Effizienter Erwerb chirurgischer Basistechniken durch "blended learning"

Zusammenfasssung: Hintergrund: Große Studierendenzahlen und heterogene Dozierende erschweren einheitliche Kursgestaltungen und die objektive Standardisierung von Prüfungen im chirurgischen Fertigkeitstraining. Diese Arbeit zeigt die Vorteile des Einsatzes neuer Medien im "Blended-learning-Konzept" für das Fertigkeitstraining im Studiengang Humanmedizin der Universität Basel. Material und Methoden: Der studentische chirurgische "Nahtkurs" wurde nach einem Blended-learning-Konzept mit multimedialer CD, Präsenzveranstaltung und SkillsLab restrukturiert. Die Lernziele des Kurses wurden am Ende der Studienjahre anhand von Posten mit Checklisten im OSCE ("objective structured clinical examination") überprüft. Die studentische Kursbeurteilung sowie die Prüfungsergebnisse vor und nach Einführung des "blended learning" wurden miteinander verglichen. Ergebnisse: Sowohl die Beurteilungen der eingesetzten Lehrmittel, des subjektiven Übungserfolges und des prospektiven Nutzens für das Wahlstudienjahr (Praktisches Jahr) als auch die Gesamtkursbeurteilung waren nach Einführung des Blended-learning-Konzeptes signifikant höher als im alten Kursformat. Auch der Anteil an bestandenen Prüfungen war mit einem Zuwachs von 10% signifikant im Vergleich zum alten Kurs erhöht. Schlussfolgerung: "Blended learning” kann sowohl Wahrnehmung und Leistung als auch die Effizienz des Fertigkeitstrainings und der Betreuungszeit verbessern. Dadurch werden indirekt Ressourcen gespart. Chirurgische Verfahren können klar und übersichtlich vermittelt werde

Breast reconstruction with flaps from the lower abdomen

Zusammenfassung: GRUNDLAGEN: Die Abdominalregion ist eine vielseitige Quelle für mehrere Gewebe, welche als Lappen zur Wiederherstellung der weiblichen Brust geeignet sind. Diese beinhalten den gestielten und freien Transverse Rectus Abdominis Myocutaneous Lappen (TRAM), den Deep Inferior Epigastric Perforator Lappen (DIEAP) und den Superficial Inferior Epigastric Lappen (SIEA). METHODIK: Diese Übersicht stellt Geschichte und Technik der Wiederherstellung der Brust mittels Lappen vom Abdomen dar. Alle relevanten Studien und Erfahrungen wurden berücksichtigt. ERGEBNISSE: Der Entscheidungsprozess zur Lappenwahl ist komplex und abhängig von einer Reihe von Faktoren, wobei Lappen mit niedrigerer Hebemorbidität deutliche Vorteile zeigen und ein postoperativ verbessertes ästhetisches Resultat der Hebestelle die Patientenakzeptanz deutlich erhöhen kann. SCHLUSSFOLGERUNGEN: In dieser Übersicht werden Anatomie und präoperative Planung in dieser Spenderregion, Fragen zur intraoperativen Entscheidungsfindung sowie Resultate und Patientenzufriedenheit behandel

Analyzing consumer-related nitrogen flows: A case study on food and material use in Austria

Nitrogen budgets cover pools and flows of nitrogen (N) contained in human-made goods and compounds, wich may potentially affect the global nitrogen cycle and in consequence the human environment. Acknowledging the importance of food and other agricultural products, this paper additionally investigates frequently neglected flows of N related to consumers and estimates their magnitude, using Austria in 2010 as an example. Specifically, N in non-food industrial products (synthetic & natural polymers, wood & paper products, waste), and N related to pets, gardens, and energy use is considered. Over the last five decades, both food and material consumption have increased distinctly. While food supply accounts for 52% of total directly consumer-related nitrogen inflows covered in this study (66,000t Na^1), also material products account for a considerable share of 28% (36,000t Na^1). N application in gardens (12%) and N in pet food (7%) do also play a role. Quantified outflows are human excretion (54%), food waste (13%), garden waste (16%), material waste (7%) and waste from pets (10%). The detected balance surplus of 34,000t Na^1, corresponding to 27% of total inflows, points to some accumulation of N in the form of durable consumer goods and to potentially missing flows. The analysis focusses on the apparent knowledge gaps. Especially flows involving material products are poorly understood and would require better understanding of nitrogen contents of products and of waste. This indicates that improvements may be possible by providing more complete nitrogen budgets in the future that cover all environmental pools

