[Liability for chronic working time violations in medicine: when does the risk of fines and imprisonment loom?] / Haftung für chronische Arbeitszeitverstöße in der Medizin ­ wann drohen Bußgelder und Freiheitsstrafen?

Against the background of the changes in the collective bargaining agreement-for municipal hospitals in the version of January 1, 2021, and for university hospitals in the version of March 7, 2020-this article deals with the legal consequences of chronic violations of the German Working Hours Act in medicine, but especially in surgical specialties such as urology. It includes an overview of current law and sanctions for violations and highlights responsibilities as well as exceptions. It is important to clarify the distribution of responsibilities with regard to working hours in the institution concerned in order to avoid fines and, in the worst case, imprisonment. It should also be clear who is liable in specific cases for persistent working time violations. When changing duty models, it is important to bear in mind that this can lead to a considerable deterioration in the opportunities for further training and education of physicians, meaning that in the long term the compatibility of further training in line with working hours can only be achieved with sufficient staffing of the hospitals. In some cases, this is diametrically opposed to economic interests in the health care system and thus presents an almost insoluble dilemma. In the view of the working group, structural changes in the diagnosis-related group (DRG)-based inpatient sector are needed in the near future.

Quantification of all 209 PCB congeners in blood-Can indicators be used to calculate the total PCB blood load?

Polychlorinated biphenyls (PCBs) are a substance group of 209 theoretically possible compounds. The human body burden of PCBs is commonly calculated based on so-called indicator congeners such as PCB 138, PCB 153 and PCB 180, which are analyzed in human blood. The German "Human Biomonitoring (HBM) Commission" assumes that the sum of these indicator congeners multiplied by a factor of 2 represents the total PCB burden. This norm is based on data obtained from exposure studies after dietary intake. Data from indoor air shows a different congener pattern, which might lead to a relatively higher intake of lower chlorinated PCBs by inhalation. In two independent studies with adult participants from two regions in Germany, we measured all 209 PCB congeners in 44 whole blood and 42 plasma samples. Participants from the whole blood study group had additional exposure to PCBs via indoor air. With our analytical method, 141 individual PCB congeners, 27 coeluted pairs of PCB congeners and 2 records of 3 and 4 coeluted PCBs could be determined. Thus, 172 analysis results were reported per sample. In the whole blood samples, 50 congeners showed values below the limit of quantification (LOQ), whereas 94 congeners could not be detected in any of plasma samples. Total PCB concentrations (Σ 209 PCB congeners, incl. ½ LOQ) in the whole blood samples ranged from 99 to 2152ng PCB/g lipid (Median: 454ng/g lipid; 95th Percentile: 1404ng/g lipid). The sum of all 209 measured PCB (incl. ½ LOQ) in plasma samples showed levels between 52 and 933ng PCB/g lipid (Median: 226ng/g lipid; 95th Percentile: 642ng/g lipid). Our results show that the burden of PCBs on the human body is caused mainly by the three highly chlorinated indicator congeners PCB 138, PCB 153 and PCB 180. In median approximately 50% of the total PCB content in human whole blood or plasma samples can be attributed to these congeners. Total PCB, calculated by multiplying the sum of the three indicator congeners by 2, showed a strong and highly significant correlation to the sum of all 209 measured congeners for each sample. A slightly stronger correlation in the whole blood samples could be achieved by choosing six indicator congeners, including the lower chlorinated congeners (PCB 28, 52 and 101) into the calculation. Although this difference is very small, it must be considered that higher PCB levels in indoor air than those measured in the present study might be associated with a higher burden of indoor-air-related congeners in exposed individuals. For precautionary reasons, it could therefore be recommended that the assessment of individuals exposed to PCB via indoor air should be carried out based on the sum of the 6 indicator congeners PCB 28, PCB 52, PCB 101, PCB 138, PCB 153 and PCB 180 multiplied by a factor of 2.

[Evaluation of intra-organisational effects after use of certification programmes in hospital]. / Evaluation einrichtungsinterner Effekte nach Durchführung eines Zertifizierungsverfahrens im Krankenhaus.

