[Methods for organisational health services research]. / Methoden für die organisationsbezogene Versorgungsforschung.

On 1 July 2009, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned below and published in this journal (Gesundheitswesen 2009; 71: 505-510). The focus of this part of the Memorandum III "Methods for health services research" is on the questions and methods of organisational health services research. In a first step, we describe the central questions which are at the core of organisational health services research. In a second step, we describe the methodological standards and requirements with regard to a) sampling, b) measurement and c) research design. We present a phase model for complex intervention trials. This model allows to conduct high quality organisational health services research, to integrate different methods of social research and to show in which phase they are of special importance.

[Surgical technique and outcome in metabolic and bariatric surgery: biliopancreatic diversion]. / Operative Techniken und deren Outcome in der metabolischen Chirurgie: Biliopankreatische Diversion.

OBJECTIVES: The aim of the study was to investigate surgical results and outcome using biliopancreatic diversion (BPD) and duodenal switch (BPD-DS) as a representative profile for Germany. PATIENTS AND METHODS: From January 2005 to December 2007, overall 163 patients had undergone BPD (n = 72) and BPD-DS (n = 91) including 21 "redo" operations who were registered in the nation-wide multicentre (n = 48) observational -study for quality assurance of surgical treatment in morbid obesity. BPD and BPD-DS were performed in 5 of the 48 participating German surgical departments. A laparoscopic approach with no conversion was possible in 96.7 % of BPD and 50.6 % of BPD-DS, respectively. RESULTS: Body weight (mean BMI, 53.6 kg / m(2)) was considerably reduced down to a mean BMI of 36.7 kg / m(2) (BPD) and 33.2 kg/m(2) (BPD-DS). The operating time in average was 134 min in BPD and 234 min in BPD-DS, respectively. Postoperative hospital stay was as follows: BPD, 8 d; BPD-DS, 15 d. The rate of general postoperative complications (pneumonia, urinary infection) was 17.6 % whereas the specific complication rate (disturbances of wound healing) was only 12.1 % (mortality, 0). Relaparotomy was required in 5 patients (post-operative bleeding, n = 3; anastomotic insufficiency, n = 2). In 50 % of the repeat cases, a laparoscopic -approach was initially favoured followed by conversion. Follow-up investigation revealed trocar hernia, n = 2 (within 1 year); abdominal hernia, n = 1 (within 6 months). CONCLUSION: The surgical results obtained with BPD and, in particular, with BPD-DS represent data similar to those of a learning curve. Occurrence, type and rate of the reported complications are comparable with international data from the literature. The ongoing benchmarking project indicates the efforts for a continuous control and improvement of the quality in this type of surgical treatment.

[PCO syndrome--is it an indication for bariatric surgery?]. / Das polyzystische Ovarsyndrom--eine Indikation zu bariatrischen Eingriffen?

BACKGROUND: The polycystic ovary syndrome (PCOS) is the most frequent cause of female infertility with an estimated prevalence of 6-10% in premenopausal women. Due to its long-term metabolic and cardiovascular consequences, it poses a severe health problem. Visceral obesity and subsequent insulin resistance represent the core pathophysiology of PCOS, clearly suggesting that measures to reduce abdominal obesity should be pursued. METHODS: Between February 1995 and October 2006, 204 patients underwent bariatric surgery in the SRH Hospital of Gera. 75% of the patients were female and three of them were suffering preoperatively from polycystic ovary syndrome and metabolic syndrome. RESULTS: 104 months after laparoscopic adjustable gastric banding, the excess body weight loss (EBWL) was 49, 67 and 41% in these three patients, respectively. Glucose levels normalised completely. One patient became pregnant after weight reduction. CONCLUSIONS: In PCOS with metabolic syndrome, bariatric surgery is an option to reduce weight and to treat associated metabolic disorders. Surgery should be performed based on the body mass index, the metabolic disorders, and the wish of the patient to become pregnant.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006.

