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The intraperitoneal instillation of perfluorocarbons augmented systemic oxygenation and was protective in mesenteric ischemia-reperfusion and experimental lung injury. To study biocompatibility and potential anti-inflammatory effects of intraperitoneal perfluorocarbons, we evaluated the influence of perfluorohexane and/or inflammatory stimuli on human mesothelial cells in vitro. Perfluorohexane exposure neither impaired cell viability nor induced cellular activation. TNFα enhanced ICAM-1 expression, which was not attenuated by simultaneous perfluorohexane treatment. Concentration of intracellular surfactant protein A tended to be higher in perfluorohexane treated cells compared to controls. Our in vitro data add further evidence that intraperitoneal perfluorocarbon application is feasible without adverse local effects.

In the weaning of patients from mechanical ventilation by gradually reducing pressure support ventilation (PSV), an automated computerized system recently proved to be superior to traditional physician-directed weaning. The aim of this study was to replicate these findings when weaning a broad surgical intensive care unit (ICU) patient population off the ventilator. Sixty patients requiring mechanical ventilation over 24 h were randomized to either automated (n = 30) or physician-directed (n = 30) weaning. The primary endpoint was duration of weaning. Secondary endpoints were duration of mechanical ventilation, length of ICU stay, reintubation rates, and workload for staff. Weaning duration did not differ significantly between the computer-driven group and the physician-directed group (0.64 vs. 2.33 d, 95%CI: -0.10 to 2.15, p = 0.167). No significant differences were detected for any secondary endpoint except the workload for PSV settings, which was lower in the computer-driven weaning group (0.0 vs. 0.15 settings/h, p

With regard to germ mutation in osteomyelitis, spondylitis, and arthritis it has been established that the frequency of Mycobacterium tuberculosis and the gram-positive pathogens (S. albus, Streptococci) has decreased in the last 20 years. To varying degrees, S. aureus and the gram-negative, aerobic organisms are the most important pathogens of bone and joint infections. Overall, there has been an increase in the frequency of infections with gram-negative, aerobic organisms. In the majority of cases the bone and joint inflammations were caused by exogenous factors, their course was chonic, and the typical localization was the lower extremity. There was a positive trend toward shorter periods of hospitalization and a shorter duration of illness.

The article reports on the performance of the proximal femoral epiphysis after isolated screw fixation, Imhauser-Weber's operation and open repositioning with subcapital osteotomy. The indication for the choice of the operation is explained. Results of the three operative treatment methods are discussed in respect of postoperative mobility, osseous fusion period and complications. Detailed attention is paid to the localisation of the first signs of ossification.

Surgical therapy had become necessary in 166 patients who had been referred to hospital with the diagnosis of necrosis of the femoral head or osteoarthrosis of hip. In these patients, the osteoarthroses of hip and necroses of the femoral head were observed separately. The secondary osteoarthroses based on a necrosis of the femoral head were classified among the latter group. We also differentiated between the following age groups: 0-20 years, 20-50 years, 50-70 years and over 70 years; the form of therapy also served as a means of distinction.

Weber's rotational osteotomy is a surgical treatment of recurrent shoulder dislocation. While eliminating recurrence of the complaint, it attempts to regain full range of movement in the joint. Of the 39 operated patients it was possible to follow up 34 cases. The percentage of recurrent dislocation was 5.7%. The range of movement was reduced in some patients; in one by 10 degrees - 20 degrees. Otherwise there were no significant complications or post-operative complaints. The operative technique, the X-ray procedure and the pathogenesis of the original dislocation are described. Typical accompanying injuries require a particular operative method. The most common accompanying damage was normally the typical defect of the humeral head (incidence 91%). The regular overstretching of the subscapular muscle and the defect of the humeral head are considered by the operational technique introduced by Weber.

