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The General Data Protection Regulation (GDPR) is applicable as of May 25, 2018 in all member states to harmonize data privacy laws across Europe. GDPR impacts also on medical data research. Non-interventional studies (NIS) in hospital are an important part of health services research and might need to be assessed by the local data protection officer. This study investigates all NIS (in house or sponsored) initiated between April 1, 2017 and July 31, 2018 in Nuremberg Hospital and their methods dealing with the GDPR.All studies in Nuremberg Hospital have to be reported to the study center of Nuremberg Hospital. We implemented some actions to fullfill GDPR, e. g. checklist for GDPR, quality circle, and all studies were assigned to a data protection officer specialized in scientific and clinical studies. We analyzed in each study the kind of data encryption (e. g., pseudonymous vs. anonymous), the need for approval from the official ethics commitee according to §15BO, and the need for approval from the hospital data protection officer. The data was analyzed using descriptive statistics.After GDPR came into effect, more NIS were started (n=77 vs. n=59), especially investigator-initiated NIS increased significantly (+84%, p0.01). The majority of inhouse studies were dealing with absolute anonymous data (before GDPR: n=28 anonymous vs. n=4 pseudonymous; after R: 51 vs.7; n.s.). 22 studies, mostly IITs (86%), needed a statement of the local data protection officer and used a patient's information. After GDPR 19% of in-house NIS showed the need for a statement of approval from the ethics committee (accordingly to §15BO) (before GDPR 12.5%; n.s.). One year after GDPR was implemented, the average processing time of the data protection officer for an NIS was 10.5 work days.Investigator-initiated NIS are an important part of scientific research at Nuremberg Hospital. After GDPR, there was an increase in the number of self-initiated studies. Standardized procedures and simple actions help implement GDPR in medical research without critical delays at the start of study.Seit 25. Mai 2018 gilt die Europäische Datenschutzgrundverordnung und führt auch im Bereich der wissenschaftlichen medizinischen Studien zu Veränderungen. Nicht-interventionelle Studien (NIS) können einen wichtigen Beitrag zur Versorgungsforschung leisten. Auch NIS benötigen nun teilweise die Beurteilung eines Datenschutzbeauftragten vor Studienstart. Diese Arbeit untersucht alle am Klinikum Nürnberg zwischen dem 01.April 2017 und dem 31.Juli 2019 gemeldeten NIS (mit Fremdsponsor oder eigeninitiiert). Dabei werden die lokal zur Umsetzung der DSGVO getroffenen Maßnahmen überprüft.Alle Studien, die am Klinikum Nürnberg durchgeführt werden, sollen ans Studienzentrum gemeldet werden. Dort erfolgt die Koordination der Forschungsvorhaben. Neben verschiedenen anderen Maßnahmen (Checkliste, Qualitätszirkel) wurde ein Datenschutzbeauftragter für den Bereich Studien implementiert. Alle registrierten NIS wurden auf die Art der Anonymysierung, die Notwendigkeit einer offiziellen ethischen Stellungnahme (gemäß §15 BOÄ) und auch einer Datenschutzerklärung überprüft. Die Daten wurden vorwiegend deskriptiv ausgewertet.Seit Geltung der DSGVO wurden mehr NIS am Klinikum Nürnberg gestartet (N=77 vs. N=59), v. a. eigeninitiierte NIS nahmen signifikant zu (+84%, p0,01). Die Mehrzahl dieser IITS arbeitete mit absolut anonymisierten Daten (vor DSGVO: N=28 absolut anonymisiert vs. N=4 pseudonymsiert; nach DSGVO: 51 vs.7; n.s.). 22 Studien, v. a. IITs (86%), benötigten eine offizielle Stellungnahme des DS-Beauftragten und verwendeten eine Patienteninformation. Nach DSGVO wurden 19% der eigeninitiierten NIS gemäß §15 BOÄ durch eine offizielle Ethik-Kommssion bewertet (vor DSGVO: 12,5%; n.s.). 1 Jahr nach Start der DSGVO lag die durchschnittliche Bearbeitungszeit des DS-Beauftragten für eine NIS bei 10,5 Werktagen.Nicht-interventionelle Studien und hier v. a. die eigeninitiierten sind ein wichtiger Bestandteil der wissenschaftlichen Forschung am Klinikum Nürnberg. Seit Wirksamwerden der DSGVO zeigte sich eine Zunahme der eigeninitiierten NIS. Durch Standardisierung der Prozesse und Zusatzmaßnahmen kann die DSGVO vollumfänglich berücksichtigt werden ohne den Studienstart wesentlich zu verzögern.

Stroke is one of the most common neurological diseases in acute care. The introduction of new organizational concepts in the rescue chain and in acute inpatient services can significantly reduce time to treatment and patients can receive specific therapeutic options that have been shown to improve acute stroke prognosis. This review provides an overview of organizational structures that lead to improved medical care and outlines the evidence-based therapeutic options. This is intended to give the reader a decision support on provision of specific treatment in acute ischemic stroke. The almost simultaneous proof of effectiveness of mechanical thrombectomy for targeted patient populations in five randomized trials has challenged the organization of stroke care. This provides a good example of how an optimized interplay within the rescue chain from emergency services via community hospitals to referral centers with intervention facilities can ensure access to this novel treatment for as many patients as possible. For the limited time span between onset of symptoms and start of treatment, creative but nevertheless well-standardized concepts have emerged that lead to measurable therapeutic success. It has become an urgent challenge to create sustainable regional infrastructures that allow access to appropriate treatment for all patients.

The requirements of the German statutory accident insurance (DGUV) for the new treatment procedure were presented on 1 January 2013 in a new catalogue. The implementation of the certification of hospitals for the very severe injury procedure (SAV) by the DGUV should have been completed by 2014. These requirements placed high demands on trauma-oriented hospitals because of the high structural and personnel prerequisites. The background to the new organization was the wish of the DGUV for quality improvement in patient treatment in hospitals for patients with very severe occupational and occupation-related trauma by placement in qualified centers with high case numbers. No increase in income was planned for the hospitals to cope with the necessary improvements in quality. After 2 years of experience with the SAV we can confirm for a community hospital that the structural requirements could be improved (e.g. establishment of departments of neurosurgery, plastic surgery and thoracic surgery) but the high requirements for qualification and attendance of physicians on duty are a continuous problem and are also costly. The numbers of severely injured trauma patients have greatly increased, particularly in 2015. The charges for the complex treatment are not adequately reflected in the German diagnosis-related groups system and no extra flat rate funding per case is explicitly planned in the DRG remuneration catalogue. The invoicing of a center surcharge in addition to the DRG charges has not been introduced.

