What is the placement scenario at IIFT

Tradition and innovation

The 45th annual congress of the German Society for Defense Medicine and Pharmacy (DGWMP) took place from September 11th to 14th in the Hotel Estrel, Berlin. 641 congress participants found their way to Berlin, the highest number of participants of all congresses that had taken place up to then. Sixty companies and clinics presented their innovations and therapy offers at a well-attended industrial exhibition, and a number of aid organizations showed great interest in military medical topics with their presence.

The motto of the congress was “Tradition and Innovation”, but at the same time the foundation of the first German Military Medical Society was commemorated 150 years ago, which was founded as the “Berlin Military Medical Society” in 1864 in the Cafe Royal in Berlin. The article by Senior Field Physician Prof. Dr. Vollmuth at the beginning of this booklet goes into detail on the history of the German military medical societies.

Ceremony on September 10, 2014

150 years of German military medical societies
The congress was preceded by a ceremony in the Eichensaal of the former Military Medical Academy, today's Federal Ministry for Economic Affairs and Energy, on the afternoon of September 10th and a parliamentary evening in the Hotel Estrel. The President of the DGWMP, Generalarzt a. D. Dr. Christoph Veit, gave an overview of the development from the “Berlin Military Medical Society” to today's DGWMP. His resume:

“150 years of military medical societies is a long time, and anyone who scrutinizes historical and critical questions will find that even when applying standards typical of the time, some things were wrong, ethically inadequate and technically incomprehensible in the past. But if you look without ideological glasses, you will find much that is worth preserving and that is progressive, e.g. B. the restless spirit of discovery, the faithful and devoted fulfillment of duty, the enthusiasm for research and further development of methods, standards and equipment. And all to do better justice to the mission of protecting the life and limb of soldiers, preventing illnesses and restoring health as far as possible. Then as now, civilian patients and the entire healthcare system benefited from this. I remind you pars pro toto about the fight against infections and epidemics, the development of vaccinations and the further development of surgical methods and prosthetics. In a comparable way, civil medical developments have found their way into military medicine, e.g. B. X-ray technology.

Without hiding the events and mistakes from history, the DGWMP e. V. is committed to good military medical traditions and is therefore consistently honoring, maintaining and developing the principles of our association's motto: "Scientiae - Humanitati - Patriae". "

The full text of the speech can be found on the Internet at www.dgwmp.de.

The inspector of the medical service of the Bundeswehr, Chief Medical Officer Dr. Ingo Patschke, in his welcoming address, emphasized the importance of a military medical specialist society for the scientific advancement of the medical service of the Bundeswehr. The promotion of young medical officers through science prizes, such as the Paul Schürmann Prize and the Heinz Gerngroß Sponsorship Prize, the organization of congresses, meetings and further training events by the DGWMP and networking in the working groups are in the tradition of the founders of the Berlin society, the was primarily dedicated to the scientific exchange within the multidisciplinarity of military medicine.

In his keynote lecture "Medical Societies in Transition - Considerations from the Perspective of the German Society for Surgery", Professor Dr. Hartwig Bauer, Secretary General of this society from 2003 to 2011, gives an overview of the development of the medical societies in Germany. He particularly welcomed the integration of military medical expertise into the further development of the specialist disciplines and demonstrated this, among other things, using the example of the operational, disaster and tactical surgery working groups (Head: Senior Physician Prof. Dr. Friemert, Ulm) of the German Society for Trauma Surgery and Surgical Working Group for Military and Emergency Surgery (CAMIN) of the German Society for General and Visceral Surgery, headed by Senior Physician Professor Dr. Schwab, Koblenz.

The ceremony was musically framed by the wind ensemble of the staff music corps of the Bundeswehr.

Congress opening

In the presence of the Federal Minister of Defense, Dr. Ursula von der Leyen, and the Armed Forces Commissioner of the German Bundestag, Mr. Hellmut Königshaus, welcomed the President of the Congress, Doctor Colonel Dr. Walter Kating (Bundeswehr Hospital Berlin), after a musical overture performed by the Military Music Corps III, the participants.

The greetings from the Federal Minister of Defense were eagerly awaited. She also greeted the auditorium with the words “Dear colleagues!” And thus, as a medical colleague, expressed her close ties to the medical service in a special way. “Tradition and innovation belong together,” emphasized the minister, who still considers the Geneva Convention to be ultra-modern. From the measures to improve the lot of the sick, injured and wounded in the field, yesterday as today, improved treatment options in the civilian area would also be developed - for the benefit of the military and civilian side in the same way. But she also emphasized that only through constant further development and the constant striving for improvement can the goal of optimal medical care also be achieved in the field. With the words: "If you start to lean back on a high level, you have already lost!" von der Leyen to the three subject areas that she sees as special priorities for the medical service. First and foremost, recruiting young people is a key question for Germany, good training and further education create elementary foundations; after all, research needs to be expanded “to keep our finger on the pulse”. "Research is one of the central fields for retaining staff," said the minister; Finally, she underlined her open ear, especially for the concerns of the medical service, with the words “Get me in!”.

The Defense Commissioner of the German Bundestag, Mr. Hellmut Königshaus, initially noted that the minister had actually already taken up the suggestions he had made for his greeting. He pointed out the deficit in caring for burn injuries and asked which rules for dealing with highly infectious diseases such as Ebola should apply in the future. He also suggested making better use of the positions available in the medical service as part of “vacancy management”.

The President of the Berlin Medical Association, Dr. Günther Jonitz, emphasized the importance of leadership and corporate culture as "soft factors" that ultimately determine the "hard quality". The rediscovery of primary medical virtues in an organized way leads to real quality management.

The deputy commander of the Territorial Tasks Command, Brigadier General Kropf, welcomed the participants as a representative of the military side and as the site commander of Berlin, before Generalarzt a. D. Dr. Veit opened the congress.

The inspector of the medical service, General Oberstabsarzt Dr. Ingo Patschke gave an assessment of the position of the medical service and discussed the sub-goals achieved so far on the way to the new structure. He also emphasized the need for close cooperation with the specialist societies and especially thanked the DGWMP for their contributions to further training and scientific cooperation.

Colonel d. R. Professor Dr. Pure Pomeranian. He went into the concepts of individual, collective and cultural memory as used in memory research. At the center of the theory of collective memory is the insight that the past is not completely forgotten, but has not yet lost its importance as a resource or mortgage for the present. The radius of responsibility of western societies has expanded considerably in recent years, as they not only assure themselves of their positive foundations, but also include negative events in their collective self-image. With the sentence of Lieutenant General Wolf Graf von Baudissin, "The decision for this or that tradition - this is my deep conviction - has little to do with the past, but much to do with the ideas of the present and future." Convinced that at the DGWMP, as in the medical service, tradition will continue to be linked with history and innovation with responsibility and concluded with the wish: “ad multos annos.” The full wording of the lecture is published at www.dgwmp.de.

Awards ceremonies

Paul Schürmann Prize 2014
As part of the opening event, Chief Medical Officer Dr. Christian Ruf was awarded the Paul Schürmann Prize worth 7,500 euros for his scientific work on the subject of “Molecular biological risk factors of metastasis in seminomatous germ cell tumors of the testicle”. The President of the DGWMP, Generalarzt a. D. Dr. Veit, presented the proud award winner with a certificate and check. Chief Medical Officer Dr. Ruf thanked him and stated that this award was an award for an excellent scientific cooperation between the Bundeswehr hospitals and the Institute for Radiobiology of the Bundeswehr. A short version of the award winner's work can be found in this issue.

Heinz Gerngroß Award 2014
On the afternoon of September 12th, six young medical officers / trainees presented themselves to a critical jury headed by Senior Physician Professor Dr. Becker. The task was to present a military medicine or military pharmaceutical topic and to defend the results or theses presented there in a discussion. The task was mastered confidently by all applicants, the result was very close.

During the festive evening on the same day, the winners, medical officer Alexander Kaltenborn from the Westerstede Bundeswehr Hospital ("The Hip Lag Sign - a new reliable clinical sign for diagnosing hip abductor damage in the light of the urgency of precise examination methods in action") and Lieutenant (SanOA) Lisa Müller-Schilling from the Medical Regiment 32 in Weißenfels (“Influence of physical performance on overuse complaints and injuries in the context of general military basic training”) presented certificates and prize money of 1,500 or 1,000 euros. Short articles from the lectures from the Young Talent Forum are printed in this issue.

