality in this group of patients with a high mortality.

Nursing Practicum in Gynaecology and Obstetrics - Early Influence Possibilities for a Specialty.

Background: The shortage of skilled personnel is ubiquitous, basic and further training is a key aspect in the recruitment of new medical colleagues. The significance of the nursing practicum in its function as gateway to the gynaecology and obstetrics discipline is practically unexplored. Methods: In an online questionnaire, medical students in all German faculties were questioned about the practica in their courses. The questionnaire reached 9079 medical students. 149 participants in nursing practica were selectively asked to answer 140 questions. We analysed those students who could, on the basis of their experiences in nursing practica, imagine undertaking an internship (clinical elective) in gynaecology (internship yes "Iy") separately from those who could not or were still undecided (internship no "In" or, respectively, internship perhaps "Ip"). Results: Altogether 149 medical students who participated in a nursing practicum in the gynaecology discipline were selected, of these 94.9 % were female. 92 (61.7 %) of the students replied that, after their gynaecological nursing practicum, they wanted to undertake an internship in gynaecology (Iy); 39 (26.2 %) answered negatively (In) and 18 (12.1 %) were still undecided (Ip). With regard to the parameters gender, age and duration of study, there were no significant differences among the 3 groups (χ2 0.83). Besides the didactic and professional quality of the training, Iy also mentioned having had a higher practical orientation. They attained their aims more frequently, were better integrated in the health-care team and acquired more practical competences. Satisfaction with the practicum was evaluated as highest among the Iy. Discussion: Those students who could imagine taking an internship in gynaecology were seen to be more satisfied with their practica than those participants who declined or were undecided. The high proportion of females is an early indicator for a feminisation of the specialty. If necessary this could be countered with the help of nursing management.

Utility of near infrared light to determine tissue oxygenation during hepato-biliary surgery.

Near-infrared spectrophotometry assesses cerebral oxygen saturation (ScO2) based on the absorption spectra of oxygenated and deoxygenated hemoglobin, and the translucency of biological tissue, in the near-infrared band. There is increasing evidence that optimising cerebral oxygenation, guided by ScO2, is associated with improved outcomes in a variety of high risk surgical settings. However, in patients with liver disease, bilirubin can potentially render cerebral oximetry inaccurate. As a result, measurement of cerebral oxygen saturation is rarely undertaken in patients undergoing hepatobiliary surgery. We prospectively measured baseline and intraoperative cerebral oxygen saturation in patients undergoing major pancreatic surgery. Indices including bilirubin, sodium, platelets and maximum amplitude on thromboelastography were associated with low baseline ScO2. However, those patients with low ScO2 (≤51%) maintained a similar trend in cerebral oximetry values both at induction and intraoperatively to those with a normal ScO2. We conclude that the pattern of cerebral oximetry is similar in patients undergoing major pancreatic surgery regardless of their underlying liver dysfunction. Therefore, cerebral oximetry may have a role in monitoring neurological function in this high risk group of patients.

Alcoholic liver disease in the intensive care unit: outcomes and predictors of prognosis.

BACKGROUND: An increasing number of patients with alcoholic liver disease (ALD) are being referred for critical care support, but limited information is available on their short- and medium-term outcomes. This study aimed to determine mortality rates, identify optimal predictors of prognosis, and determine the appropriate time to apply these predictors in patients with ALD admitted to intensive care unit (ICU). METHODS: In this retrospective study, patients admitted to ICU between 2009 and 2012 with a primary diagnosis of ALD were included. Survival was calculated using the Kaplan-Meier method, risk factors for death determined by logistic regression analysis, and discriminative capacity of models using receiver operating characteristic curves. RESULTS: Of 170 patients admitted with liver disease, 62 met the inclusion criteria. Survival rates in the ICU, in hospital, and at 6 months were 40.3% (95% confidence interval [CI], 30.7%-49.9%), 35.5% (95% CI, 25.35%-45.65%), and 29% (95% CI, 19.4%-38.6%), respectively. Multiple linear regression analysis of day 1 variables produced an equation with Sequential Organ Failure Assessment score and lactate as significant predictors of mortality; this model had an area under the receiver operating characteristic curve of 0.93. A score greater than 12 in this model correlated with a mortality of more than 80% at all time points and was more accurate than any other score examined. CONCLUSION: Patients admitted to ICU with ALD have a very high inhospital mortality. A combination of the established Sequential Organ Failure Assessment score and lactate provided the most accurate predictor of outcome on day of admission and at all subsequent time points.