Objective. Aim of this study to improve the detection rate of parametrial sentinel nodes in patients with early cervical cancer by using a new dosage of blue dye in a randomized trial. Methods. Standard labelling volume of 4 ml Patent Blue ® was compared to 2 ml Patent Blue ® diluted with 8 ml NaCl 0.9% in 60 patients using a randomized protocol. Tc-99 was not applied in any patient. All patients underwent open lymphadenectomy. Results. In each arm 30 patients were enrolled. Overall detection rate of sentinel nodes was 93.3%. Both groups did not differ with regard to patient's age, BMI, tumor stage, number of lymph nodes harvested, number of sentinel nodes detected and detection rate. Significantly more patients with parametrial sentinel nodes were detected in the diluted protocol (37.0% vs. 10.3%) which is due to the lateral part of the cardinal ligament (29.6% vs. 6.9%). Conclusion. In our study overall detection of sentinel nodes using a dye was high. The diluted solution of Patent Blue ® led to a higher detection rate of parametrial sentinel nodes. These findings might help explain the discrepancy between the high reported rate of parametrial lymph nodes in anatomical studies compared with the low rates in clinical sentinel series.

Die Radiofrequenzablation (RFA) stellt eine neue Methode zur lokalen Destruktion von Lebertumoren dar. Indikationsstellung und Durchfuhrung sind gegenwartig nicht ausreichend validiert. Zur Erfassung des aktuellen Standes der RFA in Deutschland wurden 2026 Kliniken mittels standardisiertem Fragebogen befragt. Bei einer Rucklaufquote von 17,5% setzten 58 Abteilungen die RFA zum Befragungszeitpunkt ein und behandelten ca. 1700 Patienten. 25,9% sahen eine Indikation bereits bei potenziell kurativ resezierbaren Tumoren, 22,4% auch bei erwarteter inkompletter Ablation zur Tumormassenreduktion. 75% kombinieren Resektion und RFA zur Erzielung einer „R-0-Situation“. Die maximale Tumorgrose zur vollstandigen Ablation wird mit 3–11 cm angegeben. Als Kontraindikationen wurden am haufigsten Tumorgrose, Tumoranzahl, kritische Tumorlokalisationen und Einschrankungen der Leberfunktion genannt. Die Umfrage dokumentiert eine landesweit erhebliche Diskrepanz bei Indikation, Durchfuhrung und Ergebnissen der RFA in der Behandlung von Lebertumoren. Fehlende Standards und eine Uberschatzung der methodischen Moglichkeiten konnen zu einem unkritischen Einsatz, Abweichung von Standardtherapien oder unbefriedigenden Ergebnissen fuhren.

Generalized estimating equations (GEE) for the analysis of clustered data have gained increasing popularity. Recently, the first monograph on this method has been published. GEE have been repeatedly applied in controlled clinical trials. They have, however, been generally used as secondary or supplementary analysis. Instead, the primary analysis was mostly based on a classical method that usually ignored the clustered – mostly longitudinal – nature of the data. In this paper, we discuss the applicability of GEE as primary analysis in controlled clinical trials. From theoretical results in the literature, we derive recommendations how GEE should be used in therapeutic studies for testing statistical hypotheses. We hope that our paper is the starting point for a thorough discussion on the most appropriate analysis of controlled clinical trials with clustered dependent variables. (© 2004 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim)

Economic aspects have gained increasing importance in recent years. The operating room (OR) is the most cost-intensive sector and determines the turnover process of a surgical patient within the hospital. Thus, optimisation of workflow processes is of particular interest for health care providers. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated analogously to a manufacturing process. All steps involved in producing the end-result can and should be analysed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide to manage this process is important and leads to the introduction of a specialised "OR manager". This position must have the authority to issue directives to all other members of the OR team. An OR management subordinates directly to the administration of the hospital. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. This paper gives a short introduction into the difficulties of organising an OR. Some suggestions are made to overcome common shortcomings in the daily practise. A proposal for an "OR statute" is presented that should be a basis for discussion within the OR team. It must be modified according to individual needs and prerequisites in every hospital. The single best opportunity for dramatic improvement in effective resource use in surgical services lies in the perioperative process. The management strategy must focus on process measurement using information technology and feed-back implementing modern quality management tools.However, no short-term effects can be expected from these changes. Improvements take about a year and continuous feed-back of all measures must accompany the reorganisation process.