AIM: The introduction of quality management systems might be promoted by use of recognised certification programmes. Over the years, in health care organisations the certification model named KTQ has gained more and more importance. The aim of this study is to evaluate intra-organisational effects in a clinic after introduction of quality management on the basis of KTQ. METHODS: The evaluation was performed using a 2-step approach: first, before starting the implementation process of KTQ in the year 2008, and second, after the implementation process had become successful. Data were obtained by a systematic questionnaire survey. Hospital staff (physicians, nurses, and others like administration staff, technical and medical assistants) were asked to appraise the quality management, to give own preferences, and rate their overall satisfaction with the process. RESULTS: Response rates were 56% in the year 2008 and 50% in the year 2010. Subjects regarding the working atmosphere, leading of superiors, organisational issues, and pervasion of quality management predominantly were found to be improved, almost with high statistical significance. At the same time, higher satisfaction values could be determined. CONCLUSIONS: There might be high acceptance to the undergone changes from the staff members' point of view. It appears that the implementation process has led to higher satisfaction values. Moreover it can be concluded that certification programmes might be able to promote the needed pervasion of quality management throughout the institution.

Interlaboratory comparison of the determination of chlorinated dibenzo-p-dioxins and dibenzofurans according to regulatory methods EN 1948 and EPA 1613b.

Four laboratories participated in a collaborative study to determine differences in analytical results generated according to two different compliance methods, US EPA Method 1613b and European Union Method EN 1948 for the determination of chlorinated dibenzo-p-dioxins and dibenzofurans (CDD/CDFs). Various sample matrices containing the analytes at levels ranging from parts-per-quadrillion (ppq) to parts-per-billion (ppb) were used to illustrate differences and similarities between the two analytical methods. The choice of the sample matrices analyzed in this study was made to mirror many of the real-world samples that are of interest to Dow and also to test the laboratories on many different, complex matrices. For this reason, commercially available performance evaluation samples were not used. The study results indicate that the 1613b requirement for confirmation of analyte identity and concentration on a second, polar gas chromatographic column for 2378-tetrachlorodibenzofuran (TCDF) only may lead to quantitative results which are biased high compared to EN 1948 which additionally requires confirmation for all 2378-substituted tetra--through hexachlorodibenzo-p-dioxins and dibenzofurans.

[Imaging diagnostics of the wrist: MRI and Arthrography/Arthro-CT]. / Bildgebende Diagnostik des Handgelenkes: MRT und Arthrographie/Arthro-CT.

PURPOSE: To evaluate the use of magnetic resonance imaging (MRI) compared with arthrography and arthro-CT (AG/ACT) in patients with wrist pain. METHODS: MRI and arthrography/arthro-CT (AG/ACT) of the wrist joint were retrospectively evaluated in 346 patients over a three-year period. Imaging findings were correlated to surgical results (n = 78) or clinical course in an at least 6-month follow-up. RESULTS: For tears of the triangular fibrocartilage, arthrography, arthro-CT, and MRI demonstrated a sensitivity and specificity of more than 0.96. Only the positive predictive value was superior for arthrography/arthro-CT (0.99 and 0.98, respectively) compared with MRI (0.94). Arthrography was superior for functional diagnosis of scapho-lunate ligament tears (n = 25). Ulno-lunate and ulno-triquetral ligament defects were demonstrated more exactly by arthrography. Traumatic osseous defects, particularly scaphoid fractures (n = 33) and avascular necrosis (n = 17), were better diagnosed using MRI. CONCLUSION: For suspected lesions of the triangular fibrocartilage complex, AG/ACT is slightly more reliable than MRI. However, MRI was found to be highly accurate in diagnosing TFC tears, and is superior to AG/ACT in detecting traumatic and vascular lesions of the wrist.

Levels of metals and organic substances in blood and urine of workers at a new hazardous waste incinerator.