[Protect employability: effects of prevention programs offered by the German pension scheme]. / Beschäftigungsfähigkeit teilhabeorientiert sichern (Betsi): Ergebnisse der Einjahreskatamnese von Prävention-s-maßnahmen der Deutschen Rentenversicherung.

A pilot study was carried out in 4 medical rehabilitation centers to examine the practicability and effectiveness of preventive life-style interventions for employees with risk factors. The programs were developed in cooperation with the German pension scheme and employers. Selection criteria were risk factors as lack of physical activity, overweight, dorsal pain or job strain. The results demonstrate that preventive programs, which are conducted in addition to the normal working hours on the job, can be implemented successfully in rehabilitation units. The participation in the multimodal prevention program goes along with a stable reduction of risky health behavior: increased physical activity, stress coping, dietary change und weight reduction. The healthier life-style is reflected in an enhanced state of health and has also positive impact on the occupational field scale: The percentage of employees who believed to be able to work until their old-age pension, could be increased significantly (p<0.001) from 47% to 74%. Work-related risk behaviors like excessive demands on oneself were reduced and protective strategies were -developed.

Attitudes and intentions of current anaesthetic trainees.

We report the results of a survey of Irish anaesthetic specialist trainees to establish their future training intentions, their interest in seeking a Consultant position in Ireland and identification of factors that may reduce the attractiveness of future employment in the HSE. 149 responses were received (71% of trainees). 137 (92%) are likely to complete further training abroad, but only 24 (16.1%) are definitely planning to return to work in Ireland. Factors, in order of importance that influence their return to Ireland include equivalence of all Consultants, salary level and availability of flexible work practices. Almost all (131 - 91%) would only consider working in Ireland at Consultant level. These results reveal that the current cohort of specialist trainees do not consider Ireland an attractive place to work, and any further diminution of the current Consultant grade will only serve to worsen this perception.

Acute respiratory distress syndrome: current concepts and future directions.

Acute respiratory distress syndrome is one of the leading causes of death in critically ill patients. Recent advances in supportive care have led to a moderate improvement in mortality. In particular, a much lower mortality rate than expected was evident in the severest category of patients (requiring extracorporeal membrane oxygenation) in Australia during the recent H1N1 pandemic. Though improvements in supportive care may have provided some benefit, there remains an absence of effective biological agents that are necessary to achieve further incremental reduction in mortality. This article will review the evidence available for current treatment strategies and discuss future research directions that may eventually improve outcomes in this important global disease.

[Arthroscopically assisted therapy of avascular necrosis of the femoral head]. / Arthroskopisch gestützte Behandlung der aseptischen Hüftkopfnekrose.

OBJECTIVE: Preservation of the hip joint function by treatment of the avascular necrosis of the femoral head in adults or at least avoiding progression. INDICATIONS: Avascular necrosis of the femoral head in adults in Steinberg stages I-III. In patients with Steinberg stage IVa (subchondral collapse ≤ 15% of the articular surface, depression < 2 mm) hip joint salvage therapy in early stages of femoral head collapse. CONTRAINDICATIONS: Manifest osteoarthritis of the hip joint. Joint infection. Relative contraindications: subchondral collapse > 15% of the articular surface or depression > 2 mm (Steinberg stage IVb and above). Persisting risk factors for a progression of avascular necrosis (e.g., alcohol abuse, chemotherapy, local irradiation, high-dose cortisone therapy) and obesity (BMI > 40). SURGICAL TECHNIQUE: Arthroscopy of the hip joint in case of cartilage defects and/or potential collapse of the femoral head. Without collapse of the femoral head and absence of severe damage of the cartilage: core decompression using a guiding sleeve through a lateral approach (Steinberg II, III). Subsequently curettage of the necrotic area through a central drill hole and insertion of autogenic bone cylinders using an OATS harvester (Steinberg II b/c, III b/c). In Steinberg stage IVa, reconstruction of the outline of the femoral head is attempted by reduction of the impressed portion (under intraoperative fluoroscopy). POSTOPERATIVE MANAGEMENT: Limited weight bearing (10 kg) of the operated leg for 6 weeks. In cases of large necrotic defects located directly beneath the subchondral bone (Steinberg IIIc) as well as subchondral collapse with flattening of the femoral head (Steinberg IVa) limited weight bearing (10 kg) for 12 weeks. RESULTS: Early results of femoral head preserving therapy in 53 patients (56 hips, consecutively treated between June 2004 and December 2009) after 33 ± 20 months: success rate (no arthroplasty, no reoperation, no radiological progress associated with clinical symptoms) 86% for patients treated with Steinberg stages I-III. Failure of the head preserving therapy with concern to the mentioned criteria depending on the initial Steinberg stage: 0 (0%) for stage I, 2 (10%) for stage II, 3 (25%) for stage III, and 4 (31%) for stage IVa.