Tinea capitis is caused by anthropophilic, zoophilic or geophilic dermatophytes of the genera Microsporum or Trichophyton.The aim of this study was to analyze the clinical presentation of tinea capitis among children in western Uganda.From February to June 2012, skin and hair samples were obtained from 115 patients aged from 1 to 16 years presenting at Mbarara Regional Referral Hospital (MUSC) with clinically suspected tinea capitis. Conventional mycological diagnostics comprised Blancophor preparation and cultivation of fungi for species identification.Tinea capitis among the children included in the MUSC study was mainly noninflammatory showing mostly a seborrhoeic pattern or "black dot" and "gray patch" form and highly inflammatory kerion celsi. Blancophor preparation identified 82.6 % positive and 17.4 % negative samples. Cultural species differentiation showed Trichophyton (T.) violaceum as the causative agent for tinea capitis in 56.6 % of the patients. In 13 %, Microsporum (M.) audouinii was isolated followed by T. soudanense (2.6 %), and T. rubrum (1.7 %). In addition, moulds (contamination?) such as Scopulariopsis brevicaulis, Aspergillus niger, and Fusarium oxysporum were found as well as mixed infections.The anthropophilic dermatophyte T. violaceum represents the most frequent cause of tinea capitis in western Uganda. For successful management oral antifungal therapy is necessary together with supportive topical treatment.

Clinical psychiatry changed dramatically in the past 30 years. Clinical challenges are very different from those in old mental hospitals. Psychotherapy and sociotherapy are effective but very time-consuming parts of treatments of nearly every psychiatric disorder. Planning of staff resources based on the German "Psychiatrie Personalverordnung" does not match with modern quality requirements. As a result, the standards of evidence-based treatment cannot be offered to severely mentally ill inpatients.We carried out a buttom-up calculation of medical staffing for the concrete patients considering diagnosis, and length of stay of the psychiatric department of the Danube hospital in Vienna 2013 and 2014. This is an 80 bed unit responsible for an area of 250,000 inhabitants, providing about 1100 admissions each year.The calculated yearly sum of working hours for medical doctors in the particular department was 39,527. When considering a net working-time of 80%, the actual number of medical staff should be at least doubled to allow psychiatric treatment according to current guidelines.Severely ill psychiatric patients seem to be undertreated because of low staffing of psychiatric departments.

Epidemiology and morbidity of mycoplasma-associated pneumonia in youths and children in Vienna are not known. The first objective was to elucidate the incidence and the second was to evaluate a standard antibiotic regimen with addition of a macrolid in children over 5 years.Hospitalized patients were evaluated prospectively during 3 winter seasons. In a clinical routine setting microbiologic tests were performed, nasal secretions were tested for viruses, Chlamydia pneumoniae and Mycoplasma pneumoniae, and clinical parameters were documented.Mycoplasma pneumoniae was identified in 12 patients out of 279 (4.3%). All were 5 years and older. The mean number of days in hospital was 4.6, the number of days with fever38.5 degrees was 1.2, the maximal value of C-reactive protein was 48 mg/L, no complications occurred, and all children recovered completely.Mycoplasma pneumoniae was identified in 4.3% of children and youths. The antibiotic regimen is appropriate as initial therapy.

Provision of sufficient perioperative pain therapy is an obligation in the clinical management of patients suffering from pain. The implementation of a standardized pain management concept was planned to be introduced in the clinical routine. The results of three hospitals are shown.The concept included tools which gave information about legal aspects and basic fundamentals of pain relief, management modules regarding agreements on the implementation of perioperative pain therapy, instruments to measure pain intensity, assigning accountability and documentation modules. Questionnaires were carried out according to Picker.The project revealed that, according to the Picker questionnaire, about 50% of the patients treated in the hospitals had pain, 30-40% still had intensive pain during the stay in hospital and 90% of the patients received pain relief medication within 10 min of the request. More than 78% of the patients thought the hospital staff did their best to relieve the pain and over 92% found the pain treatment adequate.It was possible to implement a standardized perioperative pain therapy concept in three hospitals of a consortium. Whether an adequate pain relief can be improved with the help of standard measurements and documentation, could not be evaluated in this study.