OBJECTIVE: To assess baseline concentrations of a number of metals and organic compounds in blood and urine of 28 workers employed at a new hazardous waste incinerator (HWI), before operation of the plant. METHODS: Plasma analyses of hexachlorobenzene (HCB), polychlorinated biphenyls (PCB 28, 52, 101, 138, 153 and 180), benzene, toluene, ethylbenzene, m-xylene, and polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) were carried out. The urinary levels of 2,4- and 2,5-dichlorophenol (DCPs), 2,4,5- and 2,4,6-trichlorophenol (TCPs) and pentachlorophenol (PCP), as well as those of 1-hydroxypyrene (1-HP) were also measured. Beryllium (Be), manganese (Mn), mercury (Hg) and lead (Pb) concentrations were determined in total blood, while the levels of arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni) and vanadium (V) were measured in urine. RESULTS: The levels of benzene, toluene, ethylbenzene and m-xylene were under their respective detection limits. The concentrations of HCB, PCBs and PCDD/Fs in plasma of the HWI workers, chlorophenols (CLPs) and 1-HP urinary concentrations, as well as those of metals in blood and urine are shown. PCDD/F concentrations in plasma of the new HWI workers ranged between 13.4 and 84.0 pg international toxic equivalents (I-TEQ)/g lipid, with a geometric mean value of 24.4 pg I-TEQ/g lipid. DISCUSSION: PCDD/F levels, as well as the concentrations of PCBs were of the same order of magnitude as those recently obtained for non-occupationally exposed populations of Catalonia (Spain). No significant gender differences were found for the levels of HCB, PCBs and PCDD/Fs. Although the present results showed a notable variability in the levels of CLPs, geometric mean values of these compounds were similar or even lower than those considered as potential reference values. Metal concentrations in blood and urine were also of the same order of magnitude than previously reported metal levels in the same area. CONCLUSION: The present results should be useful in future surveys in which internal exposure of the HWI workers will be determined.

Levels of synthetic musks; bromocyclene and PCBs in eel (Anguilla anguilla) and PCBs in sediment samples from some waters of Berlin/Germany.

The purpose of this study was to identify firstly the extent of contamination both of the aquatic biota and of sediments and secondly any regional differences in the concentrations of these compounds. In 1996, polychlorinated biphenyls (PCBs, including their coplanar congeners) were measured in 58 eel and 50 sediment samples. Furthermore, the veterinary pharmacetical bromocyclene and the nitro musks were determined in 84 (1995) and 122 (1996) eel samples. Polycyclic musk fragrances were additionally determined in analyses carried out in 1996. The mean values obtained during the two measurement periods (1995 and 1996) were 24 and 12 micrograms/kg fw. for musk xylene, 41 and 39 micrograms/kg fw. for musk ketone, 14 and 7 micrograms/kg fw. for bromocyclene and, in 1996, 592 micrograms/kg fw. for HHCB (maximum: 4131 micrograms/kg fw.). Decreasing contamination levels are seen for musk xylene and bromocylene but not for musk ketone. This tendency, and the high amounts of polycyclic musk fragrances in the edible parts of eel show that these musks are widely being used in place of nitro musks and that they reach the aquatic system via waste waters, especially those of sewage treatment plants. The mean levels of PCBs in the biota samples of a highly polluted area were 1227 micrograms/kg fw. or 119 pgTEQ/g (sediment: 203 micrograms/kg dw.) and of a slightly polluted area 340 micrograms/kg fw. or 49 TEQ/g (sediment: 47 micrograms/kg dw.).

The free radical in pyruvate formate-lyase is located on glycine-734.

Pyruvate formate-lyase (acetyl-CoA:formate C-acetyltransferase, EC 2.3.1.54) from anaerobic Escherichia coli cells converts pyruvate to acetyl-CoA and formate by a unique homolytic mechanism that involves a free radical harbored in the protein structure. By EPR spectroscopy of selectively 13C-labeled enzyme, the radical (g = 2.0037) has been assigned to carbon-2 of a glycine residue. Estimated hyperfine coupling constants to the central 13C nucleus (A parallel = 4.9 mT and A perpendicular = 0.1 mT) and to 13C nuclei in alpha and beta positions agree with literature data for glycine radical models. N-coupling was verified through uniform 15N-labeling. The large 1H hyperfine splitting (1.5 mT) dominating the EPR spectrum was assigned to the alpha proton, which in the enzyme radical is readily solvent-exchangeable. Oxygen destruction of the radical produced two unique fragments (82 and 3 kDa) of the constituent polypeptide chain. The N-terminal block on the small fragment was identified by mass spectrometry as an oxalyl residue that derives from Gly-734, thus assigning the primary structural glycyl radical position. The carbon-centered radical is probably resonance-stabilized through the adjacent carboxamide groups in the polypeptide main chain and could be comparable energetically with other known protein radicals carrying the unpaired electron in tyrosine or tryptophan residues.

