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Background: Chronic pain is frequent in elderly people and, especially if widespread, associated with poor mental health. We investigated whether a resilient personality protects older adults against the adverse effects of chronic pain.Methods: Pain status [no pain, chronic local pain (CLP) and chronic widespread pain (CWP)] was determined using the American College of Rheumatologists' criteria for widespread pain in a cross-sectional sample of 724 participants aged 68-92 years drawn from the population-based KORA-Age study in Southern Germany. Depressive symptoms and resilience were assessed via the scales GDS-15 and RS-5. The relation between pain, resilience and depressive symptoms was modelled using logistic and quantile regression.Results: CLP prevalence and CWP prevalence were 57.5% and 12.3%, respectively. Confounder-adjusted logistic regression indicated a fourfold risk of depressed mood (GDS-15 ≥ 5) in CWP, vs. no pain (OR = 4.08, 95% CI 1.90-8.74). However, in quantile regression, the adverse effect of CWP was significantly attenuated by resilience when looking at the GDS-15 score lower quartile (p = 0.011) and median (p = 0.011). This effect appeared to be mainly driven by participants aged 75-84 years. Confounder adjustment reduced the effect of CLP on depressive symptoms to non-significance, and effect modification by resilience was undetectable in regression models of CLP.Conclusions: Resilience was protective in the association of CWP with depressive symptoms in this analysis. Older adults with CWP may potentially benefit from interventions supporting resilience. Prospective research should investigate the protective role of resilience in the potentially self-perpetuating relation between chronic pain and depressed affect. WHAT DOES THIS STUDY ADD?: The association of chronic widespread pain with depressive symptoms in the elderly population is attenuated by resilience. [ABSTRACT FROM AUTHOR]

Starting shortly after the reunification of Germany and lasting up to the end of the 1990s, an extensive series of retrospective exposure investigations for the East German uranium mining industry was performed in order to provide information about the exposure situation of the miners towards respirable dust, inhalable dust, crystalline silica and heavy metals. It should provide the necessary information for legal compensation of miners with potential industrial diseases as well as for epidemiological research. Extensive side-by-side measurements using original historic equipments as well as comprehensive evaluation of the time increments of specific jobs with respect to exposure relevant tasks were performed. After attributing average exposures to the tasks, shift exposures for the jobs could be calculated. By the end a comprehensive job exposure matrix for all underground jobs of the German uranium mining industry was developed for the components mentioned, including arsenic where relevant. In the early days of SAG/SDAG Wismut dust and silica exposures were extremely high with respirable dust up to 20 mg/m3 and respirable crystalline silica well above 2 mg/m3 as shift averages. Beginning from about the early 1960s dust control measures started to improve conditions dramatically. It is absolutely necessary to invest sufficient effort for the estimation of exposure situations of past technological environments. Especially, the situation of early mechanised mining, characterised by low ventilation, dry drilling techniques and generally lacking dust control measures was characterized by extreme shift exposures. It is important to keep these in mind when metal mining exposure in different environments is considered. [ABSTRACT FROM AUTHOR]

Objective: Working conditions are known to affect motivation, well-being, and ultimately work performance. Helicopter emergency medical services (HEMS) pilots' work is highly demanding and safety critical, but virtually no published data on occupational stress and strain symptoms in HEMS pilots are available. We investigated work stressors and resources and their association with work engagement, subjective well-being, and energy levels in European HEMS pilots., Methods: Cross-sectional questionnaire data were collected consecutively from 72 European HEMS pilots (24 Western European and 48 Eastern European, mean age = 51.9 years). We examined the stressor, resource, and strain symptom levels by age group and region of origin and the association of stressors and resources with work engagement, well-being, and energy., Results: Although the responses differed notably between the Eastern and Western European pilots, their overall profile was quite favorable. At the same time, those stressor/resource variables, which on average had the most favorable ratings, were the most strongly associated with (reduced) well-being and energy., Conclusion: On the whole, the HEMS pilots' perception of their work situation appears to be positive, and they are highly engaged in their work. The pilots' strong identification with their work should be taken into account in pilot mental health support systems., (Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany., Methods: In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery., Results: From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents., Conclusion: The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