PURPOSE: Breast cancer in BRCA1 and BRCA2 gene-mutation carriers may differ from so-called sporadic breast cancer in clinical features and behavior. These potential differences may be of importance for the prevention, screening, and, ultimately, treatment of breast cancer in women with such germline mutations. Thus far, there have been very few studies on the survival of BRCA2-associated breast cancer patients. PATIENTS AND METHODS: We determined the disease-free and overall survival of 28 breast cancer patients from 14 consecutive families with eight different BRCA2 germline mutations. These patients' survival and tumor characteristics were compared with those of a control group of 112 sporadic breast cancer patients matched to them by age and year of diagnosis. RESULTS: The 5-year disease-free survival was 52% for each group (P = .91); the overall survival was 74% for BRCA2 carriers and 75% for sporadic cases (P = .50). At the time of diagnosis, tumors from the BRCA2 carriers were borderline significantly larger in comparison to the tumors in sporadic cases (P = .05), but axillary nodal status was not significantly different in the two groups (node-negativity, 63% v 52.8%, respectively; P = .34). With respect to steroid receptor status, BRCA2-associated tumors were more likely to be steroid receptor-positive, especially regarding progesterone receptor status (100% v 76.7% positive, respectively; P = .06). Stage-adjusted recurrence and death rates were nonsignificantly better for BRCA2 cases (hazard ratios of 0.84 and 0.59 [P = .61 and P = .19], respectively). In contrast, after 5 years, the rate of metachronous contralateral breast cancer in BRCA2 patients was 12% (v 2% in controls; P = .02). CONCLUSION: Patients with hereditary breast cancer due to BRCA2 have a similar prognosis when compared with age-matched sporadic breast cancer patients. Contrary to our previous observation regarding BRCA1-associated breast cancer, BRCA2 tumors tended to be steroid receptor-positive, instead of steroid receptor-negative.

Es wird uber einen Fall berichtet, bei dem es naeh einer manualtherapeutischen Masnahme an der Wirbelsaule ohne vorherige Erstellung einer Rontgenaufnahme aufgrund eines nicht erkannten Riesenzelltumors dureh Einblutung und/oder Verlagerung von Tumorgewebe in den Spinalkanal zu einer irreversiblen Paraplegie gekommen war. In einer gutachterlichen Stellungnahme im Rahmen eines Regresverfahrens muste entschieden werden, das die Unterlassung einer Rontgenuntersuchung eine grobe Fehlerhaftigkeit darstellte. Eine Manualtherapie ist bei Vorliegen von derartigen strukturellen Schaden streng kontraindiziert. Die Frage, ob die Paraplegie bei Kenntnis des Riesenzelltumors hatte vermieden werden konnen, war retrospektiv nicht definitiv zu beantworten. Wahrscheinlich hatte die Kenntnis um die Osteolyse zu einer operativen Therapie, bei der ebenfalls neurologische Komplikationen moglich sind, gefuhrt. A case of complete paraplegia due to a giant cell tumor of the dorsal spine following manual therapy without previous x-ray examination is reported. In a malpractice trial the question whether manual therapy is indicated or not had strictly to be denied. The question whether paraplegia due to a giant cell tumor could have been avoided when the tumor would have been detected radiologically was impossible to answer retrospectively. But, it is likely that with immediate surgical therapy after radiological detection of this lesions complete paraplegia should have been avoidable.

Hereditary breast cancer has been associated with mutations in the BRCA1 and BRCA2 genes and has a natural history different from sporadic breast cancer. We investigated disease-free and overall survival for patients with a proven BRCA1 alteration. We estimated disease-free and overall survival for 49 Dutch patients from 19 consecutive families with a proven specific BRCA1 mutation and one family with strong evidence for linkage to the BRCA1 gene. We compared clinical outcome and data on tumour size, histology, axillary nodal status, contralateral breast cancer, and oestrogen-receptor and progesterone-receptor status with those of 196 patients with sporadic breast cancer, matched for age and year of diagnosis. Disease-free survival for BRCA1 and sporadic patients at 5 years was 49% (95% CI 33-64) and 51% (43-59), respectively (p=0.98). Overall survival at 5 years was 63% (47-76) and 69% (62-76), respectively (p=0.88). Recurrence and death rates did not differ significantly between groups. Hazard ratios for recurrence and death among BRCA1 patients were 1.00 (0.65-1.55) and 1.04 (0.63-1.71) relative to sporadic patients (p=0.88), and these did not differ significantly after adjustment for prognostic factors. Patients with BRCA1-associated breast cancer had twice as many progesterone-receptor-negative tumours (p

