[Perceived utility of the inclusion of physician assistants in the surgical process quality and continuing education in Germany : Results of an interprofessional online survey]. / Empfundener Nutzen der Einbindung von Physician Assistants in die chirurgische Prozessqualität und Weiterbildung in Deutschland : Ergebnisse einer interprofessionellen Online-Umfrage.

BACKGROUND: Compared to Anglo-American countries, physician assistants (PA) remain an underrepresented professional group within the German healthcare system. In the surgical disciplines, PAs may relieve the administrative burden of doctors by taking on delegable routine tasks, thus creating time and resources for advanced surgical training. OBJECTIVE: According to interprofessional experts, can the use of PA lead to an optimization of surgical training and a gain in time for surgical qualification in Germany? MATERIAL AND METHODS: After searching for systematic reviews of the current state of knowledge, an online survey was initiated among surgeons and PAs via social networks to determine current and desired clinical areas of activity for PAs in surgery and their future influence on specialist training in Germany. RESULTS: A total of nine systematic reviews were identified, suggesting a beneficial impact of PAs on length of stay, direct costs, and treatment outcomes in surgical scenarios. The online survey included 234 surgeons and 114 PAs. Hospitals with ≥ 90 surgical beds employed PAs far more frequently (65%) than smaller institutions (40%). Although both professional groups are generally highly satisfied with the integration of PAs into clinical workflows, there are gradually different opinions about the preferred spectrum of tasks and duties. DISCUSSION: PAs would like to have greater responsibility in ordering and interpreting diagnostic tests, communicating with patients, and working in the operating theater. Surgeons are concerned that PAs could replace surgical interns and residents. PAs may enrich healthcare in Germany on various levels and can also improve surgical training. The voice and needs of all professional groups must be considered and respected during the upcoming health system reform.

A 55-Year-Old Man with Recurrent Gastrointestinal Bleeding Due to Stricture of the Portal Vein Anastomotic Site 12 Years After Combined Pancreas and Kidney Transplantation.

BACKGROUND Varices of the upper gastrointestinal tract are due to portal hypertension and can result from occlusion of the portal venous system. This report is of a 55-year-old man with recurrent gastrointestinal bleeding due to stricture of the portal vein anastomotic site to inferior vena cava (IVC) 12 years after combined pancreas and kidney transplantation. CASE REPORT A 55-year-old man presented bleeding episodes requiring transfusion of more than 70 units of red blood cells (RBCs), complicated by bacterial and viral infection episodes including cytomegalovirus (CMV) reactivation and hepatitis E and transient impairment of function of the renal allograft. Endoscopy, computed tomography (CT) scan, and angiography revealed jejunal varices due to anastomotic stricture at the portal vein to IVC as the cause of the hemorrhage. Neither conservative therapy nor an anastomosis between the splenic vein of the graft and the internal iliac vein as a bypass could stop the life-threatening bleeding. During the recurrent bleeding, CD4 T lymphocytes were low, indicating immunodeficiency despite paused immunosuppressive therapy. After the hemorrhage resolved and immunosuppression was restarted, CD4 T lymphocyte levels normalized. Finally, to stop the hemorrhage and save the transplanted kidney and the patient's life, graft pancreatectomy was performed. Long-term damage to the renal transplant was not found. CONCLUSIONS This report is of a rare case of portal hypertension as a long-term complication of transplant surgery. Although acute venous thrombosis at the anastomotic site is a recognized postoperative complication of pancreatic transplant surgery, this case highlights the importance of post-transplant follow-up and diagnostic imaging.

[Current hygiene regulations in the operating theatre with special focus on constructional and functional measures]. / Aktuelle Hygienevorschriften in der Operationsabteilung unter besonderer Berücksichtigung baulich-funktionaler Maßnahmen.