The German S3 Guideline on Treatment of Polytrauma/Severely Injured Patients characterizes key recommendations on the current diagnostic and therapeutic approach in concomitant thoracic and abdominal trauma based on the available scientific data. The special requirements for appropriate basic treatment can be derived for rural hospitals, even though the particular grade of recommendation often is low because evidence-based studies are still lacking.The options for adequate basic treatment of thoracic and abdominal trauma in patients with multiple injuries treated in rural hospitals substantially depend on the dedication, the level of experience and training, and the willingness of the locally responsible team to cooperate.

Background and Objective: Quality of life is of vital importance for patients undergoing surgery. However, little is known about the quality of life of surgeons who are facing a stressful and dramatically changing working environment. For this reason, this large scale study investigated the quality of life (QL) of surgeons in Germany in the context of occupational, private, and system-related risk factors with a standardized QL measurement instrument., Methods: The study population consisted of attendees (surgeons, non-surgical physicians, medical students) of the nine major annual conferences of the German Society of Surgery between 2008 and 2009. Participants filled in a single questionnaire including study-specific questions (demographic variables, professional position, and occupational situation) and a standardized quality of life instrument. Surgeons' responses with regard to their professional situation and their quality of life were contrasted with those of the two controls (non-surgical physicians, i. e. orthopedics, pediatrics, gastroenterologists and medical students). Furthermore, QL scores were compared with German population reference data and with reference data of several patient groups., Results: 3652 individuals (2991 surgeons, 561 non-surgical physicians, 100 medical students) participated in this study. 68 % of the surgeons but only 39 % of the non-surgeons worked more than 60 hours per week on average. Surgeons reported restrictions on their private and family life due to work overload, more so than non-surgeons (74 % vs. 59 %). Responses to the PLC quality of life questionnaire confirmed these results, showing score values lower than those of the German population reference data and of several patient groups., Conclusion: The time has come for surgeons to consider their own quality of life, as this is a main issue in their scientific and clinical work with patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Quality of life is of vital importance for patients undergoing surgery. However, little is known about the quality of life of surgeons who are facing a stressful and dramatically changing working environment. For this reason, this large-scale study investigated the quality of life (QL) of surgeons in Germany in the context of occupational, private, and system-related risk factors., Methods: The study population consisted of attendees (surgeons, non-surgical physicians, medical students) of the nine major annual conferences of the German Society of Surgery between 2008 and 2009. Participants filled in a single questionnaire including study-specific questions (demographic variables, professional position, and occupational situation) and a standardized quality of life instrument (Profiles of quality of life of the chronically ill, PLC). Surgeons' responses with regard to their professional situation and their quality of life were contrasted with those of the two controls (non-surgical physicians, medical students). Furthermore, PLC scores were compared with German population reference data and with reference data of several patient groups., Results: Individuals (3,652) (2,991 surgeons, 561 non-surgical physicians, 100 medical students) participated in this study. The average age of surgeons and non-surgeons was in the low forties. In terms of professional qualifications, the majority of surgeons were residents (30%) and the majority of non-surgeons consultants in private practice (38%). Sixty-eight percent of the surgeons, only 39% of the non-surgeons worked more than 60 h per week on average (p < 0.001). Surgeons regarded their administrative workload as high (67% vs. controls 57%, p < 0.001). Surgeons reported restrictions on their private and family life due to work overload, more so than non-surgeons (74% vs. 59%, p < 0.001). Of the surgeons, 40% regarded their quality of life as worse than that of the general public (non-surgeons, 22%; p < 0.001). A third (32%) of the surgeons considered their quality of life even lower than that of their patients (non-surgeons, 17%; p < 0.001). Responses to the PLC quality of life questionnaire confirmed these results, showing score values lower than those of the German population reference data and of several patient groups. Multiple regression analyses showed that the strongest and most consistent influence variable for a low quality of life on all eight quality of life scores were restrictions in private life (range of standardized beta weights beta = 0.259 to 0.325), hierarchical and uncooperative working environment (beta = 0.057 to 0.235), lack of opportunities for continuing education (beta = 0.108 to 0.161), and inadequate salary (beta = 0.036 to 0.172)., Conclusions: Improving the working conditions for surgeons requires a concerted action of all relevant parties, including hospital administrators, insurance companies, and the German Society of Surgery. The present study clearly identified measures that should be taken.

