The new competency-based continuing education regulations for surgical training (WBO) came into effect in Bavaria in August 2022.
From May to July 2022, we conducted an anonymized online survey among ...Bavarian general and visceral surgeons and surgical residents (ÄiW). The aim was to survey expectations of the effects of the new WBO.
The response rate was 35%. In total data could be collected from 80 persons, 36 ÄiW (45%), 30 specialists and senior physicians (37.5%) and 14 chief physicians (17.5%). The majority of respondents worked at a university hospital (38.8%) or a regular provider (35%). A strengthening of the competence to act through implementation of the new WBO is seen by 41.3% and 55.7% see independent operating under partial supervision by the instructor as a goal. Of the respondents 50% see the required case numbers as not achievable and 55.1% deny reaching them in the expected period of 6 years. About 60% do not expect to be able to train the same number of ÄiWs in the same amount of time. Almost 75% of the respondents state that from their point of view, a good continuing education with the achievement of a solid competence to act would not work without overtime hours. About 44% of the respondents expect that a full surgical training would continue to be possible at their institution.
Both among the instructors and among the trainees there is a tendency to fear that realistic training, in particular the achievement of the guideline figures, will no longer be possible in the usual further training time. This necessitates the consistent implementation of structured continuing education with a high degree of transparency in training.
Zusammenfassung
Hintergrund
Die neue kompetenzbasierte Weiterbildungsordnung (nWBO) für chirurgische Weiterbildungen wurde mittlerweile von allen deutschen Landesärztekammern übernommen.
Methoden
Von ...Mai bis Juni 2023 führte die Arbeitsgemeinschaft Junge Chirurgie (CAJC) eine anonymisierte Onlineumfrage unter den 5896 Mitgliedern der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) durch.
Ziel
Ziel der Arbeit war es, die Erwartungen an die nWBO zu erfassen und Lösungsstrategien zur Verbesserung der chirurgischen Weiterbildung zu entwickeln.
Ergebnisse
488 Teilnehmende (Rücklaufquote 8,3 %) bedeuten eine repräsentative Studie. Die Befragten setzten sich aus 107 Weiterbildungsassistent:innen (WBA 21,9 %), 69 Fachärzt:innen und 188 Oberärzt:innen (FÄ 14,1 % und OÄ 38,5 %) sowie 107 Chefärzt:innen (21,9 %) zusammen. Die Mehrheit war in Regelversorgern (44 %) tätig, gefolgt von Maximalversorgern (26,8 %) und Universitätsklinika (20,1 %). Nur 22 % halten das geforderte operative Spektrum der nWBO für realistisch. Die Hälfte der Befragten gibt an, dass die volle Weiterbildung in ihrer Klinik gemäß dem neuen Katalog nicht mehr möglich sein wird. 54,6 % halten eine Erreichbarkeit der Richtzahlen in 6 Jahren für unmöglich bzw. geben an, nicht mehr die gleiche Anzahl von WBAs in der gleichen Zeit ausbilden zu können. Einheitlich über alle Versorgungsstufen wurde die Endoskopie (17,1–18,8 %), Fundoplikationen (15,4–17,7 %) und Kopf-Hals-Eingriffe (12,1–17,1 %) als Engstellen genannt. Rotationen wurden laut Angaben bereits zu 64,7 % etabliert. 48 % gaben an, dass in der Abteilung das Teilschrittekonzept etabliert sei. Die Bedeutung eines strukturierten Weiterbildungskonzepts wurde von 85 % der WBA als wichtig erachtet, im Vergleich zu 53,3 % der CÄ. Lag ein strukturiertes Weiterbildungskonzept in der Abteilung vor, so wurde die Erreichbarkeit der Richtzahlen in der univariaten Analyse signifikant positiver eingeschätzt. In der multivariaten Analyse waren das männliche Geschlecht sowie der Status „habilitiert/Professor:in“ unabhängige Faktoren für eine positivere Einschätzung der nWBO. Eine objektive Zertifizierung der Weiterbildung wurde von 51,5 % als wichtig angesehen.
Schlussfolgerung
Die nWBO bereitet Sorgen und die Stimmung ist pessimistisch. Zusätzliche Vorgaben und Krankenhausreformen könnten die Lage verschärfen. Kooperationen und Rotationen sind entscheidend, aber noch nicht ausreichend umgesetzt. Qualitätsorientierte Zertifizierungen könnten die Ausbildungsqualität verbessern.
Post thyroidectomy hemorrhage is a potentially life-threatening complication. As the mechanism leading to hypoxemic brain damage and death is still unknown, our aim was to examine the underlaying ...pathophysiology in an animal model.
A series of experiments was performed in our established model for post thyroidectomy hemorrhage in 6 pigs. First, post thyroidectomy hemorrhage was simulated with an artificial increase of cervical compartment pressure. Second, spontaneous bleeding into the cervical compartment was initiated. Primary outcome measure is the correlation between cerebral oxygenation and cervical compartment pressure.