Background: Many hospital rankings rely on the frequency of adverse outcomes and are based on administrative data. In the study presented here, we tried to find out, to what extent available administrative data of German Sickness Funds allow for an adequate hospital ranking and compared this with rankings based on additional information derived from a patient survey. Total hip replacement was chosen as an example procedure. In part II of the publication, we present the results of the approach based on administrative and patient-derived data.Methods: We used administrative data from a large health insurance (AOK-Lower Saxony) of the year 2002 and from a patient survey. The study population comprised mainly beneficiaries, who received primary total hip replacement in the year 2002, were mailed a survey 6 month post-operatively and participated in the survey. Performance indicators used where "Revision", "Complications" and "Change of functional impairment". Hospitals were ranked if they performed at least 20 procedures on AOK-beneficiaries. Multivariate modelling (logistic regression and generalized linear models) was used to estimate the performance indicators by case-mix variables (a.o. age, sex, co-morbidity, medical history) and hospital characteristics (hospital size, surgical volume). The actual ranking was based on these multivariate models, excluding hospital variables and adding dummy-variables for each hospital. Hospitals were ranked by their case-mix adjusted odds ratio or Standardized Difference (SDR) with respect to a pre-selected reference hospital. The resulting rankings were compared with each other and with regard to the impact of case-mix variables.Results: 4089 beneficiaries received primary total hip replacement in 2002. 3293 patients participated in the survey (80.5%). The ranking included 60 hospitals. The agreement of rankings based on different performance indicators in the same year was low to high (a correlation coefficient of Spearman between 0.07 to 0.88). Including case-mix variables improved the model fit remarkably. Odds ratios for hospitals varied from 0.0 to 6.5 (Revision), from 0.6 to 2.4 (Complications), and SDRs varied from -2.24 to 2.44 (Change of functional impairment).Conclusions: Accounting for case-mix with patient-reported variables is more reliable than with variables that can be drawn from administrative data. Furthermore, including a patient survey allows to expand performance measurement on patient-reported, desired outcomes. Focusing on patients after primary total hip replacement weakened "revision" as performance indicator (because revisions after primary hip replacement are less frequent than after revision hip replacement). Future hospital rankings should rely on a combination of administrative data for primary and secondary hip replacements and patient-reported health outcomes after primary hip-replacement. To include as many hospitals as possible, co-operation with other health insurances is warranted. Hintergrund: Krankenhausrankings beziehen sich häufig auf schwere, unerwünschte Therapieresultate und beruhen auf routinemäßig verfügbaren Abrechnungsdaten. Im vorliegenden Projekt wurde am Beispiel der Implantation künstlicher Hüftgelenke untersucht, ob und inwieweit die den gesetzlichen Krankenkassen zur Verfügung stehenden Routinedaten für vergleichende Qualitätsbewertungen auf der Ebene einzelner Krankenhäuser bereits ausreichend sind oder ob eine inhaltlich angemessene Bewertung erst nach Ergänzung der Routinedaten um zusätzlich erhobene patientenseitige Informationen möglich ist. Im zweiten Teil der Publikation werden die Ergebnisse des auf der Kombination von Routinedaten und Patientenbefragung basierenden Qualitätsvergleichs vorgestellt. Methodik: Zur Verfügung standen Routinedaten der AOK Niedersachsen des Jahres 2002 (u.a. Stammdaten und Daten nach SGB V § 301) sowie Daten einer Versichertenbefragung. Die Studienpopulation umfasste hauptsächlich Versicherten, die im Jahr 2002 erstmals ein künstliches Hüftgelenk erhielten, sechs Monate postoperativ angeschrieben wurden und an der Befragung teilnahmen. Das Krankenhaus-Ranking erfolgte anhand der Ergebnisindikatoren "Revision", "selbstberichtete Komplikationen" und "Veränderungen in der Alltagsfunktionalität" für Krankenhäuser, die im Jahr 2002 mindestens 20 Fälle hatten. Im ersten Schritt erfolgte eine multivariate Modellierung (logistische Regression bzw. Generalisiertes lineares Modell) der Ergebnisindikatoren unter Berücksichtigung verschiedener Einflussgrößen (u.a. Alter, Geschlecht, Begleiterkrankungen, Anmanese, präoperative Alltagsfunktion, Operationsvolumen). Für das eigentliche Ranking wurden diese Modelle ohne Krankenhausmerkmale, aber ergänzt um Indikatorvariablen der einzelnen Krankenhäuser, erneut berechnet. Maßgeblich für den Rangplatz war das hinsichtlich der patientenbezogenen Einflussgrößen adjustierte Odds Ratio (Ergebnisindikatoren "Revision" und "Komplikationen") bzw. die Standardisierte Differenz SDR (Ergebnisindikator "Veränderungen der Alltagsfunktionalität") des einzelnen Krankenhauses in Bezug auf ein vorher festgelegtes Referenzkrankenhaus. Die verschiedenen Ranglisten wurden untereinander verglichen und in Bezug auf den Einfluss der Fallmix-Variablen untersucht.Ergebnisse: Im Beobachtungsjahr erhielten 4089 Versicherte der AOK-Niedersachsen erstmals ein künstliches Hüftgelenk. An der Befragung teilgenommen haben 3293 Versicherte (80,5%). In das Ranking einbezogen wurden 60 Krankenhäuser. Die Übereinstimmung der auf verschiedenen Ergebnisindikatoren beruhenden Rangfolgen ist gering bis hoch (Rangkorrelation nach Spearman zwischen 0,07 und 0,88). Die Modellanpassung wird durch Einbezug der Fallmix-Variablen deutlich verbessert. Die Odds Ratios bzw. SDRs der einzelnen Krankenhäuser bewegen sich zwischen 0,0 bis 6,5 ("Revision"), zwischen 0,6 bis 2,4 ("Komplikation") und zwischen -2,24 und 2,44 ("Veränderungen der Alltagsfunktionalität").Schlussfolgerungen: Der Fallmix lässt sich mit den in der Patientenbefragung erhobenen zusätzlichen Merkmale verlässlicher berücksichtigen als allein mit Merkmalen auf der Basis von Routinedaten. Zudem erlaubt die Patientenbefragung die zusätzliche Berücksichtigung patientennaher Ergebnisindikatoren. Die Konzentration auf Patienten, deren Index-Operation eine Erstoperation gewesen ist, schwächt die Aussagekraft des auf Routinedaten basierenden Ergebnisindikators "Revisionen im Folgezeitraum", weil Revisionen nach Erst-Operationen weniger häufig auftreten als nach Revisionsoperationen. Bei einem künftigen Vorgehen sollten demnach Routinedaten von allen mit einem künstlichen Hüftgelenk versorgten Patienten und Befragungsdaten von Patienten nach Erst-Implantation kombiniert werden. Um möglichst viele Krankenhäuser in ein Ranking einzubeziehen, sollte zudem die Kooperation mit anderen Krankenkassen angestrebt werden.

