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Background: In the past decade or so, a range of technologies have emerged that have shown promise in increasing our understanding of disease processes and progression. These advances are referred to as the "omics" technologies; genomics, transcriptomics, and proteomics. More recently, another "omics" approach has come to the fore: metabonomics, and this technology has the potential for significant clinical impact. Metabonomics refers to the analysis of the metabolome, that is, the metabolic profile of a system. The advantage of studying the metabolome is that the end points of biological events are elucidated., Results: Although still in its infancy, the metabonomics approach has shown immense promise in areas as diverse as toxicology studies to the discovery of biomarkers of disease. It has also been applied to studies of both renal and hepatic transplants. Metabolome analysis may be conducted on a variety of biological fluids and tissue types and may utilize a number of different technology platforms, mass spectrometry (MS) and nuclear magnetic resonance (NMR) spectroscopy being the most popular. In this review, we cover the background to the evolution of metabonomics and its applications with particular emphasis on clinical applications., Conclusions: We conclude with the suggestion that metabonomics offers a platform for further biomarker development, drug development, and in the field of medicine., (Copyright 2010 Elsevier Inc. All rights reserved.)

As a result of the demographic development of industrial nations the number of musculoskeletal diseases and injuries rises continuously. This challenges health care as well as clinical research and demands additional endeavours. The United Nations have recognised this issue at an early stage. With their in 2000 declared Bone and Joint Decade they have significantly contributed to a sustainable support of research activities. The German government has also perceived the need and, with their roadmap programme, encourages research of musculoskeletal disease.Today, surgical and orthopaedic clinics increasingly support the exchange between research and clinic and run their own research departments. The Berlin Center for Musculoskeletal Surgery (CMSC) and its research institute Julius Wolff Institut show the potential for surgical research. It shows that based on a clinical understanding of the problem, basic research needs to be complemented in a network with partners from other disciplines. However, interdisciplinary cooperation demands new and individual ways of communication and education. The example in Berlin also illustrates that the research on prevention not only completes the network but more over opens unexpected possibilities in understanding basic research and translation.

The structural organization of research facilities within a surgical university center should aim at strengthening the department's research output and likewise provide opportunities for the scientific education of academic surgeons. We suggest a model in which several independent research groups within a surgical department engage in research projects covering various aspects of surgically relevant basic, translational or clinical research. In order to enhance the translational aspects of surgical research, a permanent link needs to be established between the department's scientific research projects and its chief interests in clinical patient care. Importantly, a focus needs to be placed on obtaining evidence-based data to judge the efficacy of novel diagnostic and treatment concepts. Integration of modern technologies from the fields of physics, computer science and molecular medicine into surgical research necessitates cooperation with external research facilities, which can be strengthened by coordinated support programs offered by research funding institutions.

Pediatric surgery focuses not on an anatomic region or organ system, but on the development of a growing human being according to age. Recently, a tendency to reduce and to downgrade pediatric surgery could be observed which is due to economic reasons and an alarming lack of trained surgeons. Just as 60 years ago, general surgeons continue to operate on infants and children. However, this is a step backwards and an anachronism. Children are not small adults and pediatric surgery can be distinguished from adult surgery in many aspects, such as the spectrum of surgical diseases, the congenital malformations and frequently the indications and techniques of surgery. Pediatric surgeons, however, by themselves should specialize in centers which are focused on rare and complex diseases. Pediatric surgery should not be separated in the hospital, but integrated in a network with general surgery, traumatology, pediatrics, neonatology and specialists of the other surgical disciplines. Strict patient age limitations are not compatible with the individuality of adolescents and should be avoided. A well-equipped clinic for pediatric surgery is expensive, but a mandatory investment in the future!

Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and significant workload in many maxillofacial units. Although management has evolved considerably from "wiring teeth together", complex fractures can still result in cosmetic and functional deformity. Today's challenge is to consistently restore patients back to their pre-injury form and function-but this is not always possible. Greater understanding and developments have significantly improved outcomes, although controversy still exists in some areas. This review outlines some of these topics.

Vascular surgery is a young surgical discipline which has experienced a stormy development driven by internal motivation and external constraints. Changes in the field are primarily a result of diverse external influences which are expected to continue into the future. The most significant intrinsic change has been the development of stent graft technology. External influences include extensive demographic changes, rapid progress in endovascular techniques to treat obstructive vascular disease, improved advanced training, state and non-state controls, certification requests without considering the feasibility of professional and structural implementation and changing public expectations. Progress in vascular medicine is stimulated by advances in imaging techniques and subsequent improved endovascular procedures. Nevertheless, external influences have, at least within the 'surgical' sphere of influence, led to formidable innovative efforts on the part of associations representing vascular surgeons. These innovative efforts are concentrated in the Academy of the German Society of Vascular Surgery and Medicine and will determine trends in coming years. The future will reflect their quality.