The article provides an overview of the most important innovations in hygiene recommendations that were published in 2018 by the Committee for Hospital Hygiene and Infection Prevention (KRINKO) on the prevention of postoperative wound infections. This summarizes several older recommendations and supplements, updates and extends them. The article focusses on technical and constructional hygiene regulations for operating theaters and includes the position of the German Statutory Accident Insurance (DGUV).

[Survey on training in orthopedics/trauma surgery : Is Germany ready for a competence-based training?] / Umfrage zur Weiterbildung Orthopädie/Unfallchirurgie : Ist Deutschland bereit für eine kompetenzbasierte Weiterbildung?

BACKGROUND AND OBJECTIVE: A high-quality advanced training is a key factor for good and safe patient treatment. Germany is currently revising the advanced training curricula and logbooks aiming to change the training into a competence-based training. The aim of this study was to analyze the day to day reality of orthopedic and trauma surgery advanced training in Germany based on the elements of the advanced training. METHODS: In March 2020 an online survey on advanced training was carried out with 44 questions on the topics of advanced training curriculum, logbook, educational resources, evaluation, authorized trainer and distribution of working time . RESULTS: A total of 237 persons completed the survey, of which 208 fulfilled the inclusion criteria. The respondents perceived a lack of clear standards in the advanced training curriculum and 25% did not receive structured learning resources in the form of simulations or courses. Mandatory annual process interviews were performed in only 58%. Most respondents valued the expertise of the trainers in orthopedic and trauma surgery, whereas they rated their competence in supervision and giving feedback as below average. Administrative work consumed 220 min of the daily working time and on average 60min remained per day for respondents to learn operative skills. CONCLUSION: The survey revealed inconsistencies in the current advanced training curriculum and a lack of supervision and evaluation. The implementation of competence-based advanced training should therefore not only focus on a change of the curriculum but also on implementing competence-based training at all levels of training (learning resources, training, evaluation).

What it takes to become an orthopaedic surgeon: A comparison of orthopaedic surgical training programmes in 10 countries focusing on structure and fellowship requirements.

BACKGROUND: The quality of surgical training has been highlighted as one of the most important patient safety issues in the future. Training surgeons and supporting them to do their best should be considered integral in providing optimum and safe care for the individual patient and the best possible return on investment in training medical professionals. In 2011, an international consensus statement defined fundamental principles for surgical training. PURPOSE: This study examines orthopaedic surgical training to explore the similarities and differences in the requirements for trainees to obtain board certification in ten countries. METHODS: Countries of the Commonwealth Health Care Comparison: Canada, the United Kingdom, the United States of America, Australia, New Zealand, Germany, France, the Netherlands, Norway and Switzerland were chosen to be compared. The relevant information was extracted from official information from authorities and administrative bodies. RESULTS: The study revealed significant differences in duration, organisation and assessment of training. So-called "competency-based" training is not featured in every country, and the manner of its implementation is variable. In particular, the numbers in surgical cases required to be accredited varies by country ranging from 1260 (UK) to 340 (Norway). CONCLUSION: Despite the recommendation in 2011 for some degree of uniformity across surgical training in industrialised countries, evidence suggests wide variation in the training programmes which is likely to be a concern in both quality of training as well as present and future patient safety.

ESX-5-targeted export of ESAT-6 in BCG combines enhanced immunogenicity & efficacy against murine tuberculosis with low virulence and reduced persistence.