Background: Many hospital rankings rely on the frequency of adverse outcomes and are based on administrative data. In the study presented here, we tried to find out, to what extent available administrative data of German Sickness Funds allow for an adequate hospital ranking and compared this with rankings based on additional information derived from a patient survey. Total hip replacement was chosen as an example procedure. In part I of the publication, we present the results of the approach based on administrative data.Methods: We used administrative data from the AOK-Lower Saxony of the years 2000, 2001 and 2002. The study population comprised all beneficiaries, who received total hip replacement in the years 2000 or 2001. Performance indicators used where "critical incident (Mortality or revision)" and "number of revisions" within the first year. Hospitals were ranked if they performed at least 20 procedures on AOK-beneficiaries in each of the two years. Multivariate modelling (logistic and poisson regression) was used to estimate the performance indicators by case-mix variables (age, sex, co-diagnoses) and hospital characteristics (hospital size, surgical volume). The actual ranking was based on these multivariate models, excluding hospital variables and adding dummy-variables for each hospital. Hospitals were ranked by their case-mix adjusted odds ratio or SMR respectively with respect to a pre-selected reference hospital. The resulting rankings were compared with each other, with regard to temporal stability, and the impact of case-mix variables.Results: About 4500 beneficiaries received total hip replacement in each year (n2000: 4482; n2001: 4579). The ranking included 65 hospitals. Comparing the years 2000 and 2001, the temporal stability of the rankings based on a single performance indicator was low (Spearman rang correlation coefficients 0.158 and 0.191). The agreement of rankings based on different performance indicators in the same year was high (Spearman: 0.80 and 0.85). Including case-mix variables improved the model fit remarkably. Odds ratios for hospitals varied from 0.0 to 10.0 (critical incident) and SMRs from 0.0 to 6.1 (number of revisions).Conclusions: Using data of two adjacent years together improves the reliability of hospital rankings. Adding the administrative data derived patient variables improves the explanation of the performance indicators. Whether this is sufficient to account for case-mix can not be determined at this point. If the case-mix was addressed properly, the rankings showed large differences in the quality of care, raising the need for action. In the second part of the publication, we will discuss, whether administrative data are good enough to provide information on relevant health outcomes and case-mix, or if hospital rankings should be based on additional information from patient surveys. Hintergrund: Krankenhausrankings beziehen sich häufig auf schwere, unerwünschte Therapieresultate und beruhen auf routinemäßig verfügbaren Abrechnungsdaten. Im vorliegenden Projekt wurde am Beispiel der Implantation künstlicher Hüftgelenke untersucht, ob und inwieweit die den gesetzlichen Krankenkassen zur Verfügung stehenden Routinedaten für vergleichende Qualitätsbewertungen auf der Ebene einzelner Krankenhäuser bereits ausreichend sind oder ob eine inhaltlich angemessene Bewertung erst nach Ergänzung der Routinedaten um zusätzlich erhobene patientenseitige Informationen möglich ist. Im ersten Teil der Publikation werden die Ergebnisse des allein auf Routinedaten basierenden Qualitätsvergleichs vorgestellt.Methodik: Zur Verfügung standen Routinedaten der AOK Niedersachsen der Jahre 2000, 2001 und 2002 (u.a. Stammdaten und Daten nach SGB V § 301). Die Studienpopulation umfasste alle Versicherten, die im Jahr 2000 oder 2001 ein künstliches Hüftgelenk erhielten. Das Krankenhaus-Ranking erfolgte anhand der Ergebnisindikatoren "Kritisches Ereignis (Mortalität oder Revision)" und "Anzahl der Revisionsoperationen" für Krankenhäuser, die in jedem der beiden Jahre mindestens 20 Fälle hatten. Im ersten Schritt erfolgte eine multivariate Modellierung (logistische bzw. Poisson-Regression) der Ergebnisindikatoren unter Berücksichtigung der Einflussgrößen Alter, Geschlecht, Nebendiagnosen, Krankenhausgröße und Operationsvolumen. Für das eigentliche Ranking wurden diese Modelle ohne Krankenhausmerkmale, aber ergänzt um Indikatorvariablen der einzelnen Krankenhäuser, erneut berechnet. Maßgeblich für den Rangplatz war das hinsichtlich der Einflussgrößen adjustierte Odds Ratio bzw. SMR des einzelnen Krankenhauses in Bezug auf ein vorher festgelegtes Referenzkrankenhaus. Die verschiedenen Ranglisten wurden untereinander verglichen und in Bezug auf die zeitliche Stabilität sowie den Einfluss der Fallmix-Variablen untersucht.Ergebnisse: In jedem der beiden Beobachtungsjahre erhielten ca. 4500 Versicherte der AOK-Niedersachsen ein künstliches Hüftgelenk (n2000: 4482; n2001: 4579). In das Ranking einbezogen wurden 65 Krankenhäuser. Die zeitliche Stabilität der Rangfolgen bezüglich des gleichen Ergebnisparameters ist gering (Rangkorrelationskoeffizient von Spearman: 0,158 und 0,191). Die Übereinstimmung der auf verschiedenen Ergebnisindikatoren beruhenden Rangfolgen im gleichen Beobachtungsjahr ist hoch (Rangkorrelation: 0,80 und 0,85). Die Modellanpassung wird durch Einbezug der Fallmix-Variablen deutlich verbessert. Die Odds Ratios der einzelnen Krankenhäuser bewegen sich zwischen 0,0 bis 10,0 ("Kritisches Ereignis") und die SMRs variieren zwischen 0,0 bis 6,1 ("Anzahl der Revisionen").Schlussfolgerungen: Ob sich der Fallmix aus den Variablen, die man aus den Routinedaten ableiten kann, ausreichend operationalisieren lässt, kann an dieser Stelle nicht abschließend beurteilt werden. Die Analysen geben nur Hinweise darauf, dass die patientenbezogenen erklärenden Variablen das Ergebnis in höherem Maß erklären als die Indikatorvariablen für die Krankenhäuser. Durch Zusammenfassung der Daten für mehrere Jahre lässt sich die Reliabilität der Bewertung erhöhen. Die Ranglisten zeigen ein erhebliches Qualitätsgefälle auf, das, wenn der Fall-Mix aus den Routinedaten in ausreichendem Umfang abgebildet wurde, Handlungsbedarf signalisiert. In Teil 2 der Publikation werden wir uns abschließend mit der Frage auseinandersetzen, ob die Routinedaten eine ausreichende Basis bilden, das Ergebnis der TEP und den Fallmix für die Qualitätsbewertung zu operationalisieren oder ob sie zu diesem Zweck durch Daten aus Versichertenbefragungen ergänzt werden sollten.

In line with the application of evidence-based medicine as part of the day-to-day clinical practice of a community hospital internal guidelines concerning relevant diagnostic or therapeutic problems were developed. The authors retrospectively compared all data of patients with the tentative diagnosis of deep vein thrombosis (DVT), who underwent further diagnostics before and after implementation of an internally developed guideline for the diagnostics of DVT. The aim was to evaluate if the internal guideline was applied by the doctors in the daily routine and if the implementation led to a change and rationalization of the diagnostic process, in particular with regard to reducing invasive examinations.In a retrospective controlled cohort study the medical records of in- and outpatients (n = 371) receiving further diagnostics following a tentative diagnosis of DVT were screened. The kind of examinations, the duration of the diagnostic process and the rate of hospitalization for DVT were compared between the intervention group (n = 185), treated in the initial 10 months following guideline implementation, and the control group (n = 186), treated in the 10 months prior to implementation. Furthermore, the physicians' compliance with the internal guideline was assessed.After implementation in 114 of 185 cases (62%) the treating doctors based their diagnostic procedure on the internal guideline. There was a significant decrease of phlebographies (45.4% vs. 74.2%; RR 0.61 [95% CI 0.51; 0.73]). By contrast, the number of D-dimer tests (81.6% vs. 33.3%; RR 2.45 [95% CI 1.98; 3.03]) and of duplex sonographies (42.2% vs. 21.5%; RR 1.96 [95% CI 1.42; 2.71]) increased significantly. A reduction of the hospitalization rate for further diagnostics of primary ambulant patients (51.3% vs. 60.4% of the tentative cases; RR 0.85 [95% CI 0.69; 1,04]) without a significant change in the final number of DVT diagnoses (33.3% vs. 27.6%; RR 0,83 [95% CI 0,61; 1,13]) was found. There was a slight increment in the mean length of diagnostic process (2.12 vs. 1.84 days).The implementation of an internal guideline for the diagnostics of DVT led to a significant reduction of the hospitalization rate and to a considerable change of the diagnostic procedure in favor of noninvasive diagnostic tests, for patients presenting with a diagnosis of suspected DVT.

