Intrapartum care working patterns of midwives : the long road to models of care in germany

Copyright 2018 ThiemeIntroduction: Midwifery models of care help to enhance perinatal health outcomes, women's satisfaction, and continuity of care. Despite the ubiquitous presence of certified midwives at births in Germany, no research has investigated the diversity of midwives’ practice patterns. Describing the variety of working patterns through which midwives provide intrapartum care may contribute to improving the organisation of midwifery services. Methods: This cross-sectional survey took place in the region of Hannover and Hildesheim, Germany. Midwives attending births and practicing in hospitals and/or out-of-hospital were able to participate. Midwives who did not attend births were excluded. We assessed midwives' scope of services, practice locations, employment patterns, continuity of care, midwife-led births, and midwives' level of agreement with core values of midwifery care. The response rate of the survey was 32.7 % (69/211). Results: We found that midwifery care services can be described according to midwives’ employment patterns. The majority of midwives were employed in a hospital to provide intrapartum care (74.2 %, n = 49), and most also independently offered one or more antenatal and/or postpartum service/s. Only 25.8 % (n = 17) of midwives offered their services independently (laborist model of care). Independent midwives attended births in all three possible settings: hospital, free-standing birth centres and home. Significantly more independent midwives than employed midwives offered antenatal care and lactation consulting. Compared to employed midwives, significantly more independent midwives provided antenatal, intrapartum, and postpartum care to the same women, were more likely to know women before labour, and to offer one-to-one care during labour. Discussion: The most common practice pattern among surveyed midwives was ‘employment in a hospital’ for provision of intrapartum care with additional postpartum and few antenatal services provided on an independent basis. Midwives who worked solely independently reported more continuity and one-to-one intrapartum care with women. Most midwives did not work in patterns that offered continuity of care or consistently provide one-to-one care. Future research should assess whether women in Germany desire more services similar to caseload midwifery

IL-6 predicts organ dysfunction and mortality in patients with multiple injuries

<p>Abstract</p> <p>Background</p> <p>Although therapeutic concepts of patients with major trauma have improved during recent years, organ dysfunction still remains a frequent complication during clinical course in intensive care units. It has previously been shown that cytokines are upregulated under stress conditions such as trauma or sepsis. However, it is still debatable if cytokines are adequate parameters to describe the current state of trauma patients. To elucidate the relevance of cytokines, we investigated if cytokines predict development of multiple organ dysfunction syndrome (MODS) or outcome.</p> <p>Methods</p> <p>A total of 143 patients with an injury severity score ≥ 16, between 16 and 65 years, admitted to the Hannover Medical School Level 1 Trauma Center between January 1997 and December 2001 were prospectively included in this study. Marshall Score for MODS was calculated for at least 14 days and plasma levels of TNF-α, IL-1β, IL-6, IL-8 and IL-10 were measured. To determine the association between cytokine levels and development of MODS the Spearman rank correlation coefficient was calculated and logistic regression and analysis were performed.</p> <p>Results and Discussion</p> <p>Patients with MODS had increased plasma levels of IL-6, IL-8 and IL-10. IL-6 predicted development of MODS with an overall accuracy of 84.7% (specificity: 98.3%, sensitivity: 16.7%). The threshold value for development of MODS was 761.7 pg/ml and 2176.0 pg/ml for mortality during the in patient time.</p> <p>Conclusion</p> <p>We conclude that plasma IL-6 levels predict mortality and that they are a useful tool to identify patients who are at risk for development of MODS.</p

A survey of anticoagulation practice among German speaking microsurgeons – Perioperative management of anticoagulant therapy in free flap surgery [Erhebung über die antikoagulatorische Praxis unter deutschsprachigen Mikrochirurgen – Perioperatives Management der antikoagulatorischen Therapie bei freien Lappentransplantaten]