On the occasion of the 80th anniversary of the journal "Der Chirurg" (The Surgeon) this article summarizes the development of cardiac surgery. Beginning from the first cardiac suture in 1897 by Ludwig Wilhelm Carl Rehn, through the first catheter investigation of the heart by Werner Forssmann in 1923 to the year 2008 when nearly 100,000 cardiac interventions were carried out in Germany and of these some 90,000 using a heart-lung machine. The article describes the founding of the German Society for Thorax, Heart and Vascular Surgery in the year 1971 and the reintegration in the German Society for Surgery, stemming from efforts for the unification of the structure of further education (common trunk). The motto for this process, which was actively supported by both societies, was "Independence when necessary, cooperation when possible".

The discipline of general and visceral surgery will change over the next 20 years due to technical and digital developments. Of particular significance will be computer-assisted surgery, pre-operative simulation and intra-operative navigation and also the further development of the minimally invasive technique itself, which overcomes the present limitations of complex visceral surgical resection and reconstruction and will replace open surgery in more and more fields. It is extremely probable that over the next 20 years surgeons will be dealing increasingly more with old patients and the spectrum of interventions will also change. Oncologic surgery will change due to the high dynamics in the development of new anti-cancer medications. Other fields, such as obesity surgery, will become more important. An irreversible development is the economization of the discipline and quality assurance. This will accelerate the development of high-volume centers for a large proportion of visceral surgical interventions.

During the last century trauma surgery became established as an independent and academically accepted surgical specialty and significant progress was achieved. A high international reputation was also gained. Nowadays health care in Germany is under increased economical pressure mostly caused by a loss of resources as a sign of decreased public appreciation of excellent trauma care. Thus it becomes more and more necessary to find new structures for delivery of trauma care as well as for development of staff, especially in times of feminization in medicine. It is beyond any doubt that the demand for musculoskeletal surgery will rise during the next 20 years especially for the elder generation but it is uncertain how excellent trauma care should be delivered without massive spending and financing of health care including research and innovative forms of trauma treatment.

The combination of orthopedic and traumatology surgery in one specialization allows the coexistence of specialized surgical subgroups. The long term morbidity forecast predicts an increased demand for orthopedic procedures for the next 20 years. The excellent training level must be maintained for the following generation of orthopedic and trauma surgeons. Besides the physicians, health care providers and hospitals as well as politics should help in mastering this difficult challenge. Orthopedic surgery and traumatology with a multitude of subspecialties remain an attractive specialty with a promising future.

Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its "shy" beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our "small patients". The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.

Background: The quality of surgical training and competence defines the quality of patient care. The developed world evolved its surgical training over a long progressive period, whereas countries in the developing world, of which India is a reasonable example, were jettisoned into the waters, to hurriedly create their own training., Method: Surgical training is but part of the picture of any countries medical education. Keeping statistics to a bare minimum, an attempt is made to trace the evolution, progress and current state of surgical training in India. Shortcomings in the training program in a country with such a tremendously wide economic spectrum, and their possible solutions, are evaluated., Results: In a country as vast, populous and complex as India no one article could even remotely do justice to this subject. What is lost in depth and pragmatism here is hopefully compensated, to some small degree, by the 50 year personal experience (and perhaps philosophy) of one of the authors (T.E.U.)., Conclusions: Surgical Training has to be tailored to the specific needs of each country. Surgery is a humanitarian science. The thrust of surgical training in India should be, and hopefully will be, not just to be on par with the developed world, but more important, to ensure good surgical care to all Indians, in all places.

A highly skilled surgical team relies on a standardized training system and the most important subject in the development of general surgery in China is to set up standardized education and training systems for surgeons. This article reviews the history of the training of residents, delineates the current situation and problems of residency training in general surgery, and discusses reform and future development of surgical training systems and assessment of competence in surgical practice, in order to put forward the solutions and countermeasures. China needs a large number of highly trained surgeons to improve its medical care system, and some fundamental changes of its residency training system, especially in the field of surgical education, have been made. All of the experts working in this area sum up the historical experience and apply the advanced experience of foreign countries as a reference to build up a surgical education system with Chinese characteristics to achieve a continuous, sound, and rapid development of surgical education in China.