BACKGROUND: Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery. MATERIALS AND METHODS: All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial. RESULTS: In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%). CONCLUSION: Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

Gastric cancer after laparoscopic adjustable gastric banding.

A 63-year-old woman with BMI 46 underwent laparoscopic gastric banding. In the standardized follow-up after 14 and 24 months, the GI series and gastroscopy showed no pathological signs. The patient had hematemesis 32 months after gastric banding, followed by symptoms of obstruction, for which a laparotomy was performed. At operation, peritoneal carcinomatosis due to gastric cancer was found. Symptoms after bariatric procedures can be similar to symptoms of gastric or esophageal cancer. We believe that yearly postoperative gastroscopy is indicated to exclude pathological changes.

[Quality certificate "Geriatrie" from the care scientist's perspective]. / Qualitätssiegel Geriatrie aus pflegewissenschaftlicher Perspektive.

The current version of the quality certificate "Geriatrie" pretends to describe the specific content of high quality care in geriatric clinics. Besides methodological deficits, it also has deficits in the systematic choice of the quality items, including a lack of the perspectives of patients and their relatives. Thus, the certificate is actually an additional piece of paper with legitimatory function than an instrument to give quality orientation to older patients and their relatives or to insurance companies which pay for the care. Further development and the clarification of its aims are suggested.

Epiphrenic esophageal diverticulum after laparoscopic placement of an adjustable gastric band.

A morbidly obese woman (BMI 56 kg/m2) in 1998 underwent laparoscopic placement of an adjustable gastric band by the perigastric approach. 5 years later, she complained of reflux and weight regain. X-ray with contrast revealed pouch dilatation. She subsequently underwent a laparoscopic revision including retrocardia band replacement using the pars flaccida technique. During the further course, an epiphrenic diverticulum was diagnosed. Because of danger of perforation of the large thin-walled diverticulum and the esophageal motility disorder, the band was laparoscopically removed and the diverticulum was resected via a transhiatal approach. This case presents a very rare complication after placement of a gastric band and its successful management.

Rhabdomyolysis after biliopancreatic diversion with duodenal switch.

Rhabdomyolysis is an uncommon event in bariatric surgery. It can be caused by ischemia, crush injury, alcohol ingestion and drug intake, and as a consequence renal failure can develop. A few reports indicate that patients undergoing bariatric surgical intervention are at risk for rhabdomyolysis. A super-obese male (BMI 52 kg/m2) is reported, who underwent laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS). Operative time was 265 minutes, and the BPD/DS operation was uneventful. Post-operatively, the patient complained of pain in both hips and the left shoulder, and suffered oliguria. He was treated with fluids (isotonic saline), bicarbonate, and mannitol. Despite this, he developed renal failure, which subsequently required hemodialysis. The patient died from arrhythmia and cardiac arrest on the 8th postoperative day. Obese patients undergoing bariatric surgery are at risk of rhabdomyolysis. Prolonged compression of the muscles during the surgical intervention, in long laparoscopic procedures, predisposes to this complication.

[Long-term results after gastric banding]. / Langzeitergebnisse nach Gastric Banding.

BACKGROUND: Adjustable gastric banding is a popular bariatric operation in Europe. The rate of long-term complications like pouch dilatation, slippage and band migration and the long-term effect of weight loss are reported in meta-analysis and few studies for a period of more than five years. We report on experiences after gastric banding. METHODS: Over a period of 10 years 168 patients with morbid obesity were treated with gastric banding. Preoperative data, postoperative weight loss and long-term complications were prospectively obtained and retrospectively analyzed. RESULTS: Mean age of the patients was 41.7 years with a mean preoperative BMI of 49.6 kg/m2. No intraoperative or postoperative death occurred in the first 30 postoperative days. Intraoperative conversion rate was 7.1 %. 79.8 % of the patients (n = 134) were available for follow up (mean follow-up time 66.7 months). Long-term complications occurred in 22.5 % of the patients. 30 complications (17.8 %) were related to the band and 8 (4.7 %) to the access-port or to the tube. Mean excess weight loss was 39.6, 47.3, 44.2, 43.4 and 32 % after 1, 2, 4, 5 and 8 years. CONCLUSIONS: Laparoscopic gastric banding can achieve an effective weight loss. However band-related and functional complications will influence the late outcome. Pathways to choose the best surgical method for the individual patient are necessary to reduce failures after gastric banding.