With an increase in cervical compartment pressure apnea could be detected in all experiments. A significant 24.2% (9.5-34.4%) decrease of cerebral oxygenation at time of apnea (47.0%; 38.0-65.0%) compared to baseline values (63.5%; 56.0-74.0%; P=0.043) occurred due increase of cervical compartment pressure concurrent with an impaired cerebral perfusion. Apnea occurred about 200 sec after a 10% decrease of cerebral oxygenation, but 35 sec before a 10% decrease of peripheral oxygenation. Spontaneous bleeding into the cervical compartment causes an increase of cervical compartment pressure reaching levels of the mean arterial blood pressure 56.0 (35.0-72.0) mmHg.
Peripheral hypoxemia occurs with relevant delay in time after decrease of cerebral perfusion and cerebral hypoxemia, therefore cerebral hypoxemia seems to be causal for a central apnea. With this evidence of impaired cerebral perfusion and cerebral hypoxemia due to an increased cervical compartment pressure we can disprove the historic theory of tracheal collapse due to a compressive hematoma in post thyroidectomy hemorrhage. A cervical compartment syndrome seems to be causal, not only for brain hypoxemia but also an additional laryngo-pharyngeal mucosal edema.
The pathogenesis of chronic inflammatory bowel diseases (Crohn’s disease CD and ulcerative colitis) involves dysregulated TH1 and TH17 cell responses, which can be targeted therapeutically by the ...monoclonal antibody Ustekinumab directed against the joint p40 subunit of IL-12 and IL-23. These cytokines may also regulate the differentiation of T follicular helper (TFH) cells, which promote B cell function in germinal centers. However, the role of TFH cells in CD pathogenesis and impact of Ustekinumab therapy on TFH cell fate in patients are poorly defined.
Lymphocytes were isolated from peripheral blood (n=45) and intestinal biopsies (n=15) of CD patients or healthy controls (n=21) and analyzed by flow cytometry to assess TFH cell phenotypes and functions ex vivo. In addition, TFH cell differentiation was analyzed in the presence of Ustekinumab in vitro.
TFH cell frequencies in the intestine as well as peripheral blood were associated with endoscopic as well as biochemical evidence of CD activity. CD patients with clinical response to Ustekinumab, but not those with response to anti-TNF antibodies, displayed reduced frequencies of circulating TFH cells in a concentration-dependent manner while the TFH phenotype was not affected by Ustekinumab therapy. In keeping with this notion, TFH cell differentiation was inhibited by Ustekinumab in vitro while TFH cell maintenance was not affected. Moreover, Ustekinumab therapy resulted in reduced germinal center activity in CD patients in vivo.
These data implicate TFH cells in the pathogenesis of CD and indicate that Ustekinumab therapy affects TFH cell differentiation, which may influence TFH-mediated immune functions in UST-treated CD patients.
Display omitted
Background: Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options – up and ...foremost endoscopic vacuum therapy (EVT) – have become increasingly popular and have shown promising results in these patients. Methods: We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results: The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion: Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
Background & aims: The pathogenesis of chronic inflammatory bowel diseases (Crohn’s disease CD and ulcerative colitis) involves dysregulated TH1 and TH17 cell responses, which can be targeted ...therapeutically by the monoclonal antibody Ustekinumab directed against the joint p40 subunit of IL-12 and IL-23. These cytokines may also regulate the differentiation of T follicular helper (TFH) cells, which promote B cell function in germinal centers. However, the role of TFH cells in CD pathogenesis and impact of Ustekinumab therapy on TFH cell fate in patients are poorly defined. Methods: Lymphocytes were isolated from peripheral blood (n=45) and intestinal biopsies (n=15) of CD patients or healthy controls (n=21) and analyzed by flow cytometry to assess TFH cell phenotypes and functions ex vivo. In addition, TFH cell differentiation was analyzed in the presence of Ustekinumab in vitro. Results: TFH cell frequencies in the intestine as well as peripheral blood were associated with endoscopic as well as biochemical evidence of CD activity. CD patients with clinical response to Ustekinumab, but not those with response to anti-TNF antibodies, displayed reduced frequencies of circulating TFH cells in a concentration-dependent manner while the TFH phenotype was not affected by Ustekinumab therapy. In keeping with this notion, TFH cell differentiation was inhibited by Ustekinumab in vitro while TFH cell maintenance was not affected. Moreover, Ustekinumab therapy resulted in reduced germinal center activity in CD patients in vivo. Conclusions: These data implicate TFH cells in the pathogenesis of CD and indicate that Ustekinumab therapy affects TFH cell differentiation, which may influence TFH-mediated immune functions in UST-treated CD patients.
PDF