Congress photos: DGWMP / Andreas Meyer-Trümpener

Lectures and posters

Selected papers are presented below from the numerous lectures in the plenary as well as in several scientific sessions, including the working groups, and from the poster presentation. A complete reproduction is unfortunately not possible due to lack of space. For this reason, some contributions from the various subject areas are reproduced in more detail in order to give an impression of the technical breadth and depth of this congress. To contact the authors, their email address can be requested at [email protected]

Healthcare / Hospitals

The historical development of the Bundeswehr hospitals from 1957 to 2014

General doctor a. D. Prof. Dr. Dr. Erhard Grunwald
Koblenz

During the development phase of the Bundeswehr, which lasted from 1956 to 1962, the first military hospitals were set up in Gießen, Koblenz, Glückstadt, Amberg and Detmold in 1957; by the end of 1959 the military hospitals in Hamburg, Bad Zwischenahn and Kempten were added, so that after a short time the Bundeswehr already had 1,433 beds. This shows, for example, the great time pressure under which the establishment of the Bundeswehr was under, since for political reasons a visible and effective defense contribution should be made quickly after the Bundeswehr has joined NATO.

In the years 1963 to 1967, which are considered to be the expansion phase of the Bundeswehr, two more hospitals were added, so that the medical service had 2,285 beds in 1966.

In 1970 there was a significant streamlining of the medical service organization; the now twelve hospitals were combined with other departments to form the organizational area “Central Medical Services of the Federal Armed Forces” and subordinated to the inspector of the medical services in every respect. In the same year, the military hospitals were renamed and opened to civilian patients.

In the years that followed, there was a continuous expansion of the Bundeswehr hospitals in terms of technical, personnel and material aspects.

In the security situation characterized by the East-West conflict until the end of the 1980s with a possible military confrontation on the inner-German border, the hospitals would have been the only clinical facilities in the first phase of a war with then 5,000 beds that would initially have continued Treatment could have taken over.

As part of the reunification in 1990, nine hospitals of the NVA with approx. 2,000 beds and the former central hospital of the People's Police, the former imperial garrison hospital No. 1, in Berlin were taken over.

With the reduction of the army to 340,000 soldiers as part of the new overall planning of the German armed forces in 1990, a decision was made in favor of a system with four larger hospitals and four so-called “156-bed standard hospitals” that comprised 2,300 beds.

With the ministerial directive on the "realignment of the Bundeswehr" in 2000 and the associated operational restructuring of the armed forces, three small hospitals were closed and the inpatient care capabilities were now concentrated in five houses with around 1,800 beds in order to meet the mandate of comprehensive medical care for the Meet soldiers in peace, defense, and deployment.

Bundeswehr hospitals: where from? Where? Insights from a chief physician

General doctor Dr. Joachim Hoitz
Federal Armed Forces Hospital Hamburg

Bundeswehr hospitals (BwKrhs) have been in existence for over 50 years, founded in times of the Cold War and prepared to fight for national and alliance defense on German soil as the nucleus of a hospital organization that grows rapidly in the event of a defense. The armed bloc thinking turned into global crisis management and conflict prevention, the combat troops mutated linguistically into peacekeepers. How are the BwKrhs changing?

With a new Bundeswehr, today's security policy is also changing the mandate for the BwKrhs: training for highly efficient medical care for the wounded or sick on missions abroad, the deployment of specialist personnel there and the final treatment of the wounded in their home country are by far the first priority: training is the “corporate goal “In the BwKrhs system network. To this end, it is essential to treat patients with correspondingly serious illnesses and injuries every day. These can also be soldier patients, but mostly - fortunately - they are too healthy to be able to successfully prepare the medical personnel for the challenges of foreign missions. For education, state-of-the-art medicine is mandatory, which nowadays means the use of Evidence Based Medicine (EBM) and proven quality assurance, which displaces the formerly predominant experience and “eminence-based” medicine. But how much EBM exists for the care of the wounded, e.g. B. after explosion and gunshot wounds? The challenge for the medical service is to supplement EBM, wherever necessary, with experience, to combine it creatively with it and to further develop it innovatively. Today's operational experience goes as "medicina in extremis" far beyond the previously completely sufficient depth of care provided by civil medicine. While at the beginning of the BwKrhs, civil medicine had a unidirectional effect on the BwKrhs and medical officers were only marginally successful, today, as in history, military medicine is valued as a motor for creative and innovative further development impulses and doctors and nurses at the BwKrhs, whether they do it, are valued unique experiences, highly recognized as outstanding representatives of their field in the scientific specialist societies. This realization is all the more important as the battle for the best has broken out with limited human resources. The people working in the BwKrhs are also subject to change: Coming from duty-orientation and hierarchical thinking, work-life balance and striving for autonomy have become just as natural here today, as the holistic, interdisciplinary thinking interprofessional team player has developed from the experience of foreign assignments .Although the BwKrhs often do not belong to the large hospitals with regional market dominance, this is precisely one of the attractive approaches to position oneself in the completely changed healthcare market: From the general services of the old communal hospital structure with initially generous resources, there has been a change from civil to revenue-optimized and resource-saving Management with increasing specialization. Marketing shapes the external impact of all players in the healthcare sector. And since the BwKrhs want to generate patients from the same population for training reasons, marketing is necessary for them too. But it is precisely the difference in the corporate goals that is suitable for highlighting a decisive unique selling point: Here excellently trained medical soldiers who are able to work in a team anywhere in the world with all the means and under all the framework conditions that they currently find To achieve the quality of medical results as in the home country, there the need to optimize resource-limiting in order to increase shareholder value, and thereby promote both competition between specialist departments and hospitals, and to perceive training as a time-consuming and resource-consuming - and annoying - inevitability.

BwKrhs have developed from the former hospitals of basic and standard care for soldiers into sought-after cooperation partners in patient care and training, their employees into experts who can be consulted in the technical discussion and into extremely popular hospitals for patients who Appreciate the holistic therapeutic approach and the friendly atmosphere in the team with excellent medicine and personal affection. BwKrhs are therefore ideally suited to form the core of a future cluster formation for training and treatment in their regions.

The general practitioner as gatekeeper / pilot in the supply system

Professor Dr. Wilhelm Niebling
university hospital Freiburg

Contract medical care in Germany is divided into general practitioner and specialist care. General practitioners, paediatricians and internists without specialization (who have chosen general practitioner care) take part in general practitioner care (Section 73, SGB V).

In view of the increasing specialization and fragmentation of health care, general practitioners are more important than ever as “generalists”. Generalism describes a medical approach that starts with the specific patient and his / her problems. This does not include any claim to universal responsibility ("omnipotence") (future positions of the German Society for General Medicine and Family Medicine, www.degam.de).

General practitioner roles and medicine have undergone a fundamental change. Patient autonomy has increased (“critical consumers”). The comprehensive responsibility of the family doctor "from cradle to grave" has given way to a division of labor with specialized doctors. The "round-the-clock presence" was replaced by a comprehensive emergency service. Cooperative care structures, such as group practices or medical care centers, are increasingly taking the place of the previous individual practices.

Demographic change, multimorbidity and the increase in complex chronic diseases lead to an increasing need for care and require cost-effective care management by the family doctor. Last but not least, patients want comprehensive, personal and local care.

According to the statistics of the German Medical Association, there were 357 252 doctors in Germany at the end of last year - more than ever before. However, while the number of resident specialists has increased by almost 50% since 1993, general practitioners have decreased by 10% over the same period. The previous ratio of general practitioners to specialists has reversed from 60 to 40%. So we don't have the specialists that our healthcare system needs ... and especially not where they are needed, namely in rural areas.

The shortage of general practitioners, which is already noticeable in some regions and is threatening in many, is accentuated by the fact that a third of current general practitioners are older than 60 years, 10% have passed retirement age and only 3.5% are younger than 40 years. The National Association of Statutory Health Insurance Physicians (KBV) expects a gross outflow of around 15,000 general practitioners by 2020 and fears that only every second general practitioner seat that becomes vacant can be filled again. In 2013, only around a tenth of the around 11,000 specialist approvals issued were in the field of general medicine.

In addition, there were 9 023 places available in the winter semester 2012/13, fewer places in human medicine than in the old federal states before the fall of the Berlin Wall ... and a quarter of a year of approbation is looking for a job abroad, according to the German Medical Association.

What should I do?

  • Politics (coalition agreement), the Advisory Council (report from June 23, 2014), the Science Council and the German Medical Association are calling for general medicine to be strengthened in training. This includes the establishment of independent departments or institutes for general medicine at all medical faculties;
  • The establishment and promotion of training associations and competence centers for general medicine (analogous to Hessen and Baden-Württemberg) as well as
  • Attractive general conditions for future general practitioners (appropriate remuneration, part-time and / or salaried employment, etc.);
  • Sustainable financing through the establishment of a “medical education and training foundation”.