The free radical of pyruvate formate-lyase. Characterization by EPR spectroscopy and involvement in catalysis as studied with the substrate-analogue hypophosphite.

The first-derivative EPR spectrum of the active form of Escherichia coli pyruvate formate-lyase shows an asymmetric doublet with partially resolved hyperfine splittings (g = 2.0037). Isotope substitution studies demonstrated couplings of a carbon-centered unpaired electron to a solvent-exchangeable proton (a = 1.5 mT) and to further hydrogen nuclei (a = 0.36 and 0.57 mT). By selective incorporation of unlabelled tyrosine into 2H-labelled enzyme protein, a tyrosyl radical structure has been ruled out. Circumstantial evidence indicates that the organic free radical, which also displays an ultraviolet absorption signal at 365 nm, is located on a standard amino acid residue of the polypeptide chain. EPR signal quantification found a stoichiometry of 1 spin per active site. The formate analogue hypophosphite has been characterized as a specific kcat inhibitor of pyruvate formate-lyase which destroys the enzyme radical. Protein-linked 1-hydroxyethylphosphonate was previously described as the dead-end product after reaction of the analogue with the intermediary acetyl-enzyme form of the catalytic cycle [W. Plaga et al. (1988) Eur. J. Biochem. 178, 445-450]. EPR spectroscopy of this system has now identified the corresponding alpha-phosphoryl radical as a reaction intermediate [g = 2.0032; a(P) = 2.72 mT, a(3H) = 1.96 mT]; it showed a half-life of about 20 min at 0 degrees C. This finding proves that the enzyme radical is a hydrogen-atom-transferring coenzymic element.

Post-translational activation introduces a free radical into pyruvate formate-lyase.

Pyruvate formate-lyase (formate acetyltransferase; EC 2.3.1.54) of Escherichia coli cells is post-translationally interconverted between inactive and active forms. Conversion of the inactive to the active form is catalyzed by an Fe2+-dependent activating enzyme and requires adenosylmethionine and dihydroflavodoxin. This process is shown here to introduce a paramagnetic moiety into the structure of pyruvate formate-lyase. It displays an EPR signal at g = 2 with a doublet splitting of 1.5 mT and could comprise an organic free radical located on an amino acid residue of the polypeptide chain. Hypophosphite was discovered as a specific reagent that destroys both the enzyme radical and the enzyme activity; it becomes covalently bound to the protein. The enzymatic generation of the radical, which is linked to adenosylmethionine cleavage into 5'-deoxyadenosine and methionine, possibly occurs through an Fe-adenosyl complex. These results suggest a radical mechanism for the catalytic cycle of pyruvate formate-lyase.

Structure and dynamics of phospholipid membranes: an electron spin resonance study employing biradical probes.

The large zero-field splitting of rigid biradicals makes them important candidates for spin probes of phospholipid membranes. Here we develop an electron spin resonance line-shape model for such probes on the basis of the stochastic Liouville equation. Particular emphasis is given to the slow-diffusional regime, characteristic of bilayers in the gel phase. The theory is employed to study the line shapes of bis(verdazyl) biradicals, incorporated into oriented multibilayers of dimyristoylphosphatidylcholine. Computer simulations of the angular-dependent spectra provide the orientational distribution functions and rotational correlation times of the spin probes. They occupy two different sites in bilayer membrane. The orientational distribution of the spin probes is related to the structure of the phospholipid phases. In the L beta' phase the hydrocarbon chains are uniformly tilted by delta = 23 degrees with respect to the bilayer normal. For the P beta' phase we observe a random distribution of tilt angles from delta = 0 degree to delta = 19 degrees, indicating that the chains orient perpendicular to the local (rippled) bilayer surfaces. This structure has not been established previously. In agreement with other studies we find no tilt for the L alpha phase. The order parameters of the hydrocarbon chains increase with decreasing temperature, jumping from S less than or equal to 0.6 to S greater than or equal to 0.8 at the main transition. From the rotational correlation times of the spin probes, intrinsic bilayer viscosities of 0.08 P less than or equal to eta less than or equal to 20 P (50 degrees C greater than or equal to T greater than or equal to 1 degree C) are determined. An Arrhenius plot provides activation energies of the viscous flow. The values increase from Evisc approximately 10 kcal/mol in the L alpha phase to Evisc approximately 18 kcal/mol in the L beta' phase.