Although treatment in a stroke unit has been proven to be effective, most stroke patients in rural areas have no access to it. The community hospital of Ebersberg (Bavaria/Germany) joined the Telemedic Project for Integrative Stroke Care (TEMPiS) in order to optimize the quality of stroke care. This analysis focuses on changes in stroke management using generally accepted indicators for quality of acute stroke treatment.The core elements consisted of the setting up of a stroke ward in the community hospital, continual stroke education and a 24-hour telemedical consultation service offered by stroke centers. Treatment of stroke patients was documented during two 12-months periods before the project was started start (i.e. retrospectively) and during the course of the project (prospectively). In addition, data on fatal outcome and institutionalization of patients who had lived at home before the qualifying event were collected 12 months after stroke onset.There were 299 admissions for stroke or transient ischemic attacks between 1 Nov 2001 and 31 Oct 2002, and 305 between 7 July 2003 and 6 June 2004. Length of in-hospital stay decreased from 12.1 to 9.2 days. More patients (10.3 vs. 1.3%) were transferred to other acute hospitals during the later period. Indicators for stroke care quality improved: numbers of cerebral imaging rose from 56.5% to 96.4%, of duplex sonography of cervical arteries from 43.5 to 72.8 %, of speech therapy from 0% to 50.8% and of occupational therapy from 0 to 33.4%. One year after admission, 18.9% and 17.2%, respectively, of the patients had died, while 10.2% and 6.1% were living in institutions.Participation in the TEMPiS network substantially improved stroke care quality according to national and international guidelines. These improvements may lead to a better prognosis after a stroke.

Management of acute ST-elevation myocardial infarction (STEMI) demands rapid and complete reflow to the infarct related artery (IRA). Primary PCI (percutaneous coronary intervention) performed by experienced operators is superior to thrombolytic thrombolytic therapy and reduces mortality, occurrence of non-fatal reinfarction and stroke, but is not available in rural Germany. We established a regional infarction-network using established therapeutic guidelines comprising of 1 interventional center and 7 referring community hospitals without PCI facilities.We analyzed 322 patients with STEMI treated by PCI within the network; 160 patients were transferred from a community hospital without PCI facilities (transfer group (TG): 63.4 yrs., 71.8% men) and 162 patients were admitted directly to the interventional center (center group (CG): 61.7 yrs., 73.8% men). The interval from onset of symptoms to first medical contact was 205 minutes in TG, and 195 minutes in CG (n.s.); 7.8% of the CG and 7.2% of the TG patients were in cardiogenic shock; 95% of patients completed 12- months of follow-up.In the TG, median transportation time to PCI was 54 minutes. PCI of the infarct-related artery (IRA) was performed in 95.1% of TG patients and in 94.1% of CG patients. In addition, 96% of all patients received a GP IIb/IIIa receptor inhibitor. In case of pre-interventional application of GP IIb/IIIa receptor inhibitor 22.3% of patients revealed TIMI-3 flow of the IRA before PCI. After PCI, normalized flow to the IRAwas documented in 87.5% of CG versus 86.3% of TG. There were no differences between groups with respect to infarct size (TG vs. CG: CK 2482 vs. 2481 U/I; CKMB 302 vs. 264 U/I), mortality (30 days: 5.3 vs. 5.2%, 6 months: 7.3 vs. 7.1%, 12 months: 7.9 vs. 7.8%); NYHA (1.41 vs. 1.43) and left ventricular ejection fraction (0.41 vs. 0.43).The organization of a regional STEMI-network with logistic alliance of community hospitals and one experienced interventional center ensures timely PCI treatment of patients with STEMI according to present guidelines even in rural areas, and relegates thrombolytic treatment to bail-out scenarios only.

Fall Risk Factors have been analysed (RAI-MDS-System) in a population of patients, who were hospitalised between 1995 and 2000 in a geriatric department of a community hospital. In multivariate analysis, viseral-problems, incontinence and depression were fall-protective factors, whereas problems with transfer, the use of assistive walking-aids, female gender and age were fall risk-factors. No independent contribution to the fall-risk was delivered by memory-impairment, problems in decision-making, low body-mass-index, the use of more than three medications and the use of restraints. Fall injuries were analysed in a patient population (n = 218), that was hospitalized in the year 2001 in the geriatric department of a community hospital after a fall. The analysis showed an enormous heterogenicity of the injury-patterns: 58.7% of the fall-patients suffered from a fracture, 10.6% of them had more than one fracture, 34% suffered from other injuries. 77 surgical interventions were performed. The mean length of stay of the fall-patients was 4.5 days higher than the mean of all geriatric patients.

Small hospitals often lack the financial and personnel resources to realize innovative postoperative pain management concepts. This is not-as shown here-an absolute contradiction. The regular measurement of pain and its documentation by ward nurses as well as the appropriate prescription of analgesics play a key role in our concept. The joint establishment of guidelines, information sessions and the on-going dialog between the various professional groups guarantees the necessary consensus of all specialists involved in postoperative pain control. If an anesthetist is available 24 h a day, a nurse-based acute pain service (APS) becomes available for managing patients with patient-controlled analgesia (PCA) systems. The use of PCA and the performance of pain visits at regular intervals increase patient comfort and satisfaction. In addition, it can contribute to reduced hospitalization time in the context of fast-track rehabilitation programs. In our opinion, embedding the measures in a quality management program has a valuable catalytic effect, although implementation takes at least 1-2 years.