Tuberculosis (TB) is the leading infectious cause of death globally. The only licensed TB vaccine, Bacille Calmette-Guérin (BCG), has low efficacy against TB in adults and is not recommended in people with impaired immunity. The incorporation of the Mycobacterium tuberculosis (Mtb) secretion system ESX-1 into BCG improves immunogenicity and protection against TB in animal models, which is associated with the secretion of the ESX-1-dependent protein ESAT-6. However, the resulting strain, BCG::ESX1Mtb, has been deemed unsafe as a human vaccine, due to prolonged persistence and increased virulence in immunocompromised mice. In this study, we describe a new recombinant BCG strain that uncouples the beneficial aspects of ESAT-6 secretion from the detrimental ESX-1effects on virulence and persistence. The strain was constructed by fusing the ESAT-6-encoding gene esxA to the general secretion signal for the mycobacterial type VII secretion pathway protein PE25. This new strain, BCG::ESAT6-PE25SS, secretes full-length ESAT-6 via the ESX-5 secretion system, which in contrast to ESX-1 is also present in BCG. In vivo testing revealed that ESX-5-targeted ESAT-6 export, induces cytosolic contact, generates ESAT-6-specific T cells and enhances the protective efficacy against TB disease, but is associated with low virulence and reduced persistence in immunocompetent and immunocompromised mice. Additionally, compared to BCG::ESX1Mtb and parental BCG, mucosal administration of BCG::ESAT6-PE25SS is associated with more rapid clearance from the lung. These results warrant further studies to evaluate BCG::ESAT6-PE25SS as a potential live attenuated vaccine candidate for TB.

[The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]. / Der querschnittgelähmte Patient ­ Besonderheiten der viszeralchirurgischen Diagnostik und Therapie.

BACKGROUND: Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important. OBJECTIVE: This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment. MATERIAL AND METHODS: Targeted literature search in Medline and Cochrane library (German and English, 1985-2020). RESULTS AND CONCLUSION: The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.

Serum levels of hsa-miR-16-5p, hsa-miR-29a-3p, hsa-miR-150-5p, hsa-miR-155-5p and hsa-miR-223-3p and subsequent risk of chronic lymphocytic leukemia in the EPIC study.

Chronic lymphocytic leukemia (CLL) is an incurable disease accounting for almost one-third of leukemias in the Western world. Aberrant expression of microRNAs (miRNAs) is a well-established characteristic of CLL, and the robust nature of miRNAs makes them eminently suitable liquid biopsy biomarkers. Using a nested case-control study within the European Prospective Investigation into Cancer and Nutrition (EPIC), the predictive values of five promising human miRNAs (hsa-miR-16-5p, hsa-miR-29a-3p, hsa-miR-150-5p, hsa-miR-155-5p and hsa-miR-223-3p), identified in a pilot study, were examined in serum of 224 CLL cases (diagnosed 3 months to 18 years after enrollment) and 224 matched controls using Taqman based assays. Conditional logistic regressions were applied to adjust for potential confounders. The median time from blood collection to CLL diagnosis was 10 years (p25-p75: 7-13 years). Overall, the upregulation of hsa-miR-150-5p, hsa-miR-155-5p and hsa-miR-29a-3p was associated with subsequent risk of CLL [OR1∆Ct-unit increase (95%CI) = 1.42 (1.18-1.72), 1.64 (1.31-2.04) and 1.75 (1.31-2.34) for hsa-miR-150-5p, hsa-miR-155-5p and hsa-miR-29a-3p, respectively] and the strongest associations were observed within 10 years of diagnosis. However, the predictive performance of these miRNAs was modest (area under the curve <0.62). hsa-miR-16-5p and hsa-miR-223-3p levels were unrelated to CLL risk. The findings of this first prospective study suggest that hsa-miR-29a, hsa-miR-150-5p and hsa-miR-155-5p were upregulated in early stages of CLL but were modest predictive biomarkers of CLL risk.

Drug induced micellization into ultra-high capacity and stable curcumin nanoformulations: Physico-chemical characterization and evaluation in 2D and 3D in vitro models.