[english] Background: Anticoagulation is a crucial element in microsurgery. Although various clinical studies and international surveys have revealed that anticoagulation strategies can vary and result in similar outcomes, anticoagulative regimen are far away from standardization. In Germany and german speaking countries standardized anticoagulation protocols concerning free flap surgery do not exist so far. Methods: To evaluate the current practice of clinics in Germany, Austria and Switzerland with specialization in microsurgery we performed a questionnaire surveying the perioperative regimen of anticoagulant and antiplatelet therapy in free flap surgery. The microsurgeons were interrogated on several anticoagulant, rheologic and antiplatelet medications, their dosage and perioperative frequency of application pre-, intra- and postoperative.Results: The questionnaire revealed that the used antithrombotic and perioperative regimens varied from department to department presumably based on the personal experience of the surgeon. Multiple approaches are used with a wide range of anticoagulants used either alone or in combination, with different intervals of application and different dosages. Conclusion: Therefore consensus meetings should be held in future leading to conduct prospective multicenter studies with formulation of standardized anticoagulative and perioperative protocols in microsurgery reducing flap failure to other than pharmacologic reasons.<br>[german] Hintergrund: Die Antikoagulation stellt ein zentrales Element in der Mikrochirurgie dar. Zahlreiche klinische Studien und internationale Erhebungen zu antikoagulatorischen Strategien weisen eine grosse Varianz bei vergleichbaren Resultaten nach, entbehren jedoch einer Standardisierung. Auch in Deutschland und deutschsprachigen Ländern fehlen bislang standardisierte Regime zur Antikoagulation in der Mikrochirurgie.Methodik: Zur Erhebung der antikoagulatorischen Praxis unter mikrochirurgischen Kliniken in Deustchland, Österreich und der Schweiz erstellten wir einen Fragebogen zur Erfassung des jeweiligen perioperativen Regimes im Hinblick auf die Antikoagulation bei freien Lappentransplantaten.Erfasst wurden verschiedene Antikoagulantien, Rheologika und Thrombozytenaggregationshemmer, sowie deren prä-. intra- und postoperative Dosierung und Art der Anwendung.Ergebnisse: Die perioperativen Regime und verwendeten Antikoagulantien zeigen von Klinik zu Klinik eine große Varianz. Diese Heterogenität scheint am Ehesten auf der Erfahrung des Operateurs denn auf einer evidenzbasierten Datenlage zu beruhen.Sie zeigt sich sowohl in der Vielzahl der verwendeten Antikoagulantien als auch in der Art ihrer Anwendung und Dosierung.Schlussfolgerung: Aus der erhobenen Datenlage ergibt sich die Forderung nach Initiierung einer Multi-Center-Studie mit Formulierung eines evidenzbasierten Standards zur perioperativen Antikoagulation in der Mikrochirurgie, so dass sich die Ursachen für Verluste freier Lappentransplantate auf solche nicht pharmakologischer Art reduzieren lassen

A survey of anticoagulation practice among German speaking microsurgeons – Perioperative management of anticoagulant therapy in free flap surgery [Erhebung über die antikoagulatorische Praxis unter deutschsprachigen Mikrochirurgen – Perioperatives Management der antikoagulatorischen Therapie bei freien Lappentransplantaten]