Beginnings have been made. If “lighthouse projects” such as the Verbund further education plus (Baden-Wuerttemberg), competence centers for general medicine (Hesse, Baden-Wuerttemberg.) And the general practitioner perspective (Hausärzteverband Baden-Wuerttemberg.) Succeed in establishing a nationwide general practitioner Supply of our population can be ensured.

Further education network for general medicine and university teaching - future options for regional sanitary facilities? Experience from the specialist medical center in Munich

Senior Field Physician Dr. Roland Vogl et al.
Medical center in Munich

Gaps in medical care, especially general practitioner care, already exist regionally, but are likely to increase over the next few years. Therefore, strategies for solving this problem are being developed by the relevant interest groups (e.g. Medical Association, Statutory Health Insurance Association, German General Practitioner Association, General Practitioner Association). Structured advanced training networks for general medicine, but also the increased implementation of primary medical teaching content already in university studies, are in the foreground.

The implementation of these options is presented using the example of the specialist medical center in Munich. Here, the possibility of an in-house structuring of the training to become a general practitioner in a regional medical facility, especially under the aspect of civil-military networking, is discussed. This also includes the commitment of young medical officers to military medical work in the i. See the "attractiveness of the service" in focus.

In addition, the university activities of the specialist medical center in Munich were presented: occupational field exploration, public health, mandatory clinical training for civil students, teaching assignments in manual medicine, dental "high-quality training" and PJ-Tertial general medicine. This is partly done in cooperation with the medical academy of the Bundeswehr and is also a relevant component in the cooperation between the medical service and the civilian health system.

New technologies and processes

Contrast-enhanced ultrasound (CEUS) in vascular medicine and implications for field medicine

Senior field physician Christian Richter et al.
Bundeswehr Hospital Ulm

Contrast enhanced ultrasound (CEUS) is an established imaging method in everyday clinical practice that improves the quality of the informative value of sonographic examinations: CEUS enables dynamic examinations of blood flow and closes diagnostic gaps between sonography and computed tomography. In the lecture, indications, technology and clinical examples of CEUS from vascular medicine and trauma care will be presented and the application-relevant potential will be explained.

CEUS answers vascular medical questions without the side effects of conventional examination methods, such as nephrotoxicity of the radiological, allergy-prone contrast agent substances. This is why CEUS is being used more and more widely in the multimorbid vascular medical community.

The check-ups after endovascular aortic repair (EVAR) are already established. The perfusion and the related plaque stability of the carotid stenosis can already be detected and assessed with CEUS.

In the Vascular Center of the German Armed Forces in Ulm there is already extensive experience with perfusion diagnostics using CEUS.

Furthermore, as a bed-side method, CEUS discovers easily and reliably perfusion damage and injuries to the abdominal organs, e.g. on ICU or in the ER, and reduces the number of CT examinations and transports of unstable patients to the CT. Under diagnostic time pressure, with a high number of trauma patients, limited CT and transport capacity, CEUS closes the diagnostic gap between Focused Assessment with Sonography for Trauma (FAST) and CT. CEUS can serve as a back-up for CT defects.

During the first Ulmer course about CEUS in the vascular center of the Bundeswehr, examinations were carried out in the deployment hospital MASAR-E-SHARIF with a CEUS-capable ultrasound system. In a meeting at FAST, the potential of the CEUS was also demonstrated telemedically. In a second phase, routine examinations were carried out with CEUS-capable ultrasound systems (HD7Bw) that were already in use.

CEUS is already established as a leading diagnostic procedure in vascular medicine. In traumatology, it is the fastest and most efficient imaging method in terms of differential diagnosis. Placement in operational medical algorithms is obvious. FAST training concepts already exist and are designed to be interdisciplinary and cross-organizational. Further experience can be gained in operations such as emergency room supply in Germany.

Standard-compliant integration of media content from medical video towers in PACS and HIS

Dipl.-Ing. Jörg Schönfeld
Bundeswehr Hospital Berlin

The increase in non-radiological imaging processes characterizes the technical development in modern hospitals. In addition to a large number of modalities from radiology, it is the goal of doctors and hospital management to also connect other imaging processes to a digital X-ray archive (PACS) and to the hospital information system (HIS) in accordance with standards. The almost unmanageable legal situation in the field of medical device law requires the responsible system integrators (doctors, engineers and technicians) to have extensive knowledge in the field of medicine, medical technology, information technology and medical IT networks. It makes sense to connect the non-radiological devices technologically according to the same concepts as radiological modalities. On the one hand, this approach facilitates the implementation of far-reaching technical possibilities and creates the possibility of defining responsibilities and interfaces that are recommended for hospital operators in the various ordinances and standards. In the field of non-radiological imaging processes, the group of medical video towers was identified as a technical area that is characterized on the one hand by a large number of system manufacturers and on the other hand by the number of technical implementation options for connecting the systems to PACS and HIS. It makes sense to evaluate the technical connection conditions and to introduce uniform system integration procedures in order to meet all legal and technical framework conditions.

Contents of the evaluation:

  • Identification of the procedures and classification of the non-radiological video modalities
  • Overview of video towers from the field of endoscopy
  • Technical requirements at network level (medical IT network)
  • Media processing and structured reporting Endoscopy
  • Connection of information to PACS and HIS
  • Case study special application ERCP with cholangioscopy
  • Risk management according to DIN EN 80001-1
  •  

Conclusion:

The connection of non-radiological modalities in the area of ​​endoscopy or within a special medical application with integration in a digital X-ray archive (PACS) or hospital information system (HIS) requires a conceptual approach during the rollout, especially taking into account that video towers are usually not connected to a radiological one Information system (RIS) are connected.

The focus of the integration (shown using the example of video towers in endoscopy) in a medical-technical IT network is the connection to order and entry management, HL7 and DICOM communication with a connection to a manufacturer-independent PACS and HIS. In addition, ways for the practical implementation of the new standard: DIN EN 80001-1 (risk management when implementing video towers as active network components in a medical IT network) are presented.

Robot-assisted (DaVinci®) Laparoscopic Prostatectomy - Current Fashion or the Future?

Senior Field Physician Dr. Andreas Martinschek et al.
Bundeswehr Hospital Ulm

The robot-assisted (DaVinci®) Laparoscopic prostatectomy (RALP) has meanwhile established itself as the standard urological procedure, in the USA over 80% of prostatectomies are performed with robot assistance. In addition to intraoperative and perioperative advantages, the current literature now also shows significant advantages in the oncological and functional outcome (R1 rates, continence, potency).

For the oncological outcome, a review by Coelho (J Endourol 2010) on large numbers of cases (RRP n = 41,729, LRP n = 11189 and RALP n = 8472) shows that there is a significant difference in terms of the positive incision margin rate (independent prognostic factor for relapse-free survival) (RRP: pT2R1 = 16.8%, overall R1 = 24%; LRP: pT2R1 = 12.4%, overall R1 = 21.3%, RALP: pT2R1 = 9.6%, overall R1 = 13.6%) between RRP and LRP and between RRP and RALP in favor of the laparascopic procedure.

In terms of functional outcome, the 12-month continence rate in a meta-analysis by Novara (Eur Urol 2012) was 69-96%, with an average of 84% (no template) and 89-92%, respectively, and an average of 91% (no template or Security template). In this meta-analysis, the cumulative analysis showed for the first time a statistically significantly better 12-month continence according to RALP compared to RRP (OR: 1.53; p = 0.03) or LRP (OR: 2.39; p = 0.006). In a study by Tewari (BJUI 2003) the time to regain continence was significantly shorter after RALP (43 vs. 160 days).

With regard to potency, a meta-analysis by Ficarra (Eur Urol 2012) showed 12- and 24-month potency rates according to RALP of 54-90% and 63-90%, while the cumulative analysis showed a statistically significantly better 12 -Month potency rate with RALP compared to RRP (odds ratio [OR]: 2.84; 95% confidence interval [CI]: 1.46 - 5.43; p = 0.002). The comparison of RALP vs. LRP showed a non-statistically significant trend in favor of RALP (OR: 1.89; p = 0.21). A meta-analysis with strict inclusion criteria by Salinas (Adv Urol 2013) also showed an advantage for robot-assisted operated patients with regard to continence and potency.

In summary, current data from the literature show that the robot-assisted surgical procedure is superior to the open surgical procedure. The learning curve of robotic surgery is shorter than that of laparoscopic procedures. There are many indications that this innovative surgical method, with the constantly growing range of operations, also in other specialist areas (surgery, ENT, gynecology), has a firm position.