Curcumin (CUR) is a natural extract from the plant Curcuma longa and part of turmeric, a spice and herbal remedy in traditional medicine. Thousands of papers claim a plethora of health benefits by CUR, but a growing number of reports and contributions caution that many experimental data may be artifacts or outright deny any suitability of CUR due to its problematic physicochemical properties. Two major issues often encountered with CUR are its extraordinarily low solubility in water and its limited chemical stability. Here, we report on a novel nanoformulation of CUR that enables CUR concentrations in water of at least 50 g/L with relative drug loadings of >50 wt% and high dose efficacy testing in 3D tumor models. Despite this high loading and concentration, the CUR nanoformulation comprises polymer-drug aggregates with a size <50 nm. Most interestingly, this is achieved using an amphiphilic block copolymer, that by itself does not form micelles due to its limited hydrophilic/lipophilic contrast. The ultra-high loaded nanoformulations exhibit a very good stability, reproducibility and redispersibility. In order to test effects of CUR in conditions closer to an in vivo situation, we utilized a 3D tumor test system based on a biological decellularized tissue matrix that better correlates to clinical results concerning drug testing. We found that in comparison to 2D culture, the invasively growing breast cancer cell line MDA-MB-231 requires high concentrations of CUR for tumor cell eradication in 3D. In addition, we supplemented a 3D colorectal cancer model of the malignant cell line SW480 with fibroblasts and observed also in this invasive tumor model with stroma components a decreased tumor cell growth after CUR application accompanied by a loss of cell-cell contacts within tumor cell clusters. In a flow bioreactor simulating cancer cell dissemination, nanoformulated CUR prevented SW480 cells from adhering to a collagen scaffold, suggesting an anti-metastatic potential of CUR. This offers a rationale that the presented ultra-high CUR-loaded nanoformulation may be considered a tool to harness the full therapeutic potential of CUR.

Effectiveness of architectural separation of septic and aseptic operating theatres for improving process quality and patient outcomes: a systematic review.

BACKGROUND: Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted. METHODS: Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature. RESULTS: A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality. CONCLUSIONS: This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (International prospective register of systematic reviews): CRD42018086568.

LETM1-Mediated K+ and Na+ Homeostasis Regulates Mitochondrial Ca2+ Efflux.

Ca2+ transport across the inner membrane of mitochondria (IMM) is of major importance for their functions in bioenergetics, cell death and signaling. It is therefore tightly regulated. It has been recently proposed that LETM1­an IMM protein with a crucial role in mitochondrial K+/H+ exchange and volume homeostasis­also acts as a Ca2+/H+ exchanger. Here we show for the first time that lowering LETM1 gene expression by shRNA hampers mitochondrial K+/H+ and Na+/H+ exchange. Decreased exchange activity resulted in matrix K+ accumulation in these mitochondria. Furthermore, LETM1 depletion selectively decreased Na+/Ca2+ exchange mediated by NCLX, as observed in the presence of ruthenium red, a blocker of the Mitochondrial Ca2+ Uniporter (MCU). These data confirm a key role of LETM1 in monovalent cation homeostasis, and suggest that the effects of its modulation on mitochondrial transmembrane Ca2+ fluxes may reflect those on Na+/H+ exchange activity.

Penetrating chest trauma caused by a blank cartridge actuated rubber ball projectile: case presentation and ballistic investigation of an uncommon weapon type.

Recently, an increasing number of an uncommon weapon type based on a caliber 6-mm Flobert blank cartridge actuated revolver which discharges 10-mm-diameter rubber ball projectiles has been confiscated by police authorities following criminal offenses. A recent trauma case presenting with a penetrating chest injury occasioned an investigation into the basic ballistic parameters of this type of weapon. Kinetic energy E of the test projectiles was calculated between 5.8 and 12.5 J. Energy density ED of the test projectiles was close to or higher than the threshold energy density of human skin. It can be concluded that penetrating skin injuries due to free-flying rubber ball projectiles discharged at close range cannot be ruled out. However, in case of a contact shot, the main injury potential of this weapon type must be attributed to the high energy density of the muzzle gas jet which may, similar to well-known gas or alarm weapons, cause life-threatening or even lethal injuries.

Development of a Potent Wound Healing Agent Based on the Liver Fluke Granulin Structural Fold.