[english] Background: Anticoagulation is a crucial element in microsurgery. Although various clinical studies and international surveys have revealed that anticoagulation strategies can vary and result in similar outcomes, anticoagulative regimen are far away from standardization. In Germany and german speaking countries standardized anticoagulation protocols concerning free flap surgery do not exist so far. Methods: To evaluate the current practice of clinics in Germany, Austria and Switzerland with specialization in microsurgery we performed a questionnaire surveying the perioperative regimen of anticoagulant and antiplatelet therapy in free flap surgery. The microsurgeons were interrogated on several anticoagulant, rheologic and antiplatelet medications, their dosage and perioperative frequency of application pre-, intra- and postoperative.Results: The questionnaire revealed that the used antithrombotic and perioperative regimens varied from department to department presumably based on the personal experience of the surgeon. Multiple approaches are used with a wide range of anticoagulants used either alone or in combination, with different intervals of application and different dosages. Conclusion: Therefore consensus meetings should be held in future leading to conduct prospective multicenter studies with formulation of standardized anticoagulative and perioperative protocols in microsurgery reducing flap failure to other than pharmacologic reasons.<br>[german] Hintergrund: Die Antikoagulation stellt ein zentrales Element in der Mikrochirurgie dar. Zahlreiche klinische Studien und internationale Erhebungen zu antikoagulatorischen Strategien weisen eine grosse Varianz bei vergleichbaren Resultaten nach, entbehren jedoch einer Standardisierung. Auch in Deutschland und deutschsprachigen Ländern fehlen bislang standardisierte Regime zur Antikoagulation in der Mikrochirurgie.Methodik: Zur Erhebung der antikoagulatorischen Praxis unter mikrochirurgischen Kliniken in Deustchland, Österreich und der Schweiz erstellten wir einen Fragebogen zur Erfassung des jeweiligen perioperativen Regimes im Hinblick auf die Antikoagulation bei freien Lappentransplantaten.Erfasst wurden verschiedene Antikoagulantien, Rheologika und Thrombozytenaggregationshemmer, sowie deren prä-. intra- und postoperative Dosierung und Art der Anwendung.Ergebnisse: Die perioperativen Regime und verwendeten Antikoagulantien zeigen von Klinik zu Klinik eine große Varianz. Diese Heterogenität scheint am Ehesten auf der Erfahrung des Operateurs denn auf einer evidenzbasierten Datenlage zu beruhen.Sie zeigt sich sowohl in der Vielzahl der verwendeten Antikoagulantien als auch in der Art ihrer Anwendung und Dosierung.Schlussfolgerung: Aus der erhobenen Datenlage ergibt sich die Forderung nach Initiierung einer Multi-Center-Studie mit Formulierung eines evidenzbasierten Standards zur perioperativen Antikoagulation in der Mikrochirurgie, so dass sich die Ursachen für Verluste freier Lappentransplantate auf solche nicht pharmakologischer Art reduzieren lassen

Comparación de los métodos actuales de cribado prenatal del síndrome de Down

Fundamento: En España se ofrece a todas las mujeres gestantes a partir de los 35 años un examen genético a través de un diagnóstico invasivo (indicación por edad materna (IPEM)) para detectar casos fetales de trisomía 21. En la última década se elaboraron cinco distintos programas de cálculo de riesgo utilizando el «cribado del primer trimestre». El objetivo de este estudio es comparar los resultados de los diferentes métodos de screening para detectar el mejor procedimiento en la actualidad. Métodos: Desde el 31.08.1999 hasta el 24.05.2007 se realizaron 7.736 screenings del primer trimestre completos, incluyendo el estado de salud del feto, en tres centros de medicina prenatal en las ciudades de Hannover, Peine y Wolfenbüttel en Alemania, de los cuales se analizaron en este estudio retrospectivamente 6.508 casos de datos. Se determinó la edad materna y se efectuaron cálculos de riesgo con los programas PIA, PRC, JOY, AFS y AFS-3D. Resultados: La IPEM alcanzó una sensibilidad de 57,50%, detectando 23 de 40 casos de trisomía, y una tasa de falsos positivos de 21,60%. En comparación, todos los programas obtuvieron mejores resultados alcanzando una sensibilidad entre 90,00% (AFS) y 92,50% (PIA, PRC, JOY, AFS-3D) y una tasa de falsos positivos entre 2,64% (AFS-3D) y 7,87% (PIA). La diferencia fue de alta significancia (p<0,0001). Conclusiones: La IPEM es obsoleta e inadecuada en comparación a los programas de cálculo de riesgo, de los cuales todos demostraron rendimientos que se encuentran dentro del rango de publicaciones internacionales comparables. Entre estos programas JOY, AFS y AFS-3D obtuvieron los mejores resultados