In the course of the year, surgical robots were / will be put into operation in the Bundeswehr Central Hospital in Koblenz and in the Bundeswehr Hospital Ulm in the visceral surgery and urology departments.

For the year 2015, a first experience report and a detailed presentation of the current data situation are planned for publication in the military medical monthly.

First experiences with mobile patient simulators

Senior Field Doctor d. R. Dr. Burkhard Milde
Buckeburg

The use of simulation in the field of medical education and training is a globally established standard. Due to the new technological possibilities, patient simulators can now also be used on the move.

First experiences with mobile, robust and wireless simulators were among others. collected and evaluated during quota pre-training courses and workshops. Particular attention was paid to the target group, the predetermined learning content, the consideration of the external environment, the operating personnel and the selection of the target-oriented simulators, taking into account crew resource management.

Systems from CAE Healthcare (patient trauma simulator CAESAR and the patient simulator MetiMan (Prehospital)) were used. The operating personnel were mainly provided by employees from CAE Healthcare, after system briefing, members of the armed forces also took on this task. Participants in the simulation training were fire service personnel, schoolchildren and soldiers from various fields.Experience reports from CAE employees and / or DASH questionnaires were evaluated.

Ready-made scenarios (Simulated Clinical Experience - SCE) were created, e.g. B. from the areas of tactical combat casualty care (TCCC), professional association first aid training and workshops on prolonged field care.

Within the groups there were different entry requirements in terms of simulation experience, medical knowledge and motivation. As a result, the overwhelming number of participants had a positive attitude towards the use of patient simulators, but there was no complete rejection. Technically, the simulators could be used in all weather conditions and in different locations. The preparation and follow-up work on the simulators was not insignificant.

Conclusion:

Patient simulators contribute to realistic training and thus contribute significantly to success in use. They increase patient safety and improve skills for maintaining life and / or quality of life.

Mobile use is possible and realistic. Consequently, the training goals and the target group should be known in advance. Only in this way can the appropriate simulator, the appropriate operator and technical personnel and the appropriate evaluation options be brought together.

Special therapy in the paraplegic center for soldiers with acute post-traumatic paraplegia

Senior Field Doctor d. R. Dr. Yorck-Bernd Kalke et al.
University Clinic Ulm / Bundeswehr Hospital Ulm

In Germany, there are 26 paraplegic centers with currently 1,281 beds available for paraplegic patients. The incidence of paraplegia in Germany is 2,200 cases per year. About half of the cases are accident-related or, as with benign tumors, metastases, abscesses or ischemia, disease-related. In most cases the health insurances are the payers, followed by the professional associations for accidents at work and commuting, and in <1% of the cases it is the armed forces.

In the paraplegic center of the Orthopedic University Clinic Ulm with currently 50 treatment beds, 27 soldiers with post-traumatic tetra- or paraplegia were treated in the period of 30 years between 1984 and 2014, all of whom were taken over from the Bundeswehr hospital in Ulm, especially the neurosurgery department. The aim of the therapy is always - depending on the height of the lesion - to achieve the greatest possible independence and, if possible, to be released into the adapted environment at home.

Paraplegiological treatment is based on the comprehensive care doctrine according to Sir Ludwig Guttmann (1899 - 1980), according to which the paraplegic patient needs specialized help in the paraplegic center as quickly as possible, and this care should be provided by the special center for life. Because only in the paraplegic center one knows how to cope with the multifactorial impairment, such as motor and sensory deficits, neurogenic bladder and rectal evacuation disorders, sexual dysfunction, pulmonary problems, circulatory dysregulations and psychological impairment. The treatment of the numerous complications of paraplegia, such as pressure ulcers, function-impairing spasticity, musculoskeletal and neuropathic pain syndrome, contractures, neuro-urological problems, constipation and paradoxical diarrhea, hypotonia and autonomic dysreflexia, up to and including depression and embolism, dombymenorrhea, and dysreflexia, make the treatment more difficult Thoughts of suicide, added.

In the initial care of the soldier at the scene of action, priority is given to assessing and securing the vital functions, inquiring about the cause of the wound (if possible), orienting neurological recording of motor skills and sensitivity, venous access, immobilization and, if necessary, “putting your head down” -Zug-Halt “as well as the transport. Intensive care treatment includes ensuring breathing, checking the patient's position - if necessary on a special mattress - contracture prophylaxis, checking bowel activity, indwelling catheters, and certainly also suprapubic urinary diversion and registration at the paraplegic center. The spinal shock manifests itself through flaccid paralysis with reflex failure and loss of temperature regulation. In addition, it can lead to a failure of the orthostatic circulatory reflexes, cardiac arrhythmias, paralytic subileus, weakened airway reflexes and acute urinary retention. When suctioning the nasopharynx or the lungs, acute reflex bradycardia up to asystole can occur. Because of the restricted ability to regulate, changes in position can lead to a sharp drop in blood pressure.

In the paraplegic center, the individual departments with care, physiotherapy, occupational therapy, sports therapy, speech therapy, balneophysical therapy, technical orthopedics, conversation therapy and clinical pastoral care as well as other special disciplines such as spinal surgery, neuro-urology and plastic surgery are available. Particular mention should be made of the cooperation with the neurosurgery department of the Bundeswehr Hospital Ulm and the paraplegic center of the Orthopedic University Clinic with regard to the care of the post-traumatic Syrinx.

As part of the special therapy, which lasts on average between two and four months for paraplegics and three to five months for quadriplegics, state-of-the-art therapy devices such as the exoskeleton are used to enable at least therapeutic walking. For all patients, the American Spinal Injury Association (ASIA) Impairment Scale (AIS A - motor and sensitive complete, AIS B - motor complete and sensitive incomplete, AIS C - motor incomplete without function, AIS D - motor incomplete with function) as well as the Spinal Cord Independence Measurement (SCIM) score collected, with which between 0 and 100 points can be achieved, with up to 20 points for self-care, breathing and sphincter management as well as mobility 40 points each. Restitutio ad integrum (AIS E) is achieved only extremely rarely with 1 - 2% of the treatment cases.

Research and studies

The pharmacotherapy of post-traumatic stress disorder - new ideas and developments from basic research

Ulrike Schmidt
Max Planck Institute for Psychiatry (MPI-P), Munich

Post-traumatic stress disorder (PTSD) can occur after mission-related stress, but also in the civilian population after acts of violence or life-threatening accidents. The options for drug treatment for this trauma-related disorder are limited. Antidepressants of the serotonin reuptake inhibitor (SSRI) type are considered the gold standard in psychopharmacotherapy for PTSD, but a significant proportion of PTSD patients do not benefit from them at all or only inadequately.

The development of drugs that work against the cardinal symptoms of PTSD, namely reverberation memories, avoidance behavior and nervous overexcitability, and which can shorten the duration of psychotherapeutic treatments, is therefore urgently required.

In the lecture the new ideas and developments from basic research were presented; Among other things, the state of research and development of the novel anxiolytic intranasal neuropeptide S (iNPS), which was discovered 3 years ago in animal models, was explained and microRNAs were discussed as possible target structures for antipsychotraumatics.

microRNAs are short RNA molecules that do not code for proteins, but rather represent a special form of an epigenetic mechanism and thus regulate the activity of genes. As yet unpublished data from the MPI-P show that certain microRNAs show an altered expression pattern both in the blood of PTSD patients and in the prefrontal cortex and hippocampus of mice suffering from a PTSD-like syndrome. In an earlier work, the first ever to investigate the relationship between PTSD and microRNA expression, we showed that the therapeutic effect of the antidepressant fluoxetine in a mouse model for PTSD depends on a significantly reduced expression of the microRNA mmu-mir- 1971 was accompanied in the prefrontal cortex. In the collaboration study Bw-BioPTSD, which was designed jointly by the Bundeswehr (Psychotraumazentrum Berlin), the Charité Psychiatric Clinic (J.Gallinat) and the MPI-P, we use high-throughput analysis methods to investigate, among other things, whether microRNAs expressed in leukocytes contribute to the assessment of Facilitating vulnerability to mission-related stress disorders - we have just published the design of this study. At the same time, we are continuing research on the mouse model to elucidate the function of microRNAs in post-trauma disorders; i.a. we want to find out which microRNAs are involved in the regulation of the central nervous neuropeptide metabolism, since it is known that this is changed in various mental illnesses.