A large scale survey of the Galactic center region in the () transition is presented. This survey was obtained with the 1.2 m Southern Millimeter-Wave Telescope (SMWT) at the Cerro Tololo Interamerican Observatory (CTIO) near La Serena, Chile. It covers the region and with a grid spacing of 9, i.e. the sampling is at full FWHP beamwidth. 357 positions were in total observed. After reviewing the instrumentation of the 1.2 m SMWT, the observing techniques, and the methods used in the data reduction, the data of the survey are presented and morphologically described. In addition, data of the HNCO() line are presented, which was also included in the large bandwidth of the spectrometer. measurements performed for comparison purposes are presented and compared with other 12 CO results. The maps of the survey demonstrate that there are great differences between the distribution of the optically thin emission and the usually optically thick emission.

We report on our experiences with internal hemipelvectomy followed by an implantation of a endoprosthetic pelvic replacement (EPR) performed in 15 patients over a period of 15 years. Our primary aim was to determine the indications for this procedure because of its high rate of complications. Due to the malignant character of the disease and the biomechanical stress on the anatomical region, the demands on the surgeon are high. The most important factor is a sufficiently wide resection of the primary tumour because most are chondrosarcomata which do not respond to other therapies. In addition, the malignant character of the tumour has the greatest influence on the long-term results. Internal hemipelvectomy and endoprosthetic pelvic replacement are accompanied by a high rate of operative and postoperative complications. Nevertheless, nearly full anatomical and functional reconstruction can be obtained provided a medium level of function is accepted. Follow-up results of the remaining six still living patients were evaluated by means of three different scoring systems. All patients had only a medium score but emphasised subjective acceptance of the endoprosthetic pelvic replacement even when removal was necessary later on. Because of the lower functional outcome of alternative operative procedures such as pseudarthroses and arthrodeses and problems with the replantation of autoclaved autografts or implantation of an allograft, internal hemipelvectomy combined with endoprosthetic pelvic replacement is the treatment of choice for these specific acetabular lesions, provided a complete resection is feasible. Otherwise, an external hemipelvectomy is necessary because even alternative limb-salvaging procedures must incorporate the same complete resection of the tumour. In cases of metastatic lesions, internal hemipelvectomy and endoprosthetic pelvic replacement are indicated relatively because of the systemic character of the disease. The procedure should be considered only when resection of a solitary metastasis enables a cure and/ or prolongation of ilfe with an improved quality of life.

The present study analyzes the kinetics of the in vivo degradation of hydrophilic Mitrathane in the peritoneal cavity of mice over a period ranging from 1 to 180 days. The mechanical milling of the polyurethane films produced regularly flattened fragments that in vivo spontaneously oriented into piles. The morphological observations and analysis with the aid of an image analysis system demonstrated that after seven days of swelling the polymer fragments undergo a continuous degradation that leads to an irregular thinning and phagocytosis of the smaller fragments by macrophages with very little chronic inflammation response from surrounding tissues.

The peritoneal resident cell population is influenced by various inflammatory and immunogenic stimuli. The influence of intraperitoneal application of polyethyleneterephthalate (PET) (group A) and ultra-high-molecular-weight polyethylene (UHMW-PE) (group B) powders on peritoneal cell count and macrophage activity was investigated. Powders were tested to mimic wear particles from solid implant devices as these particles often cause chronic granulomatous inflammation. The results were compared with the inflammatory response following an abdominal midline incision (group C) and untreated animals (group D). On days 1, 7, 14 and 30 peritoneal cells were quantified and the number of active macrophages was assessed. Groups A and C mice showed a significant loss of macrophages in the peritoneal lavage at day 1 but this returned to normal values (group D) on day 7. In contrast, group B animals remained at low peritoneal cell counts but showed the highest number of active macrophages. Only in this latter group was adhesion formation and granulomatous clustering of polymer powder observed. Applying the parameters macrophage count and the number of active macrophages it can be concluded that PET elicits a weaker inflammatory reaction than UHMW-PE in mice peritoneal cavity. Thus this animal model may be used as a screening test for biomedical materials, especially their wear products.