Hemiface Rhytidectomy

In the current study, skin flaps raised in the subcutaneous plane were applied for 22 patients who underwent reconstruction for unilateral upper facial skin defects after skin tumor surgery. The defect was reconstructed with flaps designed via procedures similar to classic rhytidectomy techniques using periauricular and temporal skin incisions. Objective assessment of the aesthetic result was possible by comparison with the healthy contralateral side of the face. Immediate postoperative evaluation confirmed facial asymmetry due to unilateral skin tension. High patient acceptance of the procedure, uneventful flap healing, and good aesthetic results were achieved, with almost complete restoration of facial symmetry 1 year postoperatively. In conclusion, unilateral rhytidectomy without plication or resection of the subcutaneous musculoaponeurotic system (SMAS) is an ideal application of aesthetic surgical techniques for the reconstruction of unilateral skin defect

Negative association of the chemokine receptor CCR5 d32 polymorphism with systemic inflammatory response, extra-articular symptoms and joint erosion in rheumatoid arthritis

Introduction Chemokines and their receptors control immune cell migration during infections as well as in autoimmune responses. A 32 bp deletion in the gene of the chemokine receptor CCR5 confers protection against HIV infection, but has also been reported to decrease susceptibility to rheumatoid arthritis (RA). The influence of this deletion variant on the clinical course of this autoimmune disease was investigated. Methods Genotyping for CCR5d32 was performed by PCR and subsequent electrophoretic fragment length determination. For the clinical analysis, the following extra-articular manifestations of RA were documented by the rheumatologist following the patient: presence of rheumatoid nodules, major organ vasculitis, pulmonary fibrosis, serositis or a Raynaud's syndrome. All documented CRP levels were analyzed retrospectively, and the last available hand and feet radiographs were analyzed with regards to the presence or absence of erosive disease. Results Analysis of the CCR5 polymorphism in 503 RA patients and in 459 age-matched healthy controls revealed a significantly decreased disease susceptibility for carriers of the CCR5d32 deletion (Odds ratio 0.67, P = 0.0437). Within the RA patient cohort, CCR5d32 was significantly less frequent in patients with extra-articular manifestations compared with those with limited, articular disease (13.2% versus 22.8%, P = 0.0374). In addition, the deletion was associated with significantly lower average CRP levels over time (median 8.85 vs. median 14.1, P = 0.0041) and had a protective effect against the development of erosive disease (OR = 0.40, P = 0.0047). Intriguingly, homozygosity for the RA associated DNASE2 -1066 G allele had an additive effect on the disease susceptibility conferred by the wt allele of CCR5 (OR = 2.24, P = 0.0051 for carrier of both RA associated alleles) Conclusions The presence of CCR5d32 significantly influenced disease susceptibility to and clinical course of RA in a German study population. The protective effect of this deletion, which has been described to lead to a decreased receptor expression in heterozygous patients, underlines the importance of chemokines in the pathogenesis of RA

One-stage versus two-stage lymph node dissection after investigation of sentinel lymph node in cutaneous melanoma: a comparison of complications, costs, hospitalization times, and operation times

The aim of the study was to evaluate whether complication rate, costs, operation times, and hospitalization times differed in two different patient groups: in group 1, frozen section analysis of the sentinel lymph node and lymph node dissection were carried out in the same operation. In group 2, normal investigation of the sentinel lymph node and lymph node dissection were done in a second operation. One hundred thirty-five patients with cutaneous melanoma were included. Hospitalization times, costs, complication rates, and operation times of two-stage and one-stage lymph node dissection of the draining area after detection of metastases in the sentinel lymph node were retrospectively compared. Lymph node metastasis in the sentinel lymph node was found in 23 patients. In 11 patients, removal of the sentinel lymph node and dissection of the lymph node basin was performed in the same operation. In 12 patients, a two-stage procedure was the treatment of choice. Operation times were not different in the two groups (p=0.87) while two-stage operation patients were hospitalized significantly longer (14.2±9.7 vs 23.9±24days; p=0.01) and costs were significantly higher (7,836.90±2,397.95 Swiss francs vs 5,279.40±1,994.90 Swiss francs). In addition, more complications were found in the two-stage grou