As already presented at previous DGWMP congresses and published in the meantime, we found that neuropeptide S (NPS) administered as a nasal drop / spray has a strong anti-anxiety effect in mice. NPS does not act directly on the GABA receptor and therefore has no undesirable strong sedating side effects such as benzodiazepines. As yet unpublished data show that there is a high probability that NPS is also suitable as a therapeutic agent for PTSD, as it drastically reduces nervous overexcitability and avoidance anxiety in traumatized mice and also affects fear memory. In parallel to this work on the mouse model, we are trying to develop a form of NPS that is suitable for humans, namely a derivative that is well tolerated and has a long duration of action.

In addition to these two major research lines on microRNAs and neuropeptides in PTSD, other promising new approaches were cursory presented, including a preparation that is suitable for the treatment of self-injurious behavior.

Is the soldier healthy, balanced and mentally fit during deployment? ”Answers from the deployment study on sport, sleep and smoking behavior by German ISAF soldiers.

Senior Field Doctor d. R. Prof. Dr. med. Stefan Kropp
Asklepios specialist clinics in Teupitz and Lübben, Teupitz

Question:

In the ISAF mission, the parameters “physical activity and sport”, “sleep” and “nicotine consumption” were to be examined at three measurement times before, during and after a foreign mission in an investigation group (Panzergrenadierbatallion) in order to provide information on the stresses of the mission in the above-mentioned areas to obtain.

Method:

At the time of measurement, the current psychological stress of the soldiers was recorded using standardized questionnaires. A homogeneous comparison group consisted of members of another armored infantry battalion not deployed abroad, who were examined in the same time frame with the same instruments. The test samples were recruited after the approval of the investigation by the Federal Ministry of Defense, the ethics committee of the Hannover Medical School (MHH) and after approval by the respective commanders after information and direct contact with the troop doctors involved in the study.

Results:

For soldiers on duty, physical activity and sport are an important basis for resource conservation, which can also have a positive effect on mood, stress and tension. Sport should also be consciously used and promoted as a strengthening element in future scenarios. According to the first study results, a well-balanced sleep, as much as possible on duty on duty, appears to be a very reliable marker for the well-being and the stability of the "system psyche" of combat soldiers. Anomalies in this area could be indications for those affected themselves, but especially for superiors and comrades in the sense of a less stigmatizing marker. Those affected could then receive more support and attention until the quality of sleep improves again through the measures taken. The smoking quota in the combat troops is clearly above civilian age-equivalent comparison populations, especially among the teams, but this tends to decrease in the course of action, so that increased stress smoking in action is not a problem that should be dealt with as a priority.

discussion

From the point of view of the Bundeswehr Psychological Dream Center, three essential and easily ascertainable principles of resource conservation and strengthening against the background of an ongoing deployment of the combat troops could be examined for the first time by means of the study presented in comparison to a comparative unit at the home location and in deployment training. From the perspective of the study group, the role of sport in action could be further strengthened by the present results, sleep as a simple marker for mental well-being could be brought more into focus, and the role of nicotine consumption in action could be viewed somewhat less than the other two markers for mental well-being . Current and proven preventive approaches to smoking cessation and abstinence continue to be important in Germany.

Correlation of basic fitness test results with performance in ergometry as part of the assessment

Senior Field Physician Dr. Nils Gundlach et al.
Medical center Rothenburg / Wümme

The general transfer no. 80 (technical instructions of the inspector of the medical service of the armed forces, FA InspSan) regulates in chapter D01.01 the scope of the medical examination in the context of status changes and extensions of service. In particular, the exercise ECG in the form of ergometry is used to determine the physical performance and to exclude cardiovascular diseases or cardiac arrhythmias under stress. Gender-independent minimum performance (2.3 watts / kg body weight or 250 watts absolute) is prescribed. At the same time, every soldier has to pass the basic fitness test (BFT) every year to prove his or her physical performance.

In a preliminary investigation it could be shown that pathological cardiac arrhythmias during exercise ergometry do not occur in young regular soldiers as part of the further obligation examinations. It would therefore be conceivable to dispense with the stress ECG for the detection of pathological cardiac arrhythmias.

However, the extent to which testing of physical performance can be dispensed with has not yet been investigated. Therefore, the aim of the study was to determine the correlation of the results of the BFT and its individual disciplines with the performance on the bicycle ergometer as well as the false-negative and false-positive results.

For this purpose, the assessment examinations of 372 further obligation examinations (age: 24.3 ± 2.6 years) as well as survival in field assessments from the Augustdorf location (period 2010 - 2012) were retrospectively evaluated as part of a pilot study and with the individual BFT overall result and the BFT individual discipline results compared. Of the total of 362 subjects, 350 subjects passed both the ergometry and the BFT, while 19 subjects only passed the BFT and 3 subjects only passed the ergometry. Between the absolute and relative performance on the bicycle ergometer and the scores achieved in the individual disciplines of the BFT or the total number of points, there was only no correlation between the absolute performance on the bicycle ergometer and the result on the climbing slope, while all other results correlated highly significantly (p < 0.001). As an example, the figure shows the correlation diagram between the relative bicycle ergometer performance and the 1000m run.

The results presented in the context of the pilot study show impressively with a large sample that there is a highly significant correlation between the performance on the bicycle ergometer and the results in the BFT in the examined group of young patients. Only false-negative results (ergometry failed, BFT passed) predominate. In a preliminary examination it could already be shown that no pathological EKG changes could be found in the context of the stress EKG examination in young soldiers. In view of the young age of the test subjects and the large amount of time required, the ergometry test for checking physical performance can be replaced by the BFT, which is mandatory for the troops.

The contribution was awarded a poster prize.

Infectiology

Comparative evaluation of serological test procedures for the diagnosis of schistosomiasis

Medical officer Rebecca Hinz et al.
Bernhard Nocht Institute / Bundeswehr Hospital Hamburg

Schistosomiasis is a widespread and serious problem, particularly in Africa with more than 180 million cases of illness, and due to the increasing involvement of the Bundeswehr in sub-Saharan Africa, it causes an increase in the risk of illness for exposed German soldiers on duty. The selection of suitable serological test methods for the diagnosis of schistosomiasis is made more difficult by insufficient data on the test accuracy of commercially available tests. Against this background, different serological test procedures were evaluated at the Tropical Medicine Department of the Hamburg Armed Forces Hospital in order to establish suitable routine diagnostics in the Armed Forces deployment and for examinations of returnees.

100 serum samples were initially tested in 2 in-house tests by the National Reference Center for Tropical Infectious Pathogens, the Bernhard Nocht Institute for Tropical Medicine (BNITM), using an indirect immunofluorescence test (IIFT, polyvalent for IgG / A / M) and an IgG -ELISA (enzyme-linked immunosorbent assay) characterized. The positive collective for this study was made up of 35 samples that tested positive in the BNITM in-house serology (IIFT & ELISA). The BNITM-IIFT was considered the gold standard with a total of 39 positive samples. The following commercially available or under development serological test methods were evaluated: IgG-Line-Blot (prototype), IgG-ELISA (at the manufacturer's request initially without information), IgM-IIFT and IgG-IIFT (EUROIMMUN, Lübeck).

The line blot prototype showed itself to be inferior to the gold standard, but showed overall the highest sensitivity (92.3%) among the evaluated tests. The commercially available EUROIMMUN-IIFT achieved the highest specificity (96.7%) in the evaluation and is also the only one of the tests used that allows differentiation between IgM and IgG.

It is planned to expand this evaluation in combination with molecular and microscopic diagnostics to a larger sample collective in endemic areas. The use of the line blot as a screening method in combination with the EUROIMMUN-IIFT as a confirmatory test would be conceivable for this after it has been established by the manufacturer.

The contribution was awarded a poster prize.

Diarrhoesurveillance in tropical use

Chief Medical Officer Dr. Hagen Frickmann et al.
Bernhard Nocht Institute / Bundeswehr Hospital Hamburg

Background:

The Bundeswehr has been participating in the “European Union Training Mission” (EUTM) in tropical Mali since 2013; Bundeswehr soldiers are stationed mainly in Koulikoro northeast of Bamako. Since diarrhea was one of the “most pressing” health risks - especially at the beginning of the mission - the Tropical Medicine Department implemented mobile real-time PCR assays for diarrhea surveillance for the purpose of analyzing the microepidemiology on site in the Koulikoro field camp.