Each year, approximately 1,000 graduating medical students enter training in general surgery and its related specialties and subspecialties in the United States. Traditionally, residents who want to practice vascular surgery, plastic surgery, thoracic surgery, and other specialties and subspecialties derived from general surgery have been required to complete five years of training in general surgery before embarking on further training. However, three phenomena have recently emerged that are changing the picture of surgical training: (1) proliferation of fellowships in subspecialties of general surgery, (2) increasing desire of subspecialties of general surgery for recognition as specialties in their own right, and (3) pressure to reduce or eliminate the traditional general surgery training required before specialization or subspecialization. In the meantime, and perhaps as a consequence of these changes, traditional general surgery has become less attractive as a specialty and there has been significant concern about the quality of training in general surgery. As a result of fewer trainees electing general surgery as a career, there is now increasing evidence of a shortage of surgeons who are able to handle a reasonably broad caseload of emergency care in general surgery and trauma.Many of these issues are currently being addressed by the profession. Among the initiatives underway are developing a standardized curriculum in general surgery, appropriately apportioning operative experience between residency and fellowship, considering alternative pathways for training in subspecialties, and developing a system for oversight of advanced surgical training fellowships. The system for governance of graduate surgical education in the United States is less centralized than in other countries. One initiative that has been undertaken to improve coordination of efforts between educational and regulatory bodies is the formation of the Surgical Council on Resident Education (SCORE), a voluntary consortium of six organizations with the mission of defining a national curriculum for general surgery residency and with the goal of facilitating collaboration on educational issues involving general surgery and its related specialties and subspecialties.

Surgical training in the Netherlands has traditionally been characterized by learning on the job under the classic master-trainee doctrine. Over the past decades, it has become regionally organized with intensive structural training courses, and a peer-based quality control system. Recently, the nationwide programme has been modernized further and now involves a systematic, competency-based education with structural training courses, formalized assessment and room for reflection by residents under the supervision of surgical teaching groups. To this end, a uniform web-based digital portfolio is being introduced to facilitate monitoring of the individual resident's progress. Though requiring inspirational leadership, commitment, and determination, this modernization has sparked enthusiasm among trainees and teachers.

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days (P < 0.0001), intensive care unit length of stay (P < 0.0001), and hospital length of stay (P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.

Vascular diseases are common and their frequency is rising. Statistics show that 15% of the German population over 65 display some kind of peripheral arterial pathology. Even aneurysmatic degeneration and cardiac and visceral perfusion disorders are being observed more frequently, while peak age is dropping. Therapeutic surgical options are accordingly being continually advanced and refined. Additionally the range of interventional therapies and new conservative options has substantially increased vascular surgeons' armamentarium. Updates in surgical training have responded to this increase in such disorders, and the diversification of therapeutic modalities has resulted in the elevation of vascular surgery from specialized techniques to a fully accredited specialty equal in standing to the other seven surgical disciplines. Controversy exists however about the new accredition, beginning with the question of advancement from basic surgical training while excluding important elements of general surgery. Since those training for this specialty will branch off immediately after 2 years of basic surgical training, their final accreditation in the new classification would exclude essential skills that remain part of the training as general surgeons.

There no longer exist any arguments supporting a continuation of general surgery. Due to protective regulations and today's high degree of specialization, it is no longer possible for a surgeon to keep abreast of all developments in all types of surgery required. Now in surgery as in other medical fields, specialization is the guarantee of continued improvements and optimal results.

The need for a general surgical cover, with a high quality standard, following economic principles and offered 24 hours in all regions of Switzerland is not doubted. The title of a "General and Trauma Surgeon" is an additional qualification certified after further successful 4 years post-qualification training following the 6 years specialist title of surgery ('common trunk'). The main field of work encompasses primary emergency surgery as well as 'surgery of the common pathologies' in visceral, vascular, thoracic and partly hand surgery. Due to political reasons the additional qualification in surgical traumatology was completely and exclusively integrated in this sub-speciality title.The post-graduate training to gain the title of a "General and Trauma Surgeon" is mostly completed within 8-10 years and results in the full surgical competence in the above named fields. A major problem is the lack of academic representation of general surgery in the university hospitals resulting in a neglect and increasing difficulties of academic training in this field. Furthermore, there are some recurrent controversies concerning limitations of general surgery in the face of other subspecialities or specialities (e.g. orthopaedics). However, the most important and urgent problem is the lack of the possibility to gain an acknowledged and separate (from general surgery) certification in surgical traumatology, competitive to the specification in orthopaedics. There is no doubt, that, at least in the mid term, there is still a need for general surgeons. At the present moment, the future and the further development of the traumatologist's training under the roof of surgery, at university and regional level is insufficient and is at risk. Therefore, there is an urgent need to address this matter and the Swiss Society of Surgery is taking care of this with priority.