An Individualized Approach to Abdominoplasty in the Presence of Bilateral Subcostal Scars after Open Gastric Bypass

Background: Patients requiring surgical skin excision after massive weight loss are challenging and require an individualized approach. The characteristic abdominal deformity includes a draping apron of panniculus, occasionally associated with previous transverse surgical scars from open gastric bypass surgery in the upper abdomen, which compromise blood supply of the abdominal skin. Methods: We propose four different surgical techniques for safe abdominal body contouring in the presence of such scars: (1) a limited abdominoplasty of the lower abdomen is performed, and then contouring is completed by a reversed abdominoplasty with scar positioning in the submammary folds; (2) a one-stage procedure characterized by skin resection in the upper and lower abdomen, in which blood supply of the skin island between the submammary and suprapubic incisions is ensured by periumbilical perforators; (3) a perforator-sparing abdominoplasty with selective dissection of periumbilical abdominal wall perforators to secure flap blood supply and allow complete flap undermining up to the xyphoid process; (4) for patients with extensive excess skin, a modified Fleur-de-Lys abdominoplasty performed in such a way that the old transverse scar is transformed into a vertical scar. Results: The treatment of four exemplary patients is described. All techniques yielded good esthetic and functional results through preservation of abdominal blood supply. Conclusion: Through an individualized approach, adequate abdominal body contouring can be performed safely, even in the presence of transverse surgical scars in the upper abdome

Sonication of Removed Breast Implants for Improved Detection of Subclinical Infection

Background: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. Methods: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. Results: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49years (range, 31-76years). The mean implant indwelling time was 10.4years (range, 3months to 30years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n=12), submuscularly (n=6), and subcutaneously (n=4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). Conclusions: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosi

Perforator-Sparing Abdominoplasty Technique in the Presence of Bilateral Subcostal Scars after Gastric Bypass

Background: The number of patients after gastric bypass being referred to plastic surgery units for secondary plastic surgery procedures is increasing. The characteristic abdominal deformity includes a draping apron of panniculus, occasionally associated with previous transverse surgical scars in the upper abdomen. Often a limited abdominoplasty of the low transverse type with limited undermining only up to the level of the umbilicus is performed in order not to compromise blood supply in the zone between the old transverse and the new transverse scar. Method: We propose a new, modified and safe surgical technique to perform a complete abdominoplasty with wide undermining up to the xiphoid process in patients with preexisting transverse subcostal scars after gastric bypass surgery, by selectively dissecting and preserving one to three periumbilical abdominal wall perforator vessels to secure flap blood supply. Vessel tunnelling through the rectus sheath and muscle and ligation of the cephalad branch of the perforator provide sufficient flap mobility without perforator tension or traction. Flap undermining is performed around these perforator vessels. To match dissected flap perforators with blood-flow, we performed postoperative color-flow duplex scanning. Results: We treated two patients according to this new technique. In both cases the postoperative course was uneventful and a good aesthetic result was achieved. Conclusion: We conclude from our experience that with this perforator-sparing abdominoplasty technique, safe and complete abdominoplasty can be performed with no additional risk of complications and that a good cosmetic result can be achieved in patients after open gastric bypass surger

Optimizing the parameters for hydro-jet dissection in fatty tissue — A morphological Ex Vivo analysis

Summary: Background: The advantage of water-jet dissection is the preservation of vessels and nerves. Especially in liver surgery, blood loss can be significantly decreased. The use of water-jet dissectors in other fields of surgery is currently under investigation. The preparation of vessels in fatty tissue is of special interest for plastic surgeons. The optimal technical parameters were investigated. Methods: Abdominal fat tissue of fresh cadavers was cut under standardized conditions with different parameters of the water-jet dissector. Results: One single pass at a cutting pressure between 20 and 60 Bar makes an incision of 8 mm. Deeper cuts can be achieved by repeated application on the same cut. Five passes at 40 Bar results in a depth of 1.7 cm without vessel damage. If the applied pressure is 50 or 60 Bar, up to 7% damaged vessels can be found. The water-jet dissection leads to a water uptake of the cut tissue. Conclusions: The optimal pressure for water-jet dissection of fatty tissue lies between 30 and 40 Bar. The effect of the mechanical irritation of the vessels has to be investigatedin vivo before using the water-jet dissector for preparation of blood vessels in humans, e.g. for flap dissectio