The present study investigated how a cholinergic agonist modifies interdigestive motility and secretion of the upper gastrointestinal tract and how muscarinic and cholecystokinin receptor blockade interfere with this direct cholinergic stimulation. In eight healthy volunteers, gastrointestinal motor and secretory responses to bethanechol (12.5, 25, and 50 micrograms kg-1 h-1) with and without a background of atropine (5 micrograms kg-1 h-1) or loxiglumide (10 mg kg-1 h-1) were studied. Stepdoses of bethanechol caused a parallel stimulation of antroduodenal motility and gastropancreatic secretion (P < 0.01) without inducing a fed pattern. However, duration of phase I was shortened (P < 0.05). Only high doses of bethanechol enhanced gastrin (P < 0.05), cholecystokinin (P < 0.05), and pancreatic polypeptide (P < 0.01) release. Atropine completely antagonized motor and secretory responses to cholinergic stimulation. Loxiglumide left cholinergically stimulated motility and pancreatic enzyme secretion unaltered. With co-infusion of bethanechol and loxiglumide, PP release dropped by 63% (P < 0.01); gastric acid output, gastrin and CCK release increased by 56%, 16%, and 25%, respectively (P < 0.05). We conclude that stimulation by a cholinergic agonist preserves the interdigestive pattern. Low dose muscarinic receptor blockade abolishes cholinergic stimulation over the full dose range. Inhibition of somatostatin release would explain stimulation of gastrin release and gastric acid secretion with co-infusion of bethanechol and loxiglumide. Endogenous CCK appears to interact with direct cholinergic stimulation at the pancreatic PP cell and the gastric D-cell but not at pancreatic acinar and antroduodenal smooth muscle cells.

Unter den eitrigen Osteomyelitiden bzw. Arthritiden stellt die bakterielle Sakroiliitis eine grose Seltenheit dar. Ihre operative Therapie ist nach erfolgloser konservativer Behandlung, bei Abszesbildung, septischen Zustanden sowie Vorliegen von neurologischen Ausfallen indiziert. Zwischen 1983 und 1990 wurden 9 Patienten nach diesen Kriterien operativ mit Ausraumung des entzundlichen Bereichs, primarer Arthrodese des Sakroiliakalgelenks mittels autologem Knochenspan, adjuvanter Antibiotikatherapie sowie postoperativer Immobilisation behandelt. Eine Nachuntersuchung, durchschnittlich 47 Monate postoperativ, ergab in 6 von 8 Fallen gute funktionelle und rontgenologische Ergebnisse, 2 Patienten klagten uber geringe Restbeschwerden. Bei keinem der Nachuntersuchten kam es zu einem Rezidiv, ein Patient war postoperativ an den Folgen einer langfristigen, bereits praoperativ bestehenden Sepsis verstorben. Nach diesen Ergebnissen sollte die operative Behandlung der bakteriellen Sakroiliitis rechtzeitig erwogen werden, da dann die Operation mit einer geringen Komplikationsrate verbunden ist und nur eines geringen operationstechnischen Aufwands bedarf.

The application of independence estimating equations (IEE) for controlled clinical trials (CCTs) has recently been discussed, and recommendations for its use have been derived for testing hypotheses. The robust estimator of variance has been shown to be liberal for small sample sizes. Therefore a series of modifications has been proposed. In this paper we systematically compare confidence intervals (CIs) proposed in the literature for situations that are common in CCTs.Using Monte-Carlo simulation studies, we compared the coverage probabilities of CIs and non-convergence probabilities for the parameters of the mean structure for small samples using modifications of the variance estimator proposed by Mancl and de Rouen [7], Morel et al. [8] and Pan [3].None of the proposed modifications behave well in each investigated situation. For parallel group designs with repeated measurements and binary response the method proposed by Pan maintains the nominal level. We observed non-convergence of the IEE algorithm in up to 10% of the replicates depending on response probabilities in the treatment groups. For comparing slopes with continuous responses, the approach of Morel et al. can be recommended.Results of non-convergence probabilities show that IEE should not be used in parallel group designs with binary endpoints and response probabilities close to 0 or 1. Modifications of the robust variance estimator should be used for sample sizes up to 100 clusters for CI estimation.