Due to logistic, organizational and economic advantages, interdisciplinary emergency centers are gaining more and more acceptance compared to established, discipline-specific and independent emergency rooms. Organizational concepts for interdisciplinary emergency centers need to consider the mandate for comprehensive patient care and the consequential performance spectrum. Thus, the implementation of generally accepted guidelines and specifications is demanding.Currently developed concepts of the accordant interdisciplinary working groups try to fulfill these premises. Further fundamental criteria to be met are the quality and education of medical and nursing staff, which are predominantly doing their jobs within the interdisciplinary emergency centers. The concept of the German surgical societies and connected organizations is not the implementation of a new definition of the role of emergency specialized physicians but rather a substantial advancement of the existing and established regulations for further education. Therefore, a further advanced-training program for clinical emergency medicine has to be implemented in addition to the existing emergency education within the common trunk, which every physician has to pass through during discipline-specific education. Furthermore, this program should complement the existing pre-clinical emergency education, which can be acquired after specialization.The accordant criteria to be developed and the coordination with the German Medical Association (Bundesärztekammer) are currently prioritized on the agenda of the interdisciplinary working group. Due to reasons of compatibility with the regulations for further education, specific management skills for future heads and directors of such interdisciplinary emergency centers should not be stipulated within the advanced-training program for clinical emergency medicine but should be gained through specific course concepts beyond this program.

Yersinia enterocolitica is a major foodborne pathogen and the third most important bacteriological cause of diarrhea in Germany. However, studies investigating the occurrence of human pathogenic Y. enterocolitica in food at the retail level are very rare. Most of the studies published so far show qualitative but not quantitative data concerning the prevalence of this human pathogen. In this study the qualitative and quantitative assessment of human pathogenic Y. enterocolitica in different food matrices was investigated. For the qualitative analysis we used an enrichment method according to the International Organisation of Standardization (ISO) standard in combination with a real-time polymerase chain reaction (PCR) method detecting the ail gene of Y. enterocolitica. After detecting Y. enterocolitica in a sample, a quantitative investigation on Cefsulodin-Irgasan-Novobiocin (CIN) Agar was done to get information about the contamination level of the different samples. During the years 2008 and 2009, 446 samples of pork and pork products, 51 samples of game meat, and 61 raw milk samples were investigated for the presence of human pathogenic Y. enterocolitica. The samples were collected at the retail level in Bavaria. From the pork samples investigated, 81 samples (18%) were positive for the ail gene by real-time PCR, but human pathogenic Y. enterocolitica O:3 were found only in 46 (10%) pork samples by culture; the concentration in the samples ranged between 0.04 cfu/g and 2.30 × 10(5) cfu/g. Three game meat samples were positive by real-time PCR, but not by the cultural detection. All raw milk samples were negative by real-time PCR and culture.

