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Currently laparoscopic cholecystectomy is the gold standard of therapy for diseases related with gallstones, namely symptomatic cholecystolithiasis, acute and chronic cholecystitis and also as therapy for gallbladder adenoids. Together with laparoscopic appendectomy, this procedure often is one of the first laparoscopic operations performed by new interns. Therefore a standardised, reproducible approach to ensure the patient safety is necessary. The procedure can be subdivided into 10 substeps--so-called "nodal points"--which must be completed before the next substep can be started. This article and the attached video show the ten "nodal points" of a standardised laparoscopic cholecystectomy., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Right ventricular pacing predisposes to the development of heart failure and atrial fibrillation. Automatic atrioventricular search hysteresis (AVSH) is a commonly used strategy to decrease the percentage of right ventricular pacing (%VP) in patients without permanent AV block, but the results have not been optimal., Methods: The randomized, crossover PREVENT study evaluated whether an enhanced AVSH with two new features can reduce %VP compared with standard AVSH. The new features are the repetitive hysteresis [switch from extended to basic AV delay after a consistent loss of intrinsic AV conduction (IAVC) lasting for six consecutive atrial cycles] and the scan hysteresis (periodic IAVC search extension over six consecutive atrial cycles). Both standard AVSH and enhanced AVSH performed a periodic IAVC search every 180 cardiac cycles and operated with a basic AV-delay of 225 ms and a rate-independent maximum AV-delay of 300 ms for paced and sensed atrial events., Results: Among 178 patients, 53.4% had no evidence of AV block at enrollment and 46.6% had history of intermittent AV block. The median %VP was decreased by enhanced AVSH compared to standard AVSH (4.0% vs 5.5%, P < 0.001), particularly in patients with a history of AV block (21.4% vs 25.5%, P < 0.001). The primary study hypothesis that 25% of all patients would experience > 20% relative %VP reduction was not met as 46 (25.8%) patients (95% confidence interval, 20.5-31.8%) presented such relative reduction., Conclusion: The enhanced AVSH algorithm reduces %VP compared with standard AVSH in patients with intermittent AV block., (©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc.)

Objectives: To model the 2-year cost-effectiveness of secondary prevention with clopidogrel versus aspirin (acetylsalicylic acid) (ASS) in German patients with myocardial infarction (MI), ischaemic stroke (IS) or diagnosed with peripheral arterial disease (PAD), based on CAPRIE trial data and from the perspective of German third party payers (TPP)., Methods: An existing Markov model was adapted to Germany by using German cost data. The model was extended by using different datasets for cardiovascular event survival times (Framingham vs. Saskatchewan health databases) and in two separate scenarios., Results: The treatment with clopidogrel leads to a reduction of 13.19 vascular events per 1000 patients, of which 2.21 are vascular deaths. The overall incremental costs for the 2-year management of atherothrombotic patients with clopidogrel instead of ASS are calculated to be about euro1 241 440 per 1000 patients. The number of life-years saved (LYS) has been calculated as the difference in the number of life-years lost due to vascular death or events with ASS versus clopidogrel: it is 86.35 LYS when analysis is based on Framingham data and 66.07 LYS with Saskatchewan-based survival data. The incremental costs per LYS are euro14 380 and euro18 790, respectively. Cost-effectiveness is sensitive to changes in survival data, discounting and daily costs of clopidogrel, but stable against substantial (+/- 25%) changes in all other cost data., Conclusion: The findings for Germany are in line with published results for Belgium (euro13 390 per LYS) and also with results for Italy (euro17 500 per LYS), both based on Saskatchewan data, and with a French analysis based on Framingham data (euro15 907 per LYS). Even if no officially accepted cost-effectiveness threshold exists for Germany at present, incremental cost-effectiveness results of less than euro20 000 per LYS for the treatment with clopidogrel can be assumed to be acceptable for German third party payers.

Background: Current studies on secondary prevention of cardiovascular events (CARE, LIPID, 4S) illustrate the necessity of an effective lipid-lowering therapy. An important part of secondary prevention is the prompt measurement of lipids following an infarct, to be able to start therapy as quickly as possible., Aims: This study should show the general situation in the prescription of lipid-lowering drugs in patients with acute myocardial infarction (MI) and if there are gender differences in therapy and in the lipid parameters. The second aim was to determine the therapeutical conclusions for secondary prevention made in-hospital in patients with heart attacks., Methods: Post-infarct lipid parameters (total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides (TG) were examined in 5361 patients within 24 hours following an acute MI. Lipid parameters from 576 patients were measured again after 1 week., Results: 80.1% of men under examination and 81.9% of the women had suffered from their first MI. Only 9% of all patients were already under lipid-lowering therapy before the MI. After the MI TC and LDL-C levels decreased significantly in a time-dependent manner. Around 50% of patients received lipid-lowering drug, or the recommendation of one, during their hospital stay., Conclusion: The range of TC values of the patients examined was comparable to those in the CARE and the 4S secondary prevention studies. It can therefore be assumed that the results of these studies are also applicable to Germany. Nevertheless, according to existing data, therapy with lipid-lowering drugs is currently unsatisfactory, even in secondary prevention.

Due to the financial restrictions imposed on all national health services, the problem of allocating medical resources has gained new economical and political dimensions. Although each patient expects optimal treatment, the rationing of medical services make it increasingly difficult to provide the most adequate therapy. Health politicians and medical doctors have all advocated that health expenditures can be reduced by effective prevention of coronary heart disease, one of the main cost factors for all health services. Due to the introduction of statins, primary and secondary prevention of coronary heart disease can now be accomplished effectively. However, such treatment does not induce cost reduction, but rather an increase in costs. This applies predominantly to primary prevention. Treatment of all who would benefit from lipid lowering by statins would be prohibitively expensive for all national health care systems.

Three different forms of rehabilitation in patients after myocardial infarction are discussed on the basis of cost-effectiveness: 1) outpatient rehabilitation as performed in North America and other developed countries, 2) inpatient rehabilitation in Germany, and 3) outpatient rehabilitation in Germany. Parameters compared are mortality, coronary risk factor profile, and return to work. A metaanalysis of international studies on outpatient rehabilitation demonstrated a significant reduction of total and cardiovascular mortality. Similar data are not available for inpatient rehabilitation in Germany. However, data of 6 years of outpatient rehabilitation as performed in the "Heidelberg Study" demonstrate a continuous significant improvement in coronary risk factor profile and cardiopulmonary fitness. On the other hand, 4 weeks of inpatient rehabilitation exhibited only short-term and no long-lasting effects (4 years) on coronary risk factor profile. The economic benefit can be based on return to work, which is only marginally affected by rehabilitation in the USA, where more than 80% of the patients are back to work 6 months after myocardial infarction. In Germany, about 5 months after myocardial infarction 50% of the patients are retired, despite 4-6 weeks inpatient rehabilitation; i.e., the patients which are back to work can be assumed to be less than 50%. The costs of 8 weeks outpatient rehabilitation in North America has been calculated to be 804 DM per patient, 4 weeks of inpatient rehabilitation amounts to about 5320-5600 DM, and 1 year ambulatory treatment in the "Heidelberg Study" accounts for 2270 DM per patient. It can be concluded: outpatient rehabilitation as performed in North America has been shown to significantly reduce total and cardiovascular mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1.1. 1985 to 31. 12. 1990 n = 10,569 emergency cases were prospectively documented. The aim of the study was to evaluate, whether surgeons on a mobile emergency care and rescue unit were able to treat surgical and non-surgical emergencies sufficiently during the prehospital period. 16.8% of the patients were trauma patients while 47% suffered from medical disorders, e.g. myocardial infarction (12%), other cardiocirculatory disorders (7%) and acute opiate and multidrug poisoning (16%). Additionally, other problems out of the broad spectrum of emergency medicine such as disorders from pediatrics, neurology/neurosurgery, gynecology, toxicology, pulmonology, endocrinology etc. had to be solved. More than 50% suffered from life-threatening emergencies, 5.6% required cardio-pulmonary resuscitation, 45% of which were primarily successful. In-field deaths where emergency treatment was not successful occurred in 3.2%. The mortality rate during transport to the next available hospital was 0.1%. It can be concluded from the study that well trained surgeons are very capable to perform high efficient in-field emergency treatment for various disorders.