Methods:

In the dry season between December 2013 and March 2014, stool samples were collected from a total of 25 diarrhea patients from the multinational EUTM forces in the endemic environment. The real-time multiplex PCRs used for surveillance included 2 in-house protocols for enteroinvasive bacterial pathogens (Salmonella spp., Shigella spp./enteroinvasive Escherichia coli (EIEC), Campylobacter jejuni and Yersinia spp.) And intestinal pathogenic protozoa (Entamoeba histolytica, Giardia duodenalis, Cyclospora cayetanensis and Cryptosporidium spp.) as well as 3 commercial "Rida®Gene" real-time PCR kits 'EAEC', 'EHEC-EPEC' and 'ETEC-EIEC' on enteroaggregative E. coli (EAEC), enterohaemorrhagic E. coli (EHEC), enteropathogenic E. coli (EPEC), enterotoxic E. coli (ETEC) and Shigella spp./EIEC.

Results:

Positive PCR results for diarrhea pathogens were detectable in the stool of 60% (15/25) of the diarrhea patients. Above all, DNA from diarrhea-associated E. coli and phylogenetically related Shigella spp., Significantly less often from protozoa, could be detected. Specifically, EPEC was detected in 8/25 patient chairs (32%), ETEC in 6/25 patient chairs (24%) and EAEC in 6/25 patient chairs (24%). Shigella spp./EIEC, Giardia duodenalis and Cryptosporidium spp. were only detectable in one patient (4%). In eight cases (32%) there was a double infection. Abdominal pain and abdominal cramps were the main symptoms with generally bland symptoms; bloody diarrhea was not observed. About half of the patients said they ate food from outside the camp.

Conclusion:

Non-invasive diarrhea pathogens such as EPEC, ETEC and EAEC dominated the microepidemiology in the Koulikoro field camp during the dry season, while protozoa and invasive bacterial pathogens only played a subordinate role. The strong dominance of bacterial diarrhea pathogens suggests the implementation of resistance surveillance in order to be able to initiate a resistance-adapted, reliably effective antibiotic therapy in the event of an outbreak that could potentially endanger operational readiness. The food provided by the diarrhea patients only inconsistently outside the camp indicates autochthonous transmissions in the camp.

Unclear fever among ISAF staff - from index case to Q fever outbreak detection

Senior Field Physician Dr. Elmar Elsner
Bundeswehr Hospital Berlin

Introduction:

Unclear fever during an assignment abroad has always posed a special challenge for military doctors of all nations. A large number of febrile illnesses are caused by infectious diseases, so that knowledge of regionally typical and specific illnesses, especially with regard to the limited diagnostic possibilities in the field, for the diagnosis and therapy and ultimately for the operational readiness is of decisive importance.

Index case and outbreak detection:

We report on a 28-year-old soldier who presented himself in 03/2011 in the emergency room of the Mazar-e-Sharif field hospital with a fever of up to 38.5 ° C. In addition to thomobocytopenia, increased transaminases, splenomegaly and pericardial effusion were noticeable. Infection diagnostics carried out (malaria DT, smear and ST, dengue V. Ag / AK test, influenza A / B-ST, EBV-ST, HIV serology, hepatitis serology, blood cultures, serology of cardiotropic / hepatotropic pathogens) initially did not provide any indicative findings, so that the patient was discharged after defever and improvement of the general condition under the suspected diagnosis of "viral infection with accompanying hepatitis and pericarditis". On the following day, the patient again developed a high fever, chest pain that was dependent on breathing and showed signs of atypical pneumonia on the X-ray. Resumption and antibiotic treatment with levofloxacin followed. If there was only insufficient improvement, the patient was repatriated and further treated at the German Armed Forces Central Hospital in Koblenz, from which the patient was discharged symptom-free after 1 week. A repeat serology finally showed the seroconversion to Coxiella burnetii, so that the diagnosis of acute Q fever could be made retrospectively. In the following months from May to July, eight more ISAF soldiers with unclear febrile illnesses and abnormal blood counts were classified as highly suspect for Q fever according to clinical evaluation. Antibiotic treatment with doxycycline followed immediately. The hospitalization lasted an average of six days; repatriation was not necessary. Seroconversion confirmed the diagnosis of Q fever in all patients.

Summary and key messages:

From the evaluation of our own data and the current literature with particular reference to military medicine, the following key statements result on the basis of the characterization of the disease and the discussion of possible differential diagnoses:

  • The outbreak situation described underlines the importance of interdisciplinary continuous data exchange, continuous data collection and data evaluation.
  • Q fever outbreaks occur again and again around the world. Outbreaks during foreign missions have been described for Bosnia, Kosovo, Iraq and Afghanistan.
  • In soldiers with fever, possibly signs of pneumonia, suspicious thrombopenia and elevated liver enzymes (hepatitis), Q fever must be included in the differential diagnostic considerations. If there is the slightest suspicion, antibiotic therapy with doxycycline should be started immediately.

Military medical care abroad

Special features of medical care for soldiers on assignments abroad

Colonel Doctor Niels Alexander von Rosenstiel
Armed Forces Office, Bonn

The Bundeswehr medical service is tasked with protecting and maintaining the health of soldiers and restoring them in the event of illness or injury. As a result, medical care should correspond to the professional standard in Germany. This applies in particular to foreign deployments, but also to foreign assignments in military attaché staffs, multinational agencies and staffs, advisory groups and for course participants. Many of the approximately 1,800 soldiers at a total of more than 140 duty stations abroad perform their service under difficult conditions in the tropics or subtropics. Due to the long-term care of the o. A. Particularities and challenges are presented to the group of people.

The medical service of soldiers on assignments abroad is ensured by the Chief Medical Officer, Armed Forces Office (LSO SKA). At the foreign locations in Brunssum (NLD) and Mons (BEL), the soldiers are looked after by a dedicated medical team. In Fontainebleau (FRA), Izmir (TUR), Lisbon (POR), Naples (ITA), Northwood (GBR) and Reston (USA) there is a medical sergeant as a contact person for medical matters and as a direct link to the LSO SKA. In the foreign country itself, medical care is provided by military and / or civil health facilities in the host country.

In principle, every country has its own risk profile, which results from a large number of factors. Biological risks (pathogens, vectors, prevalence of infectious diseases) are of major importance. Non-infectious risks arise due to environmental risks (allergen and pollutant pollution in the air, contaminated drinking water, soil pollution with heavy metals and chemical noxious substances, toxic effects of animals and plants, security structures, climate) and cultural influences (religions and images of man). Means of transport carry additional risks, and accidents abroad are more important than any infectious disease. Depending on the local conditions, there are also professional and leisure activities, the inherent risk profile of which is added to the above. Another decisive criterion in the assessment of foreign-specific risks ultimately results from the quality of the local health system.

The health advice before and during a foreign assignment represents medical prevention at the highest level. A restriction to vaccine-preventable infectious diseases and malaria alone is not sufficient. Other risks accessible to prevention, such as food, vector and sexually transmitted infectious diseases or infections acquired through skin contact, respiratory diseases and other regionally significant vector-transmitted infectious diseases, must also be taken into account in the preventive measures.

If psychological abnormalities or disorders occur during a foreign assignment, personality structure, excessive or insufficient demands and psychosocial stress (living and working conditions abroad, "culture shock", difficulties with the national language, social isolation and loneliness, etc.) play a role disease-causing role.

Within the range of tasks of the Bundeswehr medical service, the medical care of soldiers on assignments abroad is a unique, multi-faceted and meaningful personal service. It requires a holistic medical attitude. Establishing and maintaining a stable and trusting relationship between LSO SKA and the soldiers entrusted to it as well as their superiors and relatives is one of the special challenges - primarily due to the spatial distance. In addition to good general medical knowledge and experience, the task not only requires special knowledge about the specific incidence of diseases and the possibilities of medical care abroad, but also the effects of special environmental influences and cultural conditions on the health of the soldiers. The successful provision of services depends crucially on the close interaction and interaction of all sub-areas of the medical service and health care at home and abroad.

Challenges of military medical work in a tropical environment using the example of Mali

Chief Medical Officer Dr. Claudia Frey
Bernhard Nocht Institute / Bundeswehr Hospital Hamburg

Since March 2013, the medical service has been involved in a mission in tropical West Africa as part of the European Union Training Mission (EUTM) Mali. In order to ensure the expertise in tropical medicine in the field, the post of troop doctor in the medical facility in Koulikoro has since been filled by doctors with additional qualifications in tropical medicine or advanced training in this area. It reports on the personal experiences as a troop doctor in Koulikoro in the period from January to March 2014.

One of the challenges in Koulikoro is the management of high feverish infectious diseases, which in a tropical setting usually requires the exclusion or detection of malaria through microscopy and rapid tests. The larger problem in quantitative terms, however, is the diarrhea, which is particularly evident in the rainy season. In view of the fact that they are barracked in a confined space within a field camp, they make not only close-knit medical care but also consistent hygienic management indispensable.