More than 100 stroke units have been established in Germany. In rural areas, however, acute stroke care needs to be improved. In order to advance clinical stroke therapy, two specialized stroke centers founded a telemedicine network (TEMPiS) among 12 community hospitals in eastern Bavaria. Each network hospital established specialized stroke wards where qualified teams manage acute stroke patients. Twenty-four hours daily, physicians in local hospitals are able to contact the stroke centers via videoconferencing including transmission of digital DICOM data. To study the efficacy of this network, a controlled trial will be performed. Five TEMPiS-network hospitals will be matched with five other hospitals equal in size, catchment area, and diagnostic techniques. For about 1 year, all consecutive stroke cases in the matched study hospitals will be prospectively recorded in a database. Neurological deficits will be quantified on the National Institute of Health Stroke Scale within 24 h after stroke onset. Mortality and institutional care as a combined primary endpoint will be assessed after 3 and 12 months. Furthermore, functional outcome according to the modified Rankin scale, Barthel score, and quality of life will be assessed using a standard telephone interview. Data acquisition started in July 2003, and final results are expected in 2005.

Following 25 years of psychiatric reform in West and 12 years in East Germany the status of community orientation of German psychiatry is investigated.Analysis of secondary data.Community orientation in hospital care is better realised in the smaller western states and in the eastern German states. In the large western states inpatient care is still dominated by the structures of the large regional hospitals. Outpatient care, dominated by psychiatrists and psychotherapists in private practise, is less densely provided in East Germany. Sheltered accommodation is provided predominantly in hostels. The states with better community orientation in hospital care offer fewer sheltered accommodation.The process of psychiatric reform is not accomplished yet, particularly concerning hospital care in the large western states and sheltered accommodation in general. A possible cause for the weak implementation of community orientation in hospital services in the large western states might be the strong position of hospital responsables that oppose the closing down of hospitals. Incentives for implementing supported housing are weak. The under-serving with sheltered accommodation might pose risks to the persons concerned.

Good hygienic practice in hospitals and other medical institutions is mandatory to avoid or to minimise nosocomial infections. In Germany, official recommendations of the commission for hospital hygiene and infection control have been published as guidelines for hygiene management in hospitals as well as guidelines for control measures of the public health services who are obliged by law to control the hygienic situation in hospitals. In this paper the degree of implementation of these guidelines in the hospitals is studied in respect of the hygiene management in the operation theatre.The constructive and functional situation and the personal hygienic management were documented in 22 community and private hospitals in Frankfurt am Main, including 40 operation suites with 111 operation theatres. Data of the layout of the rooms were obtained by questionnaire and the hygienic management was observed by means of standardised checklists.Layout of rooms was not compatible with the recommendations of the Guidelines of 1990 and 2000 in many cases--especially with regard to the demand that doors to the operating theatres be closed. Automatic door closers were often either not available or defective. In some theatre areas correct hand disinfection while entering the suite was not possible for lack of disinfectant distributors at appropriate sites. Recommendations regarding surgical drapes and gowns were correctly observed in most cases, with the exception of changing gowns after having gone to the toilet room. Quite often, omission of hand disinfection after glove removal was observed. A discrepancy in hygienic procedures of nursing service and physicians was seen. In 40 % of the operation suites, powdered gloves were still in use. Though in all but one suite air conditioning systems were available, they were not correctly serviced in many cases. Cleaning and disinfection after single operations and at the end of the operating day were carried out correctly in most cases--except in operation theatres for ophthalmologic operations. Here too, manual preparation and disinfection/sterilisation of surgical instruments was common, and inappropriate use of sterilisers as well as the use of so-called "quick"-sterilisers.The recommendations of the commission for hospital hygiene and infection prevention are generally accepted as guidelines, although the degree of translation into practice was often unsatisfactory.

The medical care practiced at Hallstatt was specifically influenced by its salt mine, well known since prehistoric times, and by the isolated location of this place lying on a lake as well as in the mountains. Since the 16th century the Hallstatt saltworks had a hospital, with a special isolation ward since 1772. In addition to it, a small hospital for infectious diseases was opened at the beginning of the 20th century. The barber-surgeons, whose names have been known since the 17th century, and later on the university-graduated doctors had to do their work without any outside help and moreover, they had to supply their patients with necessary medicaments. In her own house, the last local midwife used to offer delivery and lying-in rooms for women. The mine rescue service (since 1945), the mountain rescue service (since 1923), the water rescue service (since 1960) and the Red Cross (since 1978) have been playing an important part preparing the work of the local doctors. Paleoparasitological examinations of human excrements found in collapsed prehistoric tunnels proved that the miners had suffered from whip worms and eel worms. Contrary to the badly preserved skeletons found in the prehistoric burying place on the Hallstatt Salzberg, the human remains in the Hallstatt charnel house made anthropological examination possible.

In the past years the number of malpractice suits due to lack of patient information has increased. Because there have been no generally accepted guidelines for preoperative patient information, the Swiss Society of Surgery has decided to work out an informative brochure tailored to the needs of patients. It takes into account that the need to know beforehand is increasing rapidly. In collaboration with the judiciary service of the Swiss Medical Federation all the items and points of legal relevance have been compiled to establish an informative brochure. Based on this protocol, patients in surgical departments of 6 Swiss community hospitals were asked before discharge to qualify the preoperative information offered to them. 2660 questionnaires were evaluated. The majority of patients considered the information regarding their diagnosis, the complications, risks, treatment and postoperative care, the sketches describing the operation and the overall degree of information as good or very good. Almost 60% of all patients stated that no alternative treatment had been discussed with them other than the planned procedure. In most of these patients operative procedures were chosen and carried out for which there were few or no other acceptable options. 2/3 of the patients asked for immediate preoperative written information, especially if they had malignant disease. Barely 4% of the patients were not reassured by the information provided to them. The fact that 2/3 of all patients re-read the informative protocol before the operation underlines how important it is to hand out a copy of the protocol to satisfy the informative needs of the patients. To our surprise the vast majority of patients uttered little concern about giving their signature to forms that were presented to them. Only 2% of the patients felt that giving a signature would cause them grave reservations. The informative protocol devised by the Swiss Society of Surgery is well adapted to the informative needs of the patients and allows for a structured conversation. It facilitates documentation and offers valid legal proof for the physician that he/she has provided adequate information.