Clinical trials with correlated response data based on generalized estimating equations (GEE) have become increasingly popular as they require smaller samples than classical methods that ignore the clustered nature of the data. We have recently derived the recommendation to use the independence estimating equations (IEE) as primary analysis in most controlled clinical trials instead of GEE with estimated correlations. Although several approaches for sample size and power calculation have been proposed, we have shown that most of these procedures are very specific and not as general as required for designing clinical trials.We extended the previously developed SAS macro GEESIZE to overcome this restriction. Specifically, we have added the option of an independence working correlation matrix required for the IEE. Additionally, we have reformulated the hypotheses to allow for coding that includes an intercept term instead of the previously used analysis of variance coding.To demonstrate the validity of GEESIZE we investigate the calculated sample sizes for specific models where closed formulae are available. For illustration, we utilize GEESIZE for planning a new trial on the treatment of hypertension and thereby exemplify its flexibility.We show that our freely available macro is a very general and useful tool for sample size calculation purposes in clinical trials with correlated data.

Repair of diseased bicuspid aortic valves has gained increasing interest as an alternative to conventional valve replacement. Hemodynamic data at exercise have not been reported before. The aim of this study was to investigate the clinical and echocardiographic status of patients after bicuspid aortic valve repair at rest and exercise. Between 03/94 and 09/02 a reconstruction of an incompetent bicuspid aortic valve was performed in 25 patients (mean age 35+/-12.1 years, group A, mean insufficiency 2.8 preoperatively). Patients were investigated clinically and echocardiographically after 2.1+/-2.4 (0.1-8.9) years at rest and exercise and compared to 20 controls (group B). Clinical followup was complete. There were no deaths, reoperations, thromboembolic or bleeding complications. At last examination 21 patients were in NYHA class I, n=4 in NYHA class II and mean aortic valve insufficiency (AI) was 1.0 with one patient having an AI>II degrees. Maximum and mean pressure gradient (dPmax/mean) across the aortic valve at rest were 14+/-5.5/7+/-2.6 mmHg for patients of group A and 7+/-2.5/3.6+/-1.1 mmHg in group B. Mean AVA at rest was 2.6+/-0.8 (group A) vs 2.9+/-0.6 cm(2) (group B, p=0.025), valvular resistance 13.4+/-4.8 (group A) vs 13.6+/-2.9 dyn x s x cm(-5) (group B, p>0.05). All individuals were stressed up to 100 W (dPmax/mean 21+/-6.8/11+/-3.6, group A vs 11+/-2.9/6+/-1.3 mmHg, group B). 56% of group A and 85% of group B could be stressed up to 175 W with dPmax/mean 24.5+/-8.3/12+/-4.2 and 16+/-3.6/8+/-1.4 mmHg, respectively (p

Radio frequency ablation (RFA) represents a new technique for local destruction of liver tumors. Indication and procedure are poorly validated at present.To record the actual nationwide RFA application in Germany, a survey of 2026 hospitals with standardized questionnaires was conducted.With a respond rate of 17.5%, results from 58 hospitals covering 1700 ablated patients were analyzed. In 25.9% of them, RFA is already used in potentially curative resectable tumors, in 22.4% even when incomplete ablation for tumor mass reduction is expected. Of the 58 hospitals, 75% combine resection and RFA to reach a so-called R-0 situation. The maximal tumor sizes they quoted for achieving complete ablation ranged from3 cm to 11 cm. In contraindications for RFA, the tumor size, number of tumors, critical localization of the tumor, and disorders of liver function were mentioned the most.This survey documents significant discrepancies in indication, application, procedure, and results in RFA for liver tumors. The lack of general standards and an overestimation of the method may lead to uncritical application, neglect of standard therapy, or unsatisfying results.

Economic aspects have gained increasing importance in recent years. The operating room (OR) is the most cost-intensive sector and determines the turnover process of a surgical patient within the hospital. Thus, optimisation of workflow processes is of particular interest for health care providers. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated analogously to a manufacturing process. All steps involved in producing the end-result can and should be analysed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide to manage this process is important and leads to the introduction of a specialised "OR manager". This position must have the authority to issue directives to all other members of the OR team. An OR management subordinates directly to the administration of the hospital. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. This paper gives a short introduction into the difficulties of organising an OR. Some suggestions are made to overcome common shortcomings in the daily practise. A proposal for an "OR statute" is presented that should be a basis for discussion within the OR team. It must be modified according to individual needs and prerequisites in every hospital. The single best opportunity for dramatic improvement in effective resource use in surgical services lies in the perioperative process. The management strategy must focus on process measurement using information technology and feed-back implementing modern quality management tools.However, no short-term effects can be expected from these changes. Improvements take about a year and continuous feed-back of all measures must accompany the reorganisation process.

Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. On the other hand, more and more patients and health care providers are asking if they are really receiving an adequate value for their money in the treatment they receive. All this will have a strong impact on the anaesthesiologist's work and her/his perception of the different facets of quality. Quality has various aspects for the anaesthesiologist. The patient as a customer should not incur any detrimental effects after a surgical procedure, and is accompanied by the anaesthesiologist throughout the perioperative setting. The surgeon needs optimal conditions to perform a procedure. The hospital must balance equally costs and income; this requires optimal operating room utilization. Finally, health insurance companies and the government are responsible for covering the cost of treatment according to the quality of the care delivered. Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's 'plan-do-check-act cycle' has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.

Exposure to low-energy ultrasound shock waves (1000 impulses at a frequency of 2/sec and an energy density of 0.08 mj/mm2; peak positive/negative pressure 16/-7 MPa; pulse duration about 10 musec) led to the following alterations in the cells and tissues of stage 35 embryos of Oryzias latipes ranked according to their extent: (1) In various tissues, especially in the trunk musculature, orthodox mitochondria were transformed into condensed (= low energy) mitochondria. (2) Nuclear envelopes and sarcoplasmatic reticulum of muscle fibres as well as endoplasmatic reticulum of epidermal ionocytes were often vesicularly dilated. (3) Muscle fibres in the trunk musculature began to separate from each other. Epidermal intercellular spaces were enlarged and increased in number. (4) Destruction of vessels and haematomas were observed in the circulatory system of the yolk sac. (5) Necroses up to total disintegration were found in various organs of the body cavity (intestine, liver, spleen). The less serious alterations (1 and 2) occurred in organs completely surrounded by other tissues. Major damages (4 and 5), however, affected only organs with free outer and inner surfaces, probably explained by cavitation and jet stream phenomena within the adjacent fluids.

Amputation, Handicap, High Subsequent Costs. Lack of "Outpatient Wards for Diseases Involving the Feet" in German hospitals. A Challenge to Prevention: In consequence of diabetic polyneuropathy, about 25% of all diabetics develop neuropathic foot complications often resulting in amputation (about 30,000 cases in Germany per annum). Suffering and handicaps of the patients, as well as the high costs involved (estimated at 800 million Deutsche Mark per annum) systematic prophylaxis and early identification of patients at risk are imperative. According to experts every second amputation could be avoided if treatment of diabetic foot complications is started as early as possible. To prevent expensive in-hospital treatment, an outpatient clinical treatment may be offered on an interdisciplinary basis (internist, neurologist, orthopaedist, surgeon, radiologist). About 50 "outpatient wards for diseases involving the feet" exist up to now in German hospitals. Appropriate fees, subsidy by sick funds (and if necessary by politicians) and co-operation with general practitioners, internists etc. are indispensable. Other important co-operators are the family doctors. With regard to health care, preventive activities and publicity, co-operation of the local Public Health departments would also be feasible.

As perioperative prophylaxis for major orthopedic operations 81 patients were given the fixed combination of ampicillin (1 g)/sulbactam (0.5 g) or cefotiam (2 g) as short infusions. The three beta-lactams were rapidly distributed into the different tissues and their pharmacokinetic profiles were found to be very similar. It was noteworthy that ampicillin, sulbactam and cefotiam penetrated within minutes, not only into skin, fat and muscles, but also into bone. Thus 0.25 h after starting the infusion the following mean concentrations were measured in bone: 21.8 +/- 10.5 mg/kg ampicillin, 4.9 +/- 2.2 mg/kg sulbactam and 19.4 +/- 10.6 mg/kg cefotiam. For a period of at least 2 h the concentrations measured in serum and in the different tissues affected by the operation (skin, fat, muscle, bone) were above the MICs for pathogens which are involved in postoperative wound infections. On the basis of pharmacokinetic data, ampicillin/sulbactam and cefotiam seem about equally suitable for perioperative prophylaxis in major orthopedic operations.

The peritoneal resident cell population is influenced by various inflammatory and immunogenic stimuli. The influence of intraperitoneal application of polyethyleneterephthalate (PET) (group A) and ultra-high-molecular-weight polyethylene (UHMW-PE) (group B) powders on peritoneal cell count and macrophage activity was investigated. Powders were tested to mimic wear particles from solid implant devices as these particles often cause chronic granulomatous inflammation. The results were compared with the inflammatory response following an abdominal midline incision (group C) and untreated animals (group D). On days 1, 7, 14 and 30 peritoneal cells were quantified and the number of active macrophages was assessed. Groups A and C mice showed a significant loss of macrophages in the peritoneal lavage at day 1 but this returned to normal values (group D) on day 7. In contrast, group B animals remained at low peritoneal cell counts but showed the highest number of active macrophages. Only in this latter group was adhesion formation and granulomatous clustering of polymer powder observed. Applying the parameters macrophage count and the number of active macrophages it can be concluded that PET elicits a weaker inflammatory reaction than UHMW-PE in mice peritoneal cavity. Thus this animal model may be used as a screening test for biomedical materials, especially their wear products.

A case of complete paraplegia due to a giant cell tumor of the dorsal spine following manual therapy without previous x-ray examination is reported. In a malpractice trial the question whether manual therapy is indicated or not had strictly to be denied. The question whether paraplegia due to a giant cell tumor could have been avoided when the tumor would have been detected radiologically was impossible to answer retrospectively. But, it is likely that with immediate surgical therapy after radiological detection of this lesions complete paraplegia should have been avoidable.

In a clinical and radiological follow up 64 Lord-endoprostheses could be controlled after a meantime of 8.5 years. The positive judgement of the patients, which is caused by the reduction of pain, is in contrast to the poor improvement of gait and mobility. Radiological findings are suspicious for a higher rate of loosening of the cup and fractures of the shaft.

Departments of Health can function as important initiators of health promotion on community level. This includes the support of efforts for cooperation ("corporate identity"). A one-day-project for the World Diabetes Day (June 27, 1992) in the Ammerland county (Lower Saxony) gives an insight on possible activities, results and conclusions.

Surgical treatment of pyogenic infections of the sacroiliac joint is indicated in cases of ineffective conservative treatment, abscess formation, septicemia, and neurological deficits. Between 1983 and 1990 in nine patients surgical treatment was performed for pyogenic sacroiliitis under this criteria. The surgical procedure included joint debridement, primary arthrodesis of the sacroiliac joint using a autologous bone graft, antibiotic therapy and postoperative immobilisation. Follow-up examination of 8 patients in average 47 months postoperatively revealed excellent functional and roentgenological results in 6 patients. Two patients suffered only from mild low-back pain, none of the eight patients demonstrated signs of a recurrent infection, one patient died due to complications of a long-lasting preoperative septicemia. Regarding these postoperative follow-up results surgical therapy including primary sacroiliac arthrodesis should be early considered, because this treatment has a low complication rate and the surgical technique is easy to perform and results are excellent or good in most of the patients.

Ein 44jahriger Patient hatte seit etwa 5 Monaten bemerkt, das eine bekannte, Paget-typische Knochenauftreibung im Bereich der rechten Clavicula deutlich an Grose zugenommen hatte. Nachdem er zusatzlich uber verstarkten Druck- und Spontanschmerz innerhalb dieses Tumors berichtet hatte, wurde er zu einer Kontrolluntersuchung in unserer Klinik vorgestellt.

Commercial solaria are not always up to the standards that would be desirable from a Public Health point of view in respect of protection of users against health hazards of exposure to UV radiation, and also with regard to supervision, qualified personal advice given to users by the staff, and qualification of the staff members to give such advice. Hygiene is definitely also a problem, as is evident from bacteriological swabs made from tanning beds. However, the talks conducted by a local Public Health board in Lower Saxony (North Germany) revealed considerable open-mindedness on the part of the entrepreneurs who were quite willing to follow expert health advice and to display a poster with recommendations regarding protective measures. This was combined with a questioning procedure that has proved successful with the proprietors.

Basis fur eine kritische abwagende Indikationsstellung fur therapeutische Masnahmen, das gilt in besonderem Mase fur operative Eingriffe, ist die moglichst genaue Kenntnis des Spontanablaufes der zu behandelnden Krankheit.