Conversion of hemi into reverse shoulder arthroplasty: implant design limitations

Teschner H, Vaske B, Albrecht U-V, et al. Conversion of hemi into reverse shoulder arthroplasty: implant design limitations. Archives of Orthopaedic and Trauma Surgery. 2014;134(12):1683-1689

Konversion einer Hemi- in eine inverse Schulter TEP: Implantatdesign bedingte Limitierungen

Jagodzinski M, Teschner H, Vaske B, et al. Konversion einer Hemi- in eine inverse Schulter TEP: Implantatdesign bedingte Limitierungen. In: Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2012). Düsseldorf: German Medical Science GMS Publishing House; 2012

Biopsy-controlled liver fibrosis staging using the enhanced liver fibrosis (ELF) score compared to transient elastography.

BACKGROUND AND AIMS: Chronic liver diseases are characterized by inflammatory and fibrotic liver injuries that often result in liver cirrhosis with its associated complications such as portal hypertension and hepatocellular carcinoma. Liver biopsy still represents the reference standard for fibrosis staging, although transient elastography is increasingly used for non-invasive monitoring of fibrosis progression. However, this method is not generally available and is associated with technical limitations emphasizing the need for serological biomarkers staging of liver fibrosis. The enhanced liver fibrosis (ELF) score was shown to accurately predict significant liver fibrosis in different liver diseases, although extracellular matrix components detected by this score may not only mirror the extent of liver fibrosis but also inflammatory processes. METHODS: In this prospective biopsy-controlled study we evaluated the utility of the ELF score in comparison to transient elastography to predict different stages of fibrosis in 102 patients with chronic liver diseases. RESULTS: Both techniques revealed similar area under receiver operating characteristic curve values for prediction of advanced fibrosis stages. Compared to transient elastography, the ELF score showed a broader overlap between low and moderate fibrosis stages and a stronger correlation with inflammatory liver injury. CONCLUSIONS: Both the ELF score as well as transient elastography allowed for high quality fibrosis staging. However, the ELF score was less discriminative in low and moderate fibrosis stages and appeared more strongly influenced by inflammatory liver injury. This should be considered when making clinical interpretations on the basis of ELF score values

Dermoglandular Rotation Flaps for Breast-Conserving Therapy: Aesthetic Results, Patient Satisfaction, and Morbidity in Comparison to Standard Segmentectomy

We compared a dermoglandular rotation flap (DGR) in the upper inner, lower inner, and upper outer quadrant regarding similar aesthetic results, patient satisfaction, and comfort after breast-conserving therapy with standard segmentectomy (SE). Between 2003 and 2011, 69 patients were treated with breast-conserving surgery using DGR for cancers with high tumor-to-breast volume ratios or skin resection in the three above mentioned quadrants; 161 patients with tumors in the same quadrants were treated with SE. The outcome of the procedures was assessed at least 7 months after completed radiation therapy using a patient and breast surgeon questionnaire and the BCCT.core software. Symmetry, visibility of the scars, the position of the nipple-areola complex, and the appearance of the treated breast were each assessed on a scale from 1 to 4 by an expert panel and by the patients. Univariate and multivariate analysis were used to evaluate the relationship between patient-, tumor-, and treatment-dependent factors and patient satisfaction. 94.2% of the patients with rotation flaps and 83.5% of the patients with lumpectomy were very satisfied with the cosmetic appearance of their breast. Younger patient age was significantly associated with a lower degree of satisfaction. DGR provides good cosmetic results compared with SE and shows high patient satisfaction despite longer scarring and higher median resection volume

Prediction of relevant or advanced fibrosis stages by transient elastography and ELF score.

<p>The cut-off values of transient elastography (A, C) and ELF score (B, D) to predict fibrosis stages ≥F2 (A, B) or ≥F5 (C, D) with best compromise sensitivity/specificity were determined by ROC plot analysis. AUC, area under the curve; ELF, enhanced liver fibrosis; ROC, receiver operating characteristics.</p