The work input of an institutional review board, the satisfaction or dissatisfaction of project applicants with its decisions, as well as the amount of time needed for preparatory and follow-up work for projects submitted to the board were surveyed in a questionnaire. An analysis of the status quo provided proposals for improvement, with the aim of increasing the satisfaction of all parties involved. Questionnaires were returned by 41.4% (101/244) of the specialist doctors surveyed. Of these, 42 were doctors who had submitted projects for review and whose evaluation was used for the study. The proportion of trained "clinical review doctors" was 14.3%. Analysis of work input showed that 13.5 +/- 15.2 hours were invested before submitting a project and 6.3 +/- 9.3 hours in the follow-up. Although the board's work was given a satisfactory grading with a score of 2.8 +/- 1.0, the surveyed satisfaction/importance profile showed marked deficits in many areas, primarily in organization and communication, as well as in the examination and evaluation of projects. The suggestions for improvement above all requested the introduction of a review system employing specialists from outside the institution or from other disciplines, standardization of project submission, optimization of organization and improvement in communication. In summary, the institutional review board plays an important role in clinical research. The acceptance of a review board's work, however, can only be improved when the suggestions for improvement are realized step by step. The results of this evaluation and the proposed solutions can also help other boards improve their work. At any rate, it would be desirable to take a new look in several years' time at how the proposals worked out in this study have been implemented.

Comprehensive geriatric assessment (CGA) is defined as a multidimensional medical, functional, psychosocial and environmental evaluation of an older person's problems and resources, linked with an overall plan for treatment and follow-up. It is well established that CGA implemented in specialized geriatric evaluation and management units improves function and survival in frail older patients. The results of new randomized controlled trials, however, show that the application of CGA does not only improve outcomes in selected older persons, but probably in most. A randomized controlled study in unselected older patients admitted to an acute care hospital found that patients function at hospital discharge was improved, and the risk of nursing home admissions decreased, in patients receiving integrated geriatric care as compared to patients receiving the usual acute hospital care. Another trial examined the impact of follow-up geriatric home-visits in patients with unstable cardiac failure discharged from the hospital. This trial found a statistically significant reduction of hospital readmissions and cost savings in the intervention group as compared with controls. A new application for CGA emerges in the preventive arena. Annual comprehensive geriatric assessments with preventive home visits in older people living at home resulted in fewer nursing home admissions and delayed or prevented the onset of disability in the activities of daily living in persons of the intervention group as compared to controls. One of the roles of geriatricians is teaching CGA and conducting further research with a view to refining CGA methodology and its application. Practical application of the principles of geriatric assessment and management, however, should not remain in the hand of specialists alone, but should become an integrated part of primary care medicine in the ambulatory and hospital settings.

Noninvasive ventilation as well established in treatment of chronic respiratory failure. Many announcements and our own experience give evidence that this method of treatment is useful for patients with acute respiratory failure too. Also the actual situation of our health system requires increasing attention to financial points of view.We analyzed a number of 185 patients who needed mechanical ventilation in our intensive care unit in 1995. 80 of these 185 needed mechanical ventilation due to pulmonary and cardiopulmonary diseases (e. g. cardiac failure, exacerbation of chronic obstructive lung disease, pneumonia and status asthmaticus). 61 received invasive, 19 noninvasive ventilation.Nineteen of 61 patients with invasive and 1 of 19 with noninvasive ventilation died. The mean duration of ventilation was 8.9 (1-50) days in the invasive ventilated group and 2.9 (1-8) days in the noninvasive ventilated group. A cost reduction of nearly 10000 Marks per patient can be calculated, using noninvasive ventilation due to the shorter duration of treatment.So noninvasive ventilation is a cost reducing and gentle alternative compared to conventional invasive mechanical ventilation for many patients with acute respiratory failure. It is also practicable in regional hospitals. Further investigation is needed to specify those groups of patients who receive the most benefit from noninvasive ventilation.

321 colorectal operations have been performed in our institution in a 4-year period from 1992 to 1996. They included 65 laparoscopic interventions for benign disease or for palliative treatment of malignancy. 40 patients underwent low anterior resections, mostly for diverticular disease. 11 right hemicolectomies, 3 left hemicolectomies, 1 total colectomy and 7 rectopexies (6 with sigmoid resection) were performed. 3 patients with advanced malignant disease underwent colostomy. There was a conversion rate of 26%, largely due to adhesions or unclear anatomy, decreasing with increasing experience. One trokar-injury of a major vessel required immediate conversion to laparotomy. 2 reoperations were performed, for an anastomotic leakage after low anterior resection and an incarcerated port-site-hernia respectively. A rather high rate of wound infections (27%) was reduced to 15% by modifying the technique for retrieval of the specimen. The median postoperative hospital stay was 11.6 days. The trend towards shorter hospital stay and recovery should not result in uncritical use of laparoscopy in colon surgery, in an attempt to meet the rising demand for less postoperative pain and shorter hospital stay. This criticism mainly applies to tumor surgery, where laparoscopic procedures are indicated in our institution only for palliative treatment.

To overcome the donor shortage, any potential donor resource must be detected. By establishing a professional service for peripheral hospitals, the numbers of donors available in small hospitals could be nearly doubled: 85% of all donors in our region come from nonuniversity hospitals. By using total quality management techniques, the time requirements for organ donation after confirmation of brain-death and given consent could be reduced to 6 h.

Head traumas frequently occur in polytrauma patients but are also found as isolated injuries. In our hospital trauma center without a neurosurgical department, in a 21-month period, 489 patients with head/brain trauma were treated. This represents 6.5% of all patients treated in the trauma and reconstructive surgery clinic. In commotio cerebri (CC = 89.5% of the patients) constant conservative management and an uneventful course were observed; in 69 patients with contusio cerebri, 18 craniotomy operations had to be performed. In contrast, in only two cases was reoperation because of recurrent hematoma necessary. In four cases with complex and/or additional injuries, transfer to a neurosurgical center took place, and in two cases photophone consultation with that center was used. The mortality was 14.5%. The diagnostic and therapeutic regimens for the different types of injury and the requirements for the management of head/brain trauma in trauma centers without neurosurgical departments are presented: emergency service and medical staff, emergency room management, intensive care management, qualified neurological examination, X-ray imaging, including CT scan, OP-room equipment and trained surgeons. If these requirements are not available in a given hospital, early transfer of all patients for whom surgical management could be necessary to a neurosurgical department should be attempted. Only in patients with severe bleeding must immediate craniotomy be performed even in hospitals which do not have all the above mentioned facilities. In patients with intracerebral bleeding, bleeding in the dorsal fossa, injury of brain nerves, carotid artery or sinus cavernosus injuries, frontobasal injuries with liquor fistula or pneumonencephalon, transfer of the patients to specialized neurosurgical centers is indicated. With this selection, we obtained the same results in a trauma center without a neurosurgical department as reported in the literature. This avoids overloading neurosurgical centers with head/brain injury patients.