A rare but potentially serious occurrence are snakebites, mainly caused by the common sand-rattle otter (Echis carinatus spp). Although around 50% of the cases are so-called “dry bites”, treatment with Antivenin must be ensured in the event of an actual poison transmission.

When taking care of the local soldiers, sexually transmitted diseases such as gonorrhea appeared again and again. In a few cases, an HIV infection was also proven, so that a connection of these patients to the Malian HIV program was initiated. In the medical environment in the field camp, needle stick injuries represent the most significant risk of HIV transmission with a significantly higher HIV prevalence among local residents than in Germany. Risk assessment, possibly with immediate initiation of post-exposure measures, is one of the infectious tasks. But preventive medical aspects, such as the organization of supplying the troops with condoms, were part of the practical problems that one was confronted with in the field.

The experience report is intended to give the young colleagues, in particular, a feeling for the special challenges of medical work in the tropical environment “from practice for practice”. This includes being part of a multinational team and working closely with the laboratory and health overseer as well as with the Malian colleagues to look after the local soldiers on the mission.

Case reports

Neurosarcoid - the chameleon in neural imaging

Medical officer Dr. Benjamin Becker et al.
Bundeswehr Central Hospital Koblenz

Presentation of the patient and anamnesis:

In October 2013, a 24-year-old patient with hypesthesia of the left extremity, lack of strength and reduced fine motor skills and suspected encephalitis disseminata, differential diagnosis (DD) presented a lymphoma with CNS involvement for 8 weeks. As part of the inpatient admission, a contrast-enhanced magnetic resonance tomography (MRT) of the neuro-axis was carried out.

Examination protocol:

Using a 3T high field device (Skyra®, Siemens Medical, Munich), multiplanar 2D sequences with different weightings (T1w, T2w), 3D sequences (mprage T1w), diffusion sequences and contrast-enhanced T1w sequences with subsequent subtraction of the neuro-axis were acquired.

What was striking here was a bihippocampal signal disorder in the sense of an edematous increase in volume on T2-weighted with strong contrast enhancement in T1-weighted subtraction, but without a definable acute diffusion disorder. Similarly, large portions of the cervical spinal cord are affected.

In the coronal sequences with a large field of view (T2 TIRM) acquired as part of the thoracic spine display, a strong biliary and mediastinal lymphadenopathy is shown. In the subsequent PET-CT examination, the fusion sequences show a significantly increased metabolism of the lymph nodes in this area.

CNS manifestations of sarcoid:

Sarcoid is a systemic ideopathic disease that usually affects young adults. Non-caseating granulomatous changes are typical. In 10% of the systemic manifestations, neuronal involvement can be demonstrated morphologically, with only 5% becoming symptomatic. Isolated involvement of the CNS is given in the literature as only about 1%. Typically, MR morphology shows a thickening and contrast medium enhancement of the meninges. Neurosarcoidosis can, however, also appear as a parenchymal mass - analogous to the case study presented here - and cannot be differentiated from a malignant event purely radiologically. Overall, the case-associated hypesthesia and the other above-mentioned Symptoms correlate well with the myelopathic changes. There was no clinical equivalent of the hippocampal lesions. Approx. 20% of neurosarcoid MR manifestations are described as primarily asymptomatic in the literature. The therapy of choice is an individually adapted treatment with glucocorticoids IV and oral. The response to metabolically active and symptomatic neuronal changes is poor at approx. 25%.

Confirmation of diagnosis and clinical course:

Multiple laboratory tests (ACE, neopterin, lysozyme, IL-2 receptor, quantiferon®Test, etc.) as well as a detailed imaging protocol attached (PET-CT, CT-thorax). In addition to a bone marrow biopsy to rule out lymphatic genesis, a punch biopsy sample excision was carried out from the mesenteric lymph node packages. Typical non-caseating granulomatous changes were found here.

Thus, the diagnosis was made in terms of sarcoid stage I with CNS involvement. A high-dose intravenous corticosteroid therapy (methylprednisone) was initiated, which was later switched to oral therapy.

In the medium term, almost complete freedom from symptoms could be achieved. After 6 months the patient was completely free of symptoms. The imaging protocols acquired here show a restitutio ad integrum of the hippocampal and myelopathic lesions.

Summary:

The case shown shows one of the manifold forms of presentation of neurosarcoidosis in the MRI. The working diagnosis was made by chance through the detection of the lymphadenopathy included in the primary MR imaging. A differential diagnostic differentiation from lymphoma can only be made histologically.

Third degree open dislocation fracture of the cervical spine with unilateral traumatic dissection of the vertebral artery and incomplete tetraplegia

Chief Medical Officer Dr. Dan Bieler et al.
Bundeswehr Central Hospital Koblenz

Introduction:

Primarily survived open injuries to the cervical spine are extremely rare trauma entities; there are only a few ideas about this in the literature and then usually as a result of a gunshot wound.

Case history:

We report on a case of a third-degree open dislocation fracture C6 / 7 with initially complete paraplegia, which a 31-year-old woman suffered in a traffic accident in the form of a high-speed injury. The first medical care on site had a Glasgow Coma Scale (GCS) of 15 with complete tetraplegia sub C6 in connection with a heavily bleeding large wound on the left side of the neck and an additional distant lower leg fracture on the right. After C-Spine protection, intubation and tamponade of the wound, it was transported to the target clinic by air.

As part of the emergency room care after polytrauma spiral and angio CT, the leading diagnosis was an unstable dislocation fracture of the C6 / 7 segment with left-sided tearing of the joint facet and traumatic dissection of the left vertebral artery, with a retrograde filling via the basilar artery persisted to the lesion. There was also a closed, distal right lower leg fracture. The injured person was immediately treated in an emergency. The cause of the bleeding was a rupture of the left internal iugular vein; the laceration had also completely severed the muscle belly of the sternocleidomastoid. The left carotid artery was uninjured, as was the ansa cervicalis and the Nn. vagus and phrenicus. In the unstable cervical spine segment, after repositioning and exploration, the left vertebral artery was found exposed ventrally without any signs of external injury.

The large jugular vein was ligated, the surgical stabilization of the cervical spine was carried out as a ventral monosegmental reduction spondylodesis after disc extirpation with autologous pelvic spine and cervical spine plate. Postoperatively, if there was sufficient spontaneous breathing, an improvement in the neurological failure symptoms could be determined with return of left-sided 2/5 and right-sided 3/5 finger motor activity; there was Horner's syndrome. Doppler sonography of the vertebral arteries showed normal flow velocity in V3 / 4 on the left, the finding compatible with a relevant stenosis. On the second postoperative day, the patient was transferred to a cross-sectional center, where a three-month neurotraumatological rehabilitation followed as well as the outstanding osteosynthesis on the right ankle. At the end of the treatment there, the injured person was mobile on the rollator for longer distances.

Conclusion:

On the basis of this case study, the successful treatment of a primarily life-threatening, open injury to the cervical spine with tetraplegia as well as the improvement of the neurological deficits due to an immediate surgical intervention could be demonstrated.

Burst fracture of LWK 4 after being shot through the abdomen with incomplete paraplegia

Chief Medical Officer Dr. Dan Bieler et al.
Bundeswehr Central Hospital Koblenz

Introduction:

Open fractures in the lumbar spine are among the rare trauma entities in German-speaking countries. They are usually caused by gunshot wounds. The algorithm of this special injury differs from the usual vertebral trauma procedure, since the penetrating involvement of the body trunk initially has the higher treatment priority in terms of the primarily life-threatening component. Furthermore, the obligatory and severe contamination of the wound area, especially after perforation of a hollow organ, must be taken into account during surgical treatment. It significantly delays the time of definitive vertebral surgery.

Case history:

We report on the case of a 31-year-old man with gunshot wounds in the back and right upper arm. This resulted in a third-degree open burst fracture of the LWK 4 with complete paraplegia sub L3 / 4 and rejects through the abdomen as well as a third-degree open fracture fragment of the right humeral shaft with initially complete radial palsy. Initial medical care, including emergency surgery, took place in the home country. According to the sparse files, an exploratory laparotomy was performed. At the lumbar spine, the decompression and debridement of the LWK 4 as well as the implantation of a vertebral replacement body introduced from the dorsal side and an overarching internal fixator took place. Subsequently, at the instigation of the Foreign Office, she was transferred to the Bundeswehr Central Hospital (BwZKrhs) for definitive therapy.