Background: Surgeons have criticized the working conditions at German hospitals. They complain in particular about long working hours, an inadequate salary for their work, insufficient training/supervision, and an increasing amount of time spent on administration duties. Since these critics are only subjective perceptions, they should be compared to data that can be quantified more objectively and accurately. In this study, we sought to report precise data on surgeons' workflow in several German hospitals., Method: General surgeons were shadowed unobtrusively over 567 h during their shifts at four urban German hospitals. All job tasks surgeons performed were recorded using a tablet PC., Results: The average work day of the surgeons in this study was 9 h 26 min (95% CI 09:10:30 to 09:42:44 h). Within this time span, an average of 02:03:08 h were spent on documentation and administration duties (95% CI 01:47:29 to 02:18:47 h), 01:47:40 h on operating procedures (95% CI 01:20:44 to 02:14:35 h), 01:43:46 h on internal communication (95% CI 01:32:55 to 01:54:36 h), and 0:48:25 h on ward rounds (95% CI 0:39:55 to 0:56:55 h)., Conclusion: For the first time, surgeons' workflow in German hospitals was studied in real time. The study results substantiate physicians' statements about their own working conditions, especially with concerns to large amount of time spent on administration tasks. The findings of this study form a basis upon which further analysis can be built and recommendations for improvements in physicians' workflows at German hospitals can be made.

Medical developments have led to extensive specialization in the field of surgery. This has already been reflected for many years in altered structure and organization forms of surgical clinics. Indispensable quality standards, statutory general conditions, increasing competition in service providers and health insurance with transparency of the service procedure all intensify this trend. The aim of this investigation was, therefore, to determine how far this differentiation of service supply in the field of surgery is also reflected in the area and in surgical departments and clinics of basic and routine supply. To achieve this, all available published information on the structure and organization of surgical clinics in the Federal Republic of Germany was classified according to current departmentalization into "undivided" or general/visceral surgery facilities compared to orthopedic/trauma surgery departments.

Background: The concept of evidence-based medicine was introduced into surgery in the mid-1990s, initially focussing on the integration of best research evidence, surgeons' expertise and patients' value. The lack of relevant external evidence [randomised controlled trials (RCTs), systematic reviews] in favour of surgical procedures has led to the need for a new approach in clinical research., Design: Development and implementation of the Study Centre of the German Surgical Society (SDGC) in order to design, perform and analyse multicentre randomised controlled trials in surgery., Results: The German Surgical Society has recently initiated four surgical RCTs within the SDGC in order to improve the national infrastructure for clinical research and its international scientific standing. All surgical trials focus on procedures in various fields (thyroid and parathyroid diseases, pancreatic surgery, abdominal wall closure) and are designed to fit the specific needs of each study (blinding of patients and assessors, ranking of endpoints, patients' perspective). Additionally, in a nationwide survey of 1,274 surgical departments in Germany, 307 replied, of which 237 (19%) were willing to participate in multicentre projects., Conclusion: Evidence-based medicine has changed surgical practice, leading to an increase in demand for RCTs and requiring a new infrastructure in surgical departments and scientific societies.

The Brief Repeatable Battery of Neuropsychological Tests (BRB-N) is a neuropsychological screening battery, often applied in multiple sclerosis (MS) patients. It is almost exclusively administered in trials and not in the daily practice routine because of the lack of normative values. Using a stepwise linear regression analysis, the dependence of test results on age, gender, and education of 241 healthy control subjects was investigated. Z-values of -1.68 or less were considered pathological. Based on the normative values, the proportions of cognitively impaired patients with relapsing-remitting MS (RRMS, n=43) and secondary progressive MS patients (SPMS, n=60) were calculated. The regression model explained 2.7-25.0% of the variance of test performances. Cognitive impairment occurred in 38% and in 47% of the RRMS and the SPMS groups, respectively. In both groups attention and concentration impairment was prominent, while in the SPMS group memory was also frequently affected. The proportion of cognitively impaired MS patients reflected the figures that could be found in the literature.

Introduction: The main objective of surgery of rectal carcinomas is to avoid a permanent colostomy by sphincter-sparing surgical procedures. A variety of different abdominoperineal resection rates is described in the literature., Material/method: The study was performed in 2000 within the framework of a multicentric study including 282 hospitals. The purpose of the study was to document the quality of diagnosis and therapy for colorectal carcinomas.A total of 9477 patients were included in this study: 3402 suffering from a rectal carcinoma and 6075 suffering from a colon carcinoma., Results: A total of 866 abdominoperineal resections was performed. This corresponds to an abdominoperineal resection rate of 27.4%. In 30.4% of all men and in 23.0% of all women an abdominoperineal resection was performed. Of all tumor patients who underwent abdominoperineal resection, 8.3% had a pT4 carcinoma and 57.5% a pT3 carcinoma. Adapted to the localization of the tumor in the rectum, i.e., the distance of the aboral tumor margin to the anal verge, the following abdominoperineal resection rates were found: <4 cm from the anal verge 84.6%, 4-7.9 cm 43.9%, 8-11.9 cm 5.8%, and 12-16 cm 0.5%.Intraoperative complications occurred in 11.8%, specific postoperative complications in 33.1%, and general postoperative complications in 27.4% of the patients. The postoperative lethality was 2.8%. The mean postoperative hospital stay was 21.7 days. Logistic regression identified the body mass index, gender, the distance of the carcinoma from the anal verge, and the T category as independent factors influencing the abdominoperineal resection rate., Discussion: Despite an overall decrease in use, abdominoperineal resection will continue to play an important role for the surgical treatment of low rectal cancers in routine clinical practice in Germany. It will remain an individual decision for each patient whether the tumor and the patient allow sphincter preservation or whether abdominoperineal resection seems to be necessary. According to the results of the present study,a general definition of an abdominoperineal resection rate in an unselected group of patients should be viewed critically.

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

Surgery and surgeons have a direct relationship to publicity. In the media, the entertainment aspect prevails over information (infotainment), and scandal also dominates because of negative reports. The cause in many cases is a lack of information, which is always a problem when transmitting scientific information to the public. Economic pressures and diminished resources as well as a simultaneous increase in the demands made on medicine make it mandatory that surgeons communicate properly. They are being degraded more and more to "delivering" medicine, and the relationship between the surgeon and his patient has been reduced to a collision of greediness on both sides. We are in continuous conflict with the power of the media and are being challenged to improve our public relations. The public image of surgery today is determined by surgical performance and competence in communication.

Quality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance. Regarding the triage, for example, it was noted that 28% of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7% of patients two additional mistakes and in 4% of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment. Preclinical intubation and mechanical ventilation was not performed in 16.5% although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38% of patients suffering from severe thoracic trauma (AISThorax > or = 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17% of all documented patients. According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.

Deficits in the treatment of patients with chronic pain lead the German Parliament of Physicians (Deutscher Arztetag) in 1996 to adapt a special curriculum called "Special Pain Treatment". Objectives and contents are defined in detail in guidelines accepted from 10 out of 17 federal commissions in Germany at this time. Because transitional regulations have been administered until now, surgeons have not yet been required to obtain the qualification. The prescribed curriculum and particularly the contract between the association of general practitioners and the insurance companies make the acquisition of the qualification and the permission to use it in private practice covered by insurance very difficult for surgeons.

From the new payment system of procedure (covering anesthesia and surgery with all personal and material costs) or case related payment (including all costs of operation and hospital stay, medical as well as room-and-care and administrative), in 1996 for all German hospitals obligatory introduced, 22 respectively 9 concern abdominal surgery. The calculation of the prizes, carried out nation wide in reference hospitals, with defined point numbers in the whole republic and different point values in singular countries, are very questionable in their economic value. Before the introduction of these reimbursement systems it is necessary to calculate the hospital specific costs, to analyze possible savings of resources through rationalization and to estimate prospectively the expected case numbers. In consequence increasing economic responsibility comes up to the surgeon.

Aim: The perioperative risk in patients undergoing coronary artery bypass grafting (CABG) might be influenced by premedication procedures. This study was undertaken to evaluate present premedication regimens in CABG patients in Germany., Methods: Using a detailed written questionnaire, each of the 58 German centres of cardioanaesthesia were asked to complete it., Results: 37 (64%) of all questionnaires were returned and analysed. All centres used orally administered drugs for premedication in the evening before the operation. Flunitrazepam is the most often administered drug (54%), followed by dipotassium clorazepat (8%), and diazepam (8%). Premedication in the morning on the day of surgery is performed orally in 29 centres (78%), of which 18 centres (49%) prefer flunitrazepam and 6 centres (16%) midazolam as first choice. In contrast, 7 centres (19%) used intramuscularly administered regimens. 5 centres (14%) combined intramuscularly opioids with sedatives for that indication. If anaesthesia was induced late in the morning or in the afternoon, respectively, 11 centres (30%) administered additional benzodiazepines early in the morning. 68% of all centres maintained the administration of chronic treatment with ss-blockers until the morning of the operating day. Chronic treatment with nitrates is continued in 65%, treatment with calcium-channel blockers in 62%. Angiotensin converting enzyme inhibitors are continued in 30%, alpha 2-agonists in 27%, other antihypertensive drugs in 19%, and inotropic glycosids in 11%. 31 of 37 centres (84%) discontinued the administration of acetylsalicylic acid 5 or more days prior to surgery, but 68% tolerate individual exceptions from this principle., Conclusions: The results of our survey indicate that most of the German cardioanaesthesia centres use oral premedication regimens in patients undergoing coronary revascularisation. Anti-anginal medications, with the exception of anti-platelet agents, were continued until the day of surgery in most of the centres.

The legally defined providing order for hospitals as a presupposition for the providing contract with insurance companies will be of increasing importance for hospital management in the future. The legal basis is described and discussed.

Progress in perioperative management, anesthesia, surgical technique and intensive care have led to a continuous reduction in risk for geriatric patients. Thus advanced age itself means no higher operative risk and should not be a cause for excluding the elderly from greater curative procedures. But it is necessary to define a special strategy of treatment which takes the special situation of the elderly into consideration. Older people are very often high risk patients because they must be operated with advanced diseases. Earlier operations in the elective state, therefore, have great significance in the prevention of geriatric surgery.

The theoretical knowledge and practical experience necessary for the certification as a specialist are laid down in the rules for continuing medical education and are acquired during the time as a resident usually in a curricular manner. After a final exam, the formal graduation as a specialist is confirmed by handing over a specialist certificate by the society of physicians of Germany. According to the current jurisdiction (so-called "specialist" judgment by the German court of justice from March 3, 1992) and the arrangement of the self-administration, the terms "specialist quality" and "specialist certification" got a particular meaning which may not be set to equal from the medical point of view. This is demonstrated by a critical comment to the "specialist" judgment. Future problems of the specialist training in hospitals are pointed out.

According to new German health care laws (Gesundheitsstrukturgesetz, Bundespflegesatzverordnung) hospital payment will be given a new basis. Abandoning the "length of stay"--related compensation in the future surgical services should be refunded either by special payments for a given surgical procedure (covering anesthesia, surgery, instruments), or by case-related payments (including all costs of stay, medical as well as room-and-care and administrative). This should lead to a more equitable payment getting a transparent insight into the relation service/cost. Calculations for the so far 103 special payment and 40 case related payment items have been obtained by a nationwide analysis in reference hospitals. Besides numerous problems introducing these new refund systems in very different hospital structures, our own 3-year experience using case related payment on our surgical department (based on individual calculation) shows promising results. The main intention still has to be--by setting free economic resources--to avoid rationing though rationalization.

The necessary and possible rate of transplantations is limited by the insufficient availability of donor organs. In the FRG, only 36% of all hospitals (transplantation centers excluded) are active in postmortem organ donation. In only 57% are other organs than the kidneys (liver, pancreas, heart, lung) explanted. The main problems do not derive primarily from structural difficulties (no intensive care unit, limited capacity of operation room or staff), but from an insufficient degree of cooperation with the transplantation center and an uncertain legal position. Possible solutions to the problem (transplantation coordinator, legal regulation) are discussed.