Granulins are a family of protein growth factors that are involved in cell proliferation. An orthologue of granulin from the human parasitic liver fluke Opisthorchis viverrini, known as Ov-GRN-1, induces angiogenesis and accelerates wound repair. Recombinant Ov-GRN-1 production is complex and poses an obstacle for clinical development. To identify the bioactive region(s) of Ov-GRN-1, four truncated N-terminal analogues were synthesized and characterized structurally using NMR spectroscopy. Peptides that contained only two native disulfide bonds lack the characteristic granulin ß-hairpin structure. Remarkably, the introduction of a non-native disulfide bond was critical for formation of ß-hairpin structure. Despite this structural difference, both two and three disulfide-bonded peptides drove proliferation of a human cholangiocyte cell line and demonstrated potent wound healing in mice. Peptides derived from Ov-GRN-1 are leads for novel wound healing therapeutics, as they are likely less immunogenic than the full-length protein and more convenient to produce.

[The Vulnerable Heel of Achilles: Intratendinous Abscess Following a Cat Bite]. / Die vulnerable Ferse des Achilles ­ intratendinöser Abszess nach Katzenbiss.

An 83-year-old patient suffered a cat bite dorsally to the Achilles tendon. In the further course, he developed an isolated intratendinous abscess of the Achilles tendon, which was surgically revised twice and subsequently healed with antibiotic treatment. In Germany, about 40,000 bite injuries of different origins occur annually. Most of these injuries are cat or dog bites, while human bites are rare. Although the course is often complicated, there are no standard recommendations for treatment. An intratendinous abscess after animal bite injury has not been described in the literature as yet.

Ballistic parameters and trauma potential of pistol crossbows.

Hand-held pistol crossbows, which are smaller versions of conventional crossbows, have recently increased in popularity. Similar to conventional crossbows, life threatening injuries due to bolts discharged from pistol crossbows are reported in forensic and traumatological literature. While the ballistic background of conventional crossbows is comprehensively investigated, there are no investigations on the characteristic ballistic parameters (draw force, potential energy, recurve factor, kinetic energy, and efficiency) of pistol crossbows. Two hand-held pistol crossbows (Barnett Commando and Mini Cross Bow, rated draw force 362.9 N or 80 lbs) were tested. The maximum draw force was investigated using a dynamic tensile testing machine (TIRAtest 2705, TIRA GmbH). The potential energy was determined graphically by polynomial regression as area under the force-draw curve. External ballistic parameters of the bolts discharged from pistol crossbows were measured using a redundant ballistic speed measurement system (Dual-BMC 21a and Dual-LS 1000, Werner Mehl Kurzzeitmesstechnik). The average maximum draw force was 190.3 and 175.6 N for the Barnett and Mini Cross Bow, respectively. The corresponding total energy expended was 10.7 and 11 J, respectively. The recurve factor was calculated to be 0.705 and 1.044, respectively. Average bolt velocity was measured 43 up to 52 m/s. The efficiency was calculated up to 0.94. To conclude, this work provides the pending ballistic data on this special subgroup of crossbows which operate on a remarkable low kinetic energy level. Furthermore, it demonstrates that the nominal draw force pretended in the sales brochure is grossly exaggerated.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma.

BACKGROUND: Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. METHODS: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. RESULTS: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%). INTERPRETATION: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Functional separation of septic and aseptic surgical procedures.

Current evidence does not favour constructional over functional separation of septic and aseptic surgical procedures in terms of overall hygiene maintenance and incidence of skin and soft tissue infections. In both laminar and turbulent flow air operating theatres, air is not a relevant source of pathogens if surface disinfection is carried out properly.Final cleaning after a septic procedure includes a thorough wipe-disinfection of all potentially contaminated near and distant surfaces, including maintaining the necessary and effective exposure time of the chosen surface disinfectant. Cleaning utensils and clothes of all team members must be disposed of before leaving the theatre, and a complete change of gowns is mandatory before re-entering the operating room area. Strict adherence to this code of behaviour will allow for efficient functional separation of clean and contaminated surgical procedures without compromising patient safety.