[Band migration. A late complication of gastric banding]. / Bandmigration. Eine Spätkomplikation nach "Gastric Banding".

BACKGROUND: Adjustable silicone gastric banding is an effective and safe treatment for morbid obesity. Migration of the band through the stomach wall is a long-term complication. The causes, clinical symptoms, timing, and incidence of band migration have not yet been investigated. METHODS: We report our experience over 9 years. Between February 1995 and February 2004, we performed adjustable silicone gastric banding in 161 patients, with follow-up of about 90.5% of cases. Mean follow-up time was 60.4 months. Cases of erosion were studied retrospectively. RESULTS: Eight patients (4.9%) developed band migration. In seven, the migration occurred between 30 and 86 months after band implantation. In one case, the migration occurred 10 months after laparoscopic repositioning of the band to avoid pouch dilatation. In all cases, the bands were removed. CONCLUSION: Band migration is a late complication after gastric banding that requires band removal. Various symptoms and complications of band migration influence the kind of band removal. The causes of band migration and its treatment are discussed.

Bacterial artificial chromosome-derived molecular markers for early bolting in sugar beet.

Early bolting in sugar beet (Beta vulgaris L.) is controlled by the dominant gene B. From an incomplete physical map around the B gene, 18 bacterial artificial chromosomes (BACs) were selected for marker development. Three BACs were shotgun-sequenced, and 61 open reading frames (ORFs) were identified. Together with 104 BAC ends from 54 BACs, a total number of 55,464 nucleotides were sequenced. Of these, 37 BAC ends and 12 ORFs were selected for marker development. Thirty-one percent of the sequences were found to be single copy and 24%, low copy. From these sequences, 15 markers from ten different BACs were developed. Ten polymorphisms were determined by simple agarose gel electrophoresis of either restricted or non-restricted PCR products. Another five markers were determined by tetra-primer amplification refractory mutation system-PCR. In order to select candidate BACs for cloning the gene, genetic linkage between seven markers and the bolting gene was calculated using 1,617 plants from an F2 population segregating for early bolting. The recombination values ranged between 0.0033 and 0.0201. In addition, a set of 41 wild and cultivated Beta accessions differing in their early bolting character was genotyped with seven markers. A common haplotype encompassing two marker loci and the b allele was found in all sugar beet varieties, indicating complete linkage disequilibrium between these loci. This suggests that the bolting gene is located in close vicinity to these markers, and the corresponding BACs can be used for cloning the gene.

Ultrastructural analysis of chromatin in meiosis I + II of rye (Secale cereale L.).

Scanning electron microscopy (SEM) proves to be an appropriate technique for imaging chromatin organization in meiosis I and II of rye (Secale cereale) down to a resolution of a few nanometers. It could be shown for the first time that organization of basic structural elements (coiled and parallel fibers, chromomeres) changes dramatically during the progression to metaphase I and II. Controlled loosening with proteinase K (after fixation with glutaraldehyde) provides an enhanced insight into chromosome architecture even of highly condensed stages of meiosis. By selective staining with platinum blue, DNA content and distribution can be visualized within compact chromosomes as well as in a complex arrangement of fibers. Chromatin interconnecting threads, which are typically observed in prophase I between homologous and non-homologous chromosomes, stain clearly for DNA. In zygotene transversion of chromatid strands to their homologous counterparts becomes evident. In pachytene segments of synapsed and non-synapsed homologs alternate. At synapsed regions pairing is so intimate that homologous chromosomes form one filament of structural entity. Chiasmata are characterized by chromatid strands which traverse from one homolog to its counterpart. Bivalents are characteristically fused at their telomeric regions. In metaphase I and II there is no structural evidence for primary and secondary constrictions.

[Lesions of the spleen in chronic pancreatitis by thrombophlebetic splenomegaly and cyst penetration]. / Milzläsionen im Rahmen der chronischen Pankreatitis durch Milzvenenverschluss und durch Zystenpenetration.

UNLABELLED: Chronic pancreatitis leads to changes of nearby organs with possible acute and chronic complications including lesions of the spleen. Among 341 patients operated upon between January 1981 and June 2002 in the surgical department Gera, we found 7 spontaneous spleen ruptures or such after minimal trauma and 4 pseudocysts, which expanded to the splenic hilus. In all cases splenectomy was carried out with resection of the tail of the pancreas with or without drainage of the pancreas. 2 patients with a history of splenectomy after minimal trauma underwent duodenum-preserving resection of the pancreatic head to Frey, and distal pancreatectomy, resp. CONCLUSIONS: Lesions of the spleen belong to the rare complications of chronic pancreatitis. With known case history and mostly delayed course, the operative concept must be concentrated not only on the splenic lesion but also on the therapy of the chronic pancreatitis.

[Rare tumors of the pancreas]. / Seltene Befunde am Pankreas.

From 1984 to 2001, 486 operations were carried out at the surgical clinic in Gera for pancreatic neoplasms, including 49 patients with rare neoplasms of the pancreas. In 23 patients malignant pancreatic tumors were present (9 solitary metastases, 9 endocrine carcinomas, 2 cystadenocarcinomas, 2 schwannomas and one non-Hodgkin's lymphoma). In 28 benign lesions a resection of the tumor was performed, concerning 8 insulinomas, 8 serous cystadenomas, 3 mucinous cystadenomas and 4 rare cystic tumors. A sarcoidosis, an autoimmune pancreatitis and a radiation fibrosis were diagnosed in 3 patients operated under the suspicion of a malignant pancreatic tumor. By means of own case examples and data from the literature these rare entities are described with their diagnostic and therapeutic special features.

A bacterial artificial chromosome (BAC) library of sugar beet and a physical map of the region encompassing the bolting gene B.

In sugar beet (Beta vulgaris L.), early bolting is caused by a single dominant gene, designated B. Twenty AFLP markers selected from a 7.8-cM segment of the B region on chromosome 2 were used to screen a YAC library, and a first-generation physical map including the B gene, made up of 11 YACs, was established. Because the genome coverage of the YAC library was low, a BAC library was constructed in the vector pBeloBAC11. This library consists of 57,600 clones with an average insert size of 116 kb, corresponding to 8.8 genome equivalents. Screening of the BAC library with chloroplast and mitochondrial DNA probes indicated that less than 0.1% of the clones contained organelle-derived DNA. To fill the gaps in the physical map around the B gene, the BAC library was screened with four AFLP markers and 10 YAC-derived probes. In total, 54 different BACs were identified. Overlaps between BACs were detected by using BAC termini amplified by PCR as probes, and by RFLP fingerprinting. In this way, a minimal tiling path of the central 4.6-cM region was constructed, which consists of 14 BACs. The B locus was localized to a 360-kb contig, a size which makes positional cloning of the gene feasible.

C-to-U conversion in the intercistronic ndhI/ ndhG RNA of plastids from monocot plants: conventional editing in an unconventional small reading frame?