Today, orthotopic liver transplantation is the treatment of choice for the endstage of various liver diseases, and a 1-year survival rate of over 80% is reported in international surveys. The liver transplant program of the Inselspital is very small compared to international centers and this may raise questions about the results and the justification for such a program. In a 24-month period, 20 liver transplants (including 2 retransplants) have been performed in 18 patients at the Inselspital. 2 patients (11%) died 20 and 268 days respectively after transplantation. 2 patients (11%) had significant morbidity 502 and 529 days respectively after transplantation. After a median follow-up of 11.5 months postoperatively, 14 (80% of all patients) lived an independent life. 9 (50%) were fully reintegrated in the household or in their profession and 5 others (30%) were working part time. We conclude that even a small liver transplant program based only on routine resources can achieve results comparable to international standards.

Though German hospitals are normally not built for day case surgery, this became a new challenge based on changed legal regulations. A stepwise adaptation of the present facilities to the altered necessities seems to be a relatively simple way to realise day case surgery also in hospitals. Preoperatively surgeons and anaesthetists offer office hours during the same time to avoid patients having to wait. On the day of surgery patients are admitted to the hospital and treated like inpatients with regular transport to the operating room for anaesthesia and surgery, followed by recovery room stay and transmission to the normal ward. At a fixed time in the afternoon patients are visited by the surgeon and the anaesthetist to clear the conditions for dismission. While anaesthesia, surgery and recovery take the same time as for inpatients, the pre- and postoperative procedures are more time consuming. With a rising number of outpatients a separate department for outpatient surgery with its own administration, operating theaters and day case ward should be developed.

The report describes the inpatient and out-patient treatment facilities for alcoholics in a defined catchment area and the experience gathered by the initiation of out-patient group therapy for a group of alcoholics at the general community hospital in Offenbach/Main. The goal of the group therapy at the hospital was to establish post-withdrawal treatment care for alcoholics after short-term clinical and long-term sanatorium withdrawals. It was hoped that group therapy experience would reduce the high drop-out rate of patients after hospitalization and after long-term sanatorium treatment, especially by patients with more severe social or psychic disorders. Experience showed that those capable of group therapy maintained contact to the group, others, the main target group of patients took little advantage of the therapy offered.

We describe a case of severe hypothermia in a 32-year-old patient who fell into a crevasse. Three hours later he was rescued and flown to a district hospital. On arrival he was apparently dead, with cadaveric skin, dilated and fixed pupils, pulseless and in respiratory arrest. His rectal temperature was 26 degrees C. On the ECG monitor there was first ventricular fibrillation, then, after several unsuccessful attempts at defibrillation, the heart became asystolic. Cardiopulmonary resuscitation was begun with orotracheal intubation and external cardiac compression, which eventually lasted 4 hours and continuously required a team of 6 persons. Only at a temperature of 32.5 degrees C could the patient be defibrillated with success. In the absence of extracorporeal circulation (ECC) the victim was rewarmed by warm-air breathing and by instillation of warm saline in peritoneum, stomach and bladder. In this way the rewarming velocity was 1.8 degrees C/hour. The postacute course was characterized by severe rhabdomyolysis (CK of 100,000 U/L) with non-oliguric renal failure, which necessitated several sessions of hemodialysis. Four months later the asymptomatic patient returned to work. Our case shows that a severely hypothermic patient can successfully be treated in a primary hospital not equipped with an ECC, provided that there is a sufficiently large team. Further, uninterrupted external cardiac compression guarantees efficient circulation even over several hours. Electric defibrillation in a hypothermic patient is ineffective unless normal body temperature has been reached. Lastly, every effort to continue resuscitation must be made in the still hypothermic patient whose absence of clinical response may obscure the real possibility of complete recovery.

From January 1, 1989 to September 30, 1990, 116 patients with acute myocardial infarction were hospitalized at the regional hospital of Langenthal. Of those 116 patients, 27 (23%) were treated with intravenous streptokinase; in 12 of them (44%) CPK reached its peak within 6 hours after starting lysis; all were admitted within 4 hours after the beginning of chest pain. Of the fibrinolyzed patients, 18 (67%) had arrhythmias which needed to be treated. In 10 of these 18 patients CPK reached its peak within 6 hours. Of the 89 patients not treated with streptokinase, 27 (30%) did not fulfill the entry criteria of the protocol, 16 (18%) had exclusion criteria, and 46 (52%) had exclusion criteria as well as absent inclusion criteria. In only 4 patients (4.5%) was lysis not possible because they entered hospital later than 6 hours after the beginning of pain, and 8 patients (9%) exceeded the upper age limit of 70 years. Of the 116 patients, 13 (11.2%) died; 12 were not treated with streptokinase. Our study shows that fibrinolytic treatment with streptokinase is a safe and effective therapy for patients with acute myocardial infarction and can easily be performed in a regional hospital.

Data of the German Microcensus of 1989 and DTI (diagnosis and therapy index) of Infratest Health Research for 1989 are used to provide a detailed description of the situation of patients of 65 years and older in German acute-care hospitals. Among others the average length of stay, diagnosis, intensity of care, or success of therapy are calculated for ages 65-74, 75-84, and 85+ for both sexes.

Motivated by own experiences in consultation- and liaison-psychiatry in the USA and in internal medicine in Switzerland, the author describes history, present state and value of consultation- and liaison-psychiatry for patient care. Obstacles against implementation of consultation- and liaison-psychiatry in Switzerland are discussed.

There is no correlation between the number of places for surgical education and the real demand for surgeons. In Bavaria 86.7% of all surgeons licensed to train surgeons between 1-6 ys. took part in an inquiry. They asked for 25-30% surgeons in their residency staff but got only 8-24% in reality. In addition 60.2% of all resident wait for a place to finish their surgical training in fully licensed hospitals. In a big community hospital there are no problems for residents to get the needed number of operations. Beside this surgical education should include 6 months clinical training in ICU, 2.5 ys. general, 1.5 trauma and 1 year vascular-thoracis surgery. Basic science and research can be done only in universities, but clinical control of patients outcome, i.e. in tumor patients is mandatory.