On admission, there was clinically flaccid paraparesis sub L4 and a drop hand on the right. Microbiologically, there was ubiquitous contamination with 3- and 4-MRGN germs with compulsory isolation. In the course of the disease, a relaparotomy was first performed in the case of ileus and an infection of a retroperitoneal hematoma, which continued without complications. With regard to the lumbar spine, the radiological evidence of the internal fixator was dismantled in situ and the cage was dislocated to the dorsal side as an expression of the complex instability.

After the lumbar spine had definitely ruled out the infection, the surgical revision was carried out with complete implant removal, subtotal corporectomy for LWK 4, insertion of a new expandable WK replacement and placement of new dorsal instruments from LWK 3 to LWK 5.

Intraoperatively, the spinal nerves L 3 to 5 could be safely seen and spared in the large defect on the right side, the counterparts were no longer present on the left side. As an antimicrobially effective placeholder, 2 gentamycin-PMMA chains were inserted dorsally into the defect cavity. This was followed by the definitive treatment of the bullet fracture on the humerus. The injured person was transferred to a cross-sectional department for further, special neurotraumatological rehabilitation. At this point in time there was again a check for micturition and defecation when the sphincter tone reoccurred and the symptoms of paralysis on the left side improved.

Conclusion:

The case presented here gives an overview of the modified therapeutic algorithm after a gunshot fracture of the spine with penetrating cavity injury and additional, severe trauma to the extremities. In addition, the high personnel and logistical effort in the case of severe contamination with multi-resistant, gram-negative germs can be demonstrated using an example.

Interdisciplinary care of a child with high paraplegia in the TraumaNetzwerk (TNW)

Senior Field Physician Dr. Sebastian Hentsch et al.
Bundeswehr Central Hospital Koblenz

Case:

The 12-year-old patient had an accident in the evening while riding a BMX in a rural region. When the ambulance service arrived, he suffered from quadriplegia and failed to breathe.

After intubation and land-based transport to the supra-regional trauma center (arrival 9:45 p.m.), the clinical examination revealed the following:

Pupils narrow on both sides and sensitive to light without focus; Corneal reflexes present on both sides; no haemato / liquorrhea, no reaction to pain stimuli, muscle reflexes extinguished, no sphincter tone, priapism.

After the “primary survey” according to the ATLS scheme, the emergency radiological diagnosis was carried out using angio-CT and MRI of the skull and cervical spine. The implementation of the entire imaging diagnosis was agreed by telephone with the children's neurotraumatology St. Augustin and a transfer after imaging was agreed. An unstable fracture situation of C4 3/4 with spinal cord contusion, intramedullary hemorrhage and extensive hematoma ranging from C1 to C5 was demonstrated.

Further injuries were clinically excluded. At the same time, consular examinations of ENT, maxillofacial and neurosurgery were carried out.

At 11:11 p.m. the patient was transferred using the SAR helicopter of the German Armed Forces. In the St. Augustin Clinic, electrophysiological examinations were also carried out preoperatively, in which a complete failure of the SSEP stimulus responses for the medianus and tibialis (in the case of pathological, but preserved stimulus responses of the MEP leads for M. triceps brachii on both sides, M. pollicis brevis on both sides. as well as M. gastrocnemius and M. abductor hallucis both sides). Spontaneous breathing on the device was still not seen. After completing the diagnosis, a dorsal instrumentation was performed using an internal fixator C2 on C5, dura expansion plastic with laminectomy C3 and C4. No structural disruption of the spinal cord was seen intraoperatively.

A ventral C2 / C5 fusion (angle-stable plate, pelvic graft) and the placement of PEG, tracheostoma and suprabubic urinary catheter were then carried out.

Result:

Eight months after the accident, the patient is currently breathing spontaneously and moving his shoulder. He is mobilized in the wheelchair. After an initial psychological low, he was very motivated and moody 9 months after the accident.

Summary:

Thanks to the structures in the TNW, interdisciplinary emergency treatments and patient transfers can be carried out quickly and in a coordinated manner in the case of severely injured children and adolescents. In the presented case of a high cross-sectional injury of a 12-year-old boy, the complete imaging was carried out by means of CT, angio and MRT as part of the nocturnal emergency room management in the supraregional trauma center in consultation with the pediatric specialist clinic. After imaging diagnostics including consultancy examinations, the transfer to the pediatric acute hospital was carried out after 1.5 hours, thus enabling the specialized therapy to be continued promptly.

Dentistry

Reproducibility of microbiological diagnostics with two different gene probe tests in severe forms of periodontitis

Medical officer d. R. Dr. Madline P Gund et al.
Bundeswehr Central Hospital Koblenz

Introduction / question:

In periodontology, gene probe tests are used to detect bacteria that are pathogenic to periodontal disease. Among other things, they are used to select a suitable, accompanying antibiotic therapy for anti-infectious non-surgical periodontal therapy. The aim of this study was the clinical comparison of two microbiological test methods: RNA probe (IAI PadoTest 4-5, Institute for Applied Immunology, Zuchwil, CH) and DNA probe (mikro IDent Plus, Hain Lifescience) with analysis in Dept. XIII Pathology of the Bundeswehr Central Hospital (BwZKrhs) Koblenz.

Methodology:

In 66 patients referred by dentists with recurrences of severe inflammatory periodontal disease and probing depths of more than 6 mm, four test sites with probing depths> 6 mm were examined. In 55 patients, two samples were taken using sterile paper points (ISO 35 for IAI PadoTest 4 - 5 and ISO 50 for MikroIDent Plus), which were simultaneously inserted into the gingival pockets for 10 seconds (s) and in eleven patients for 20 s. won. A match was checked with regard to the germs Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf) and Treponema denticola (Td). In 20 patients, samples were taken for 10 and 20 s using different paper point sizes (ISO 35 and ISO 50) for DNA probe examination. All samples were obtained prior to periodontal therapy. In addition, Prevotella intermedia (Pi), Parvimonas micra (Pm), Fusobacterium nucleatum (Fn), Campylobacter rectus (Cr), Eubacterium nodatum (En), Eikenella corrodens (Ec) and Capnocytophaga spc. (Cs).

Results:

The mean age of the patients was 45.7 ± 9.6 years. The average depth of the microbiologically examined gingival pockets was 7.25 ± 1.21 mm.

The following matches were found for the 4 bacteria examined in the various test methods: Aa 70%, Pg 76%, Tf 83% and Td 85%. The detection frequency when using DNA probes was increased by collecting the plaque samples over 20 s and using ISO 50 paper points.

Discussion / conclusions:

The examination of the results of two gene probe tests showed a good agreement of the results for Aa, Pg, Tf and Td. Nevertheless, a cautious interpretation of the results seems to be advisable due to recognizable minimal differences taking into account the clinical findings, drug history and previous sensitivity reactions / adverse drug reactions to antibiotics. Obtaining the plaque samples from the DNA probes we use using ISO 50 paper points and over a period of 20 seconds seems to be advantageous. The use of different gene probe tests in therapy-resistant cases of periodontitis and relapses produces additional results that are decisive for therapy.

Due to the relatively low detection frequency of Aa of 15-38% in our patient collective, routine microbiological diagnostics, which enable an adjuvant, risk-oriented systemic antibiosis selection, is recommended. Further studies to evaluate an optimized routine microbiological diagnosis of periodontal diseases are necessary.

Chairside MMP-8 measurements using saliva samples in soldiers with mild and severe periodontal diseases

Medical officer d. R. Dr. Madline P Gund et al.
Bundeswehr Central Hospital Koblenz

Introduction:

To diagnose periodontitis and peri-implantitis, the clinical parameters bleeding after probing (BnS) and probing depth are used in conjunction with a radiological follow-up. Numerous studies describe a dominance of gram-negative anaerobic bacteria that trigger a pro-inflammatory host response. Mediators stimulate z. B. Fibroblasts for the production of prostaglandins (PGE-2) and activate collagenase-2 / metallomatrix proteinases (aMMP-8), which lead to the breakdown of alveolar bones (Mantylä et al 2003). Depending on various risk factors (e.g. general state of health, smoking, hormonal changes, stress, diabetes), a chronic overreaction can occur. The rapid test (aMMP-8 RAPID TEST KIT, dentognostics GmbH, Jena) is a lateral flow immunoassay method for examining mouthwash samples for the detection of collagenase with a detection limit of 1 mg / l MMP-8. The quick test is performed painlessly before or after the dental examination or even at home in the bathroom within less than ten minutes on the basis of a saliva test containing the gingival sulcus fluid. The aim of the study was to compare the results of the aMMP rapid test in patients with at least 20 teeth with clinical test results for periodontal inflammatory reactions and periodontal diagnosis.

Material and methods: