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Introduction Regional health care networks with interfaces between clinics, general practitioners and patients can act faster when utilizing digital measures. This manuscript describes the establishment of an online video consultation service in a clinic and its broad health care region to exemplify challenges and solutions for potential future approaches from a management perspective. Method The underlying pilot project was planned and implemented for follow-up monitoring and consultative presentation of orthopedic and trauma patients within the Bundeswehr Medical Service from 2018 to 2020. With predominantly positive evaluation results regarding quality and acceptance among users, this research investigated organizational and processual aspects including total quality management, strategic control and change management approaches. Results The affected main and subprocesses of patient treatment could be streamlined by the project, as physician recommendations and arrangements could be accelerated and patient travel could be significantly reduced. A SWOT and portfolio analysis showed a high potential for improving existing patient treatment processes for health care enterprises via the use of digital technology. The involved staff should be strategically included at an early stage and continuously involved. By means of a PDCA cycle, the processes of the given project could be exemplarily illustrated with an outlook in the future. Discussion It has proven successful to consciously use management approaches to establish telemedical integrated care structures in a health region. Recommendations for the strategic introduction of an online video consultation for regional network strengthening and care development for a patient-oriented increase in efficiency could be compiled.

Accumulation of stress is a prognostic trigger for cardiovascular disease. Classical scores for cardiovascular risk estimation typically do not consider psychosocial stress. The aim of this study was to develop a global stress index (GSI) from healthy participants by combining individual measures of acute and chronic stress from childhood to adult life. One-hundred and ninety-two female and male soldiers completed the Perceived Stress Scale (PSS4), Trier Inventory for Chronic Stress (TICS), Hospital Anxiety and Depression Scale (HADS), Childhood Trauma Questionnaire (CTQ), Posttraumatic Diagnostic Scale Checklist (PDS), and the Deployment Risk and Resilience Inventory (DRRI-2). The underlying structure for the GSI was examined through structural equation modeling. The final hierarchical multilevel model revealed fair fit by taking modification indices into account. The highest order had a g-factor called the GSI. On a second level the latent variables stress, HADS and CTQ were directly loading on the GSI. A third level with the six CTQ subscales was implemented. On the lowest hierarchical level all manifest variables and the DRRI-2/PDS sum scores were located. The presented GSI serves as a valuable and individual stress profile for soldiers and could potentially complement classical cardiovascular risk factors., publishedVersion

Objective: Due to the combination of local trauma, extracorporeal circulation (ECC), and pulmonary and myocardial reperfusion, cardiac surgery leads to substantial changes in the immune system and possibly to post-operative complications. Procedures without ECC, however, have failed to demonstrate clear advantages. We hypothesized that ECC is far less important in this context than the reperfusion/reventilation of the lung parenchyma and the surgical trauma. We therefore conducted a prospective observational study to compare immune reactions after cardiac operations with those after thoracic surgery. Methods: Serum levels of pro-inflammatory interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-alpha as well as C-reactive protein (CRP), lipoprotein-binding protein (LBP) and procalcitonin (PCT) were measured pre-operatively (d0), at the end of the operation (dx), 6 h after the operation (dxC), on the 1st (d1), 3rd (d3), and 5th (d5) post-operative days in 108 patients (pts) undergoing elective coronary artery bypass grafting (CAB) with ECC (nZ42, CPB CAB), off-pump coronary artery bypass surgery (nZ24, OP CAB) without ECC or thoracic surgery (nZ42, TS). Results: After cardiac surgery (CS), IL-6 and IL-8 increased and reached a maximum on dxC. IL-6 returned to baseline values at d3, whereas IL-8 remained elevated until d5. No difference was found between OP CAB and CPB CAB patients. In the TS patients, IL-6 increased later (dxC) and absolute levels were lower than in the CS patients. No increase in IL-8 was noted in the TS patients. Due to the high variation in the results obtained in all three groups, there was no significant change in TNF-alpha. A comparison of TS, OP CAB, and CPB CAB revealed that the CS patients had higher levels on d0, dx, d3, and d5. Serum levels of CRP, LBP, and IL-2R increased from dxC to d5 in all groups and reached maximum values on d3. Whereas we found no difference in CRP and IL-2R between the groups, LBP levels were significantly higher from dxC to d3 after OP CAB. PCT was elevated from dxC to d3 in all pts. Similar levels were noted for the TS and OP CAB patients. The CPB CAB patients showed the highest levels. Conclusions: Surgical trauma and reperfusion injury appear to represent the predominant factors resulting in immunologic changes after cardiac surgery. Cardiopulmonary bypass (CPB) may be less important for immune response and acute-phase reactions than previously suspected. In addition, our data indicate a relationship between IL-6 synthesis and the degree of surgical trauma. IL-8 appears to be elevated only after cardiac surgery whereas PCT liberation depended on the use of ECC. Q 2005 Elsevier B.V. All rights reserved.

Background . Cardiac operation produces substantial alterations within the immune system, which possibly predispose postoperative complications. However, the interplay between proinflammatory and antiinflammatory reactions and the cells involved in this process are not completely clear. Therefore, we investigated serum levels, as well as synthesis patterns, of proinflammatory and antiinflammatory cytokines. Methods . Serum levels and production of interleukin (IL) IL-5, IL-6, IL-10, tumor necrosis factor-α, and interferon-γ, using a mixed cell culture, (ie, monocytes, macrophages, and lymphocytes), as well as a purified lymphocyte culture were measured preoperatively (day 0), on postoperative day 1, on postoperative day 3, and on postoperative day 5 in 25 patients undergoing cardiac operations and were compared with 10 healthy volunteers. Results . Serum level and mixed cell culture, production of IL-6, tumor necrosis factor-α, and IL-10 increased on postoperative day 1, but decreased in lymphocyte culture. Base line values were reached on postoperative day 5. Interferon-γ serum levels remained unchanged, whereas IL-5 serum levels increased on postoperative days 3 and 5. Cell culture synthesis showed a significant suppression for both mediators in both cell cultures, which returned to baseline on postoperative day 3 in mixed cell culture. Interferon-γ production by lymphocytes was suppressed until postoperative day 5, whereas IL-5 returned to preoperative values on postoperative day 5. Conclusions . Cardiac operation induces a biphasic immune response. The first phase (postoperative day 1) appears to represent the proinflammatory and antiinflammatory reaction of the innate immune system returning to base line on postoperative day 3. The second phase (postoperative day 5) may represent the response of the adaptive immune system and is characterized by an antiinflammatory type of reaction. This may explain why the systemic inflammatory response occurs immediately after cardiac operation, whereas infections occur later.

We treated 19 patients for chronic ankle instability with a modified Evans procedure. All patients were evaluated after an average follow up of 128 months with detailed questionnaire, clinical examination, and stress radiographs. Although the subjective results were reported as 8 excellent, 7 good, and 4 fair, residual pain was reported by 11 patients. There was a significantly increased number of osteophytes in the treated ankle joint Stress radiographs demonstrated significantly improved stability in the operated ankle joint. Range of motion was significantly reduced in hindfoot inversion. The results showed that the modified Evans procedure achieved sufficient joint stability at the expense of inversion range of motion. This reconstruction method apparently did not prevent the development of arthrosis.

This study investigated the effect of anesthesia of the peroneal communis nerve on stress diagnostics in acute ankle ligament rupture. Using a special holding device, the anterior drawer sign was measured under loading of 4 to 15 kg with and without a peroneal nerve block. In 65 patients, we found a highly significant difference between these two conditions. In a total of 110 patients, the measurement of anterior drawer sign was correlated to other diagnostic procedures. Absolute values of mechanical anterior drawer sign had a correlation of 0.479, whereas the difference of the measurements in injured and noninjured feet correlated with 0.582. We suggest anesthesia in stress diagnostics to increase accuracy. The anterior drawer sign alone, even under anesthesia, is not reliable to detect the full extent of the ligament damage.

Now that field hospitals and rescue stations have been provided with state-of-the-art equipment, it is important to tailor the medical qualifications of military surgeons to the specific requirements of missions outside Germany. The objective of this article is to provide guidelines for a new training model. Einsatzchirurgie is defined as surgical treatment provided under restricted conditions in an unfamiliar environment. Its purpose is, first and foremost, to provide emergency treatment. The spectrum of Einsatzchirurgie, however, also encompasses maximum medical treatment on a case-by-case basis and emergency surgical treatment in a mass casualty situation. Training, for example, may consist of a 6-year basic training course in surgery followed by specialist training in abdominal surgery, traumatology, and courses in further disciplines — e.g., urology, gynecology, or neurosurgery. In addition to the qualifications required by the Landesarztekammem (professional organizations of German physicians at the federal countries level), military surgeons who are to become senior medical officers should also be qualified to provide immediate non-surgical emergency care. In these times, the education of military surgeons remains a great challenge. Motivation to work as a surgeon in the armed forces with multiple deployments during the career requires enthusiasm and professionalism. The attractivness of the training institution and the home hospital is key for successful work as a military surgeon.

To compare the clinical and functional outcomes after using different reconstruction methods for chronic ankle instability, the authors followed 2 groups of patients after 69 and 72 months, respectively. Thirty patients (mean age, 28; range, 23-39 years) were treated with modified Evans tenodesis. Twenty-three patients (mean age, 32.2; range, 22-39 years) underwent total replacement of the lateral ankle ligaments by carbon fibers. The protocol of the retrospective study included a questionnaire, clinical examination, radiographic stress diagnostics, and gait analysis with use of the EMED-SF system. Dorsiflexion and inversion were significantly restricted after tenodesis in contrast to the carbon fiber replacement. Although radiographic stability was improved after surgery for both groups, progress of the arthrosis could not be stopped. After tenodesis, the measurement of plantar pressure distribution revealed a 20% increase of midfoot loading as compared with the opposite foot, whereas symmetrical loading of both feet was found after carbon fiber replacement. Additionally, the tenodesis feet had a significantly increased loading of the medial side of the foot. It was concluded that tenodesis and anatomic reconstruction of ankle ligaments lead to subjectively similar results. Foot function and range of motion, however, were less influenced after anatomic repair.

Mehrere Arbeitsgruppen haben sich mit der Erprobung sinnvoller Indikationen fur die Verwendung von SR-Polyglykolid- Stiften am Menschen beschaftigt. Der Durchmesser der Stifte betrug je nach Implantationsort 1.5, 2.0, 3.2 und 4.5 mm. Ohne den Anspruch auf Vollstandigkeit wurden bisher nach Literaturangaben derartige Osteosynthesen allein oder in Kombinationen mit anderen Techniken durchgefuhrt: Innen- und Ausenknochelfrakturen, O 3.2 od. 4.5 mm (14, 22, 47, 66) Frakturen am am Radiuskopfchen, O 3.2 mm und am distalen Radius, O 2.0 mm (38, 39) Osteochondrale (Flake)-Frakturen, O 2.0 mm (73) Ellenbogenfrakturen bei Kindern, O 1.5 und 2.0 mm (41) Epiphysenfrakturen des distalen Humerus bei Kindern, O 1.5 mm (50) Stabilisation der Chevron-Osteotomie bei Hallux-valgus-Operation O 1.5 und 2.0 mm (62)

Im Rahmen des vorliegenden Buches wollten wir einen Uberblick uber den derzeitigen Stand der Entwicklung und der klinischen Verwendung von resorbierbaren Biomaterialien zur Osteosynthese geben. Dabei versuchten wir unsere eigenen Erfahrungen im Zusammenhang mit denen der aktuellen Literatur zu sehen.

In a retrospective study, the long term outcome of the modified Watson-Jones tenodesis according to Lemberger and Kramer was determined using a questionnaire, clinical examination, radiographic data, including stress views, measurement of plantar pressure distribution, and peroneal reaction times on a tilt board. Twenty-five male patients (mean age, 34 years) with a mean followup of 12 years from surgery were available for examination. Eighteen patients (72%) were classified clinically as having excellent or good results. The higher presence of osteophytes in the surgically treated ankle in comparison with the opposite side indicated the progression of arthrosis with time, but this finding could not be related to the reconstruction method. Anterior drawer and talar tilt were reduced significantly in comparison with the preoperative stress radiographs. No differences in plantar pressure distribution were seen between the patients' surgically treated and nonsurgically treated feet. The peroneal reaction times of the peroneus brevis and peroneus longus muscles were significantly shorter in the surgically treated foot compared with the opposite side. It was concluded that the modified Watson-Jones tenodesis effectively corrected lateral ankle instability with no clinical deterioration with time and no influence on gait.

To elucidate whether thoracoscopy for surgical therapy of pneumothorax leads to a reduction of inflammatory responses in comparison with standard thoracotomy.A prospective randomized studyEleven patients (9 men and 2 women; median age, 28 years; range, 21-44 years) were treated by thoracotomy; 10 patients (9 men and 1 woman; median age, 26 years; range, 21-28 years) were managed thoracoscopically. The plasma concentrations of the following were determined: polymorphonuclear granulocyte elastase and C-reactive protein as inflammatory parameters and prostanoids (prostacyclin, thromboxane A2, prostaglandin F2 alpha, prostaglandin M, and prostaglandin E2) as vasoactive parameters. Blood sampling was performed perioperatively and on day 3 after surgery.The thoracoscopy group revealed a shorter hospital stay (5 vs 7 days; P.05) and a significantly reduced need for intravenous pain medication within 48 hours (1 vs 3 requirements; P.01) vs the thoracotomy group. The release of inflammatory (C-reactive protein, P.01) and vasoactive (prostacyclin and thromboxane A2, P.01) mediators was less during thoracoscopy compared with standard thoracotomy.The thoracoscopic procedure is less invasive when performing wedge resection of apical blebs. With intracavitary management being equivalent to the conventional technique, the curtailed morbidity after thoracoscopic surgery is considered to be related to the minimal trauma associated with the access to lung tissue and the reduced handling of lung tissue.