Neonatal surgery is the most specialized and sophisticated field of pediatric surgery. I herein review esophageal atresia, abdominal wall defects, gastrointestinal perforation, and congenital diaphragmatic hernia (CDH) as representative types of neonatal surgery. The clinical results of esophageal atresia have been considered to reflect the level of medicine of an individual country. Owing to an early diagnosis, improved operative techniques, and better perioperative management, the mortality rate has now become almost 0%. In addition, a minimally invasive thoracotomy is considered to improve long-term quality of life. The overall mortality rate of neonatal surgical disease has markedly decreased and is now less than 10%. However, abdominal wall defects, gastrointestinal perforation, and CDH still show a high mortality rate. A high incidence of chromosomal anomalies results in a poor outcome for abdominal wall defect. A gastrointestinal perforation in an infant complicated with an extremely how birth weight shows a high mortality rate. In CDH, pulmonary hypoplasia as well as pulmonary hypertension often causes an acute respiratory and circulatory deterioration after birth. Neither intensive care for pulmonary hypertension, including ECMO, nor fetal intervention has yet achieved a satisfactory outcome. Permissive hypercapnea and a delayed operation aiming at circulatory stabilization have resulted in a good survival rate. However, CDH survivors may be at risk for long-term morbidities. The method to induce pulmonary development is considered to be mandatory to achieve a good quality of life for severe CDH.

Objective: To determine the relative contribution and importance of five surgical specialties (general surgery, urology, otolaryngology, neurosurgery, and orthopedics) to the total National Institutes of Health (NIH) funding at medical schools., Methods: Publicly available NIH funding data from 1996 to 2004 were analyzed., Results: From 1998 through 2003 the NIH budget increased from 11.2 billion to 21.9 billion dollars. Overall, NIH funding to departments of medicine was the greatest contributor to any individual medical school's total NIH funding, comprising 28.4% of total NIH awards on average, with a correlation coefficient highly predictive of medical school's ranking for NIH awards (cc = 0.93). Total NIH funding by different surgical specialties varied greatly, both within and between institutions. Together all of the surgical subspecialties combined accounted for 4.8% of medical school NIH awards on average from the years 1996 to 2004. Among the surgical specialties, general surgery received the largest fraction of NIH dollars followed by otolaryngology, neurosurgery, urology, and orthopedics. Although general surgery had the highest overall correlation coefficient of the surgical departments during the early years of the study period (r = 0.71 in 1996), its correlation significantly decreased during the period of study (as low as r = 0.54 in 2002)., Conclusions: Surgical departments as an aggregate have continued to receive a stable overall fraction of NIH awards. The total funding to the different surgical departments varies considerably between institutions and does not correlate well with total institutional funding. The downward trend in the correlation of general surgery funding to total institutional funding suggests a decline in support for surgical research in this specialty nationwide.

Background: The proportion of arterial and venous diseases is increasing due to shifts in population. Therapy is based on conventional vascular surgery and conservative endovascular methods., Material and Methods: Based on data from the Federal German Statistics Office and the Federal Chamber of Physicians, information was gathered on primary vascular diseases, active special vascular groups, surgical qualifications, and surgical clinics. Additionally, the status of vascular surgery at university clinics and non-university clinics with more than 900 beds was assessed., Results: In 2004, 413,763 patients with primary vascular disease were treated in 1,846 German general hospitals. More than 70% of these patients were handled in vascular surgical or general surgical clinics, and operations were performed in 50% of cases. There exist independent vascular surgical departments in 213 hospitals. Thirty-three university clinics at 38 locations showed a total of six independent vascular surgery clinics (16%) and seven partially independent sections (18%). Vascular surgery is done within cardiac surgical departments in ten clinics and in general surgery department in 15 clinics. In contrast, there are independent vascular surgical departments in 39% and 53% of non-university clinics with more than 900 and 600-899 beds respectively., Conclusions: Vascular surgery has been established in hospitals as an independent speciality. This development must continue in general surgical and university clinics.

Ten years after telemedicine hit the mainstream, growing pains are evident, robotic surgery and other "wows" relatively rare. But home-based care is set to explode.