Editing of plastid RNAs proceeds by C-to-U, in hornwort species also by extensive U-to-C, transitions, which predominantly lead to the restoration of codons for structurally and/or functionally important, conserved amino acid residues. So far, only one instance of editing outside coding regions has been reported - in the psbL/ psbF intergenic region of Ginkgo biloba. This site was proposed to have no functional importance. Here we present an evaluation of an editing site in the ndhI/ ndhG intergenic region in a related group of monocot plants. Efficient editing of this site, as well as the phylogenetic conservation of the resulting uridine residue, point at an important role for the sequence restored by editing. Two potential functions can be envisaged. (1) RNA secondary structure predictions suggest that the C-to-U conversion at this site can lead to a modified stem/loop structure of the ndhG 5' UTR, which could influence ndhG expression. (2) Alternatively, editing of the ndhI/ ndhG intergenic region may tag a so far unidentified small (12-codon) ORF, and lead to the restoration of a conserved phenylalanine codon. A screen with specific antibodies elicited against the putative peptide failed to detect such a peptide in chloroplast fractions. However, this failure may be attributable to its low and/or development-specific expression.

Comparative genomic in situ hybridization (cGISH) analysis on plant chromosomes revealed by labelled Arabidopsis DNA.

A new approach for comparative cytogenetic banding analysis of plant chromosomes has been established. The comparative GISH (cGISH) technique is universally applicable to various complex genomes of Monocotyledonae (Triticum aestivum, Agropyron elongatum, Secale cereale, Hordeum vulgare, Allium cepa, Muscari armenaticum and Lilium longiflorum) and Dicotyledonae (Vicia faba, Beta vulgaris, Arabidopsis thaliana). Labelled total genomic DNA of A. thaliana generates signals at conserved chromosome regions. The nucleolus organizing regions (NORs) containing the majority of tandemly repeated rDNA sequences, N-band regions containing satellite DNA, conserved homologous sequences at telomeres and additional chromosome-characteristic markers were detected in heterologous FISH experiments. Multicolour FISH analysis with repetitive DNA probes simultaneously revealed the chromosome assignment of 56 cGISH signals in rye and 61 cGISH signals in barley. Further advantages of this technique are: (1) the fast and straightforward preparation of the probe; (2) the generation of signals with high intensity and reproducibility even without signal amplification; and (3) no requirement of species-specific sequences suitable for molecular karyotype analysis. Hybridization can be performed without competitive DNA. Signal detection without significant background is possible under low stringency conditions. The universal application of this fast and simple one-step fluorescence banding technique for plant cytogenetic and plant genome evolution is discussed.

[Intraoperative diagnosis of pheochromocytoma preoperative symptoms in a case of Recklinghausen's disease]. / Intraoperative Diagnose eines präoperativ symptomlosen Phäochromozytoms bei Morbus Recklinghausen.

Phaechromocytoma is a rare catecholamine secreting tumor, which occasionally presents as a life threatening crisis in association with surgery and anesthesia. We report a 58-year-old women with known Recklinghausen's disease who was admitted for elective resection of a pancreas tail cystadenoma. A cystadenocarcinoma was taken into account differential diagnostically. No clinical symtoms or signs pointing to a hormone active tumor were found preoperatively. After opening of the abdomen and palpation of the tumor, a hypertensive crisis occurred accompanied by considerable tachycardia, leading to the tentative diagnosis of a phaeochromocytoma in connection to the known phacomatosis. The hypertensive crisis was treated with nitroglycerin and esmolol. The putative tumor of the pancreas represented itself as an adrenal tumor without relationship to the pancreas. Following ligature of the suprarenal vein, antihypertensive therapy could be finished. For stabilization of blood pressure a noradrenaline application was necessary in descending dosage over a period of two days. The further postoperative course was without complications. The results of the urine catecholamine measurements and histological examinations confirmed the intraoperative diagnosis. An unidentified phaeochromocytoma is a vital threat for patients during surgery and anesthesia. Phaeochromocytomas are observed in patients suffering from Recklinghausen's disease (and other phacomatoses) in an above average incidence. Therefore, such a tumor should be excluded in these patients before elective surgery even if the patient does not show symptoms (asymptomatic phaeochromocytomas occur). The determination of catecholamines in 24 hour urine collections is an easy and specific diagnostic procedure and should be used in patients suffering from phacomatoses before elective surgery.