[DGRW-Update: musculo-skeletal diseases]. / DGRW-Update: Erkrankungen des Muskel-Skelettsystems.

BACKGROUND: Orthopedic rehabilitation is a major entity in rehabilitation. Due to coming demographic changes and its challenges concerning mobility of elderly patients it will increase. The criticism on orthopedic rehabilitation in Germany focuses on its missing evidence in therapeutic eff ectiveness especially in chronic low back pain. This overall-criticism is actually no more valid as there are a number of studies showing eff ectiveness of orthopedic treatment in rehabilitation if psychosocial comorbidities are respected and treatment is focussed on occupational training and eintegration. GOALS: This overview describes the actual situation in orthopedic rehabilitation and its research. RESULTS: The need for orthopedic rehabilitation will increase over the next years due to demographic changes. Important fi elds in orthopedic rehabilitation research are chronic low back pain, new rehabilitation models with focus on occupational reintegration, rehabilitation in elderly and following joint surgery as well as the analysis of health-care-system changes due to disease related groups.

An early botulinum toxin A treatment in subacute stroke patients may prevent a disabling finger flexor stiffness six months later: a randomized controlled trial.

OBJECTIVE: The study asked whether an early botulinum toxin A (BTX-A) injection in subacute stroke patients may prevent a disabling finger flexor stiffness six months later. DESIGN: Single-blind, randomized pilot study. SETTING: Inpatient rehabilitation centre. SUBJECTS: Eighteen stroke patients, interval 4-6 weeks, non-functional arm, Fugl-Meyer arm score (0-66) <20, beginning elevated finger flexor tone, randomly allocated to group A or B. INTERVENTIONS: In group A patients 150 units BTX-A (Xeomin) injected into the deep and superficial finger (100 units) and wrist flexors (50 units), no injection in group B patients. Comprehensive rehabilitation in both groups. MAIN MEASURES: Primary variable was the Modified Ashworth Scale score (0-5) of the finger flexors; secondary variables were whole arm muscle tone with REPAS (a summary rating scale for resistance to passive movement), its motor control with the Fugl-Meyer arm score, and a disability scale, blindly assessed at T0 (start), T1 (four weeks) and T6 (six months). RESULTS: Homogeneous groups at T0. Significantly less finger flexor stiffness in the BTX-A group at T1 and T6, the mean (SD) Modified Ashworth Scale scores in group A (B) were: 1.7 ± 0.5 (1.6 ± 0.5) at T0; 0.4 ± 0.5 (1.9 ± 0.7) at T1; and 1.4 ± 0.7 (2.4 ± 0.9) at T6. Among the secondary measures, the disability score, namely the items pain and passive nail trimming, was lower in group A at T1 and T6. CONCLUSIONS: The results indicate an effect of early BTX-A injection on finger flexor stiffness six months later, presumably attributable to a reduced contracture development. Effect size calculation suggests inclusion of at least 17 patients per group excluding drop-outs in a warranted placebo-controlled trial.

Renopathological Microstructure Visualization from Formalin Fixed Kidney Tissue by Matrix-Assisted Laser/Desorption Ionization-Time-of-Flight Mass Spectrometry Imaging.

Understanding early stage renal malfunctions with regard to the glomerular filtration processes is essential for nephropathological prescreening strategies and intervention at an early stage. Mass spectrometry imaging (MSI) in combination with histopathology can provide an universal analytical approach. Proteomic and lipidomic aspects of glomerular biocompositions were applied for micro-structural differentiation in healthy rat kidney samples. Usability of commonly used tissue embedding media and the compatibility of histological staining and fixation methods were of interest. It was demonstrated that ultra-thin tissue samples (500 nm, 1 and 10 µm) can be used for lipid and peptide-based differentiation at the glomerular resolution level in formalin-fixed tissue samples in combination with preceding histological staining for correlating optical and molecular mass images.