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1.  The ‘Aachen Falls Prevention Scale’ - development of a tool for self-assessment of elderly patients at risk for ground level falls 
The incidence of falls in the elderly population is difficult to determine and therefore potentially underestimated. Screening algorithms usually have in common that the evaluation is undertaken by trained individuals in a hospital setting. This leads to the inclusion of a high proportion of low-risk people and a waste of resources. It would be advantageous to pretest the individuals at risk in their own environment using a simple self-assessment approach.
The consensus process of our group of clinicians and physical therapists included: 1. a preparative literature review about risk profiles and assessment tools for ground level falls; 2. a selection of appropriate questions that cover all health aspects involved in an increased risk for falling; and 3. a selection of a simple physical test that can be used at home without the need of a health care professional. We thus searched to develop a scale that can be used by older citizen at higher risk of falling. The current manuscript summarizes the results of this review, consensus and selection process.
The literature search was undertaken between March and August 1, 2013. The selection process for the questions used (Part I) lasted between March 2013 and January 2014. Among all tests evaluated the 20 second standing test (Part II) was deemed to be safe to be performed even by an individual at risk for a fall, as it closely resembles activities of daily living. The `Aachen Falls Prevention Scale` finally uses a self-assessment tool grading falls risk on a scale of 1 to 10 by the individual itself after completion of Part I and Part II. In summary, we present a scale that might offer a self-assessment option to improve the measures of falls prevention pass for elderly citizens.
The introduction of the `Aachen Falls Prevention Scale` which combines a simple questionnaire with a safe and quick balance tool, meets the criteria to identify whether or not a balance problem exists – the first step in evaluation of falls risk. Further studies will have to assess the ability of an individual to estimate his or her individual falls risk on a longitudinal basis and possibly trigger the necessity for the assessment by a physician.
PMCID: PMC4328308
Orthogeriatrics; Co-managed care; Fractures in the elderly; Geriatric trauma center; Fall prevention; Balance assessment
2.  Impact of peer feedback on the performance of lecturers in emergency medicine: a prospective observational study 
Although it is often criticised, the lecture remains a fundamental part of medical training because it is an economical and efficient method for teaching both factual and experimental knowledge. However, if administered incorrectly, it can be boring and useless.
Feedback from peers is increasingly recognized as an effective method of encouraging self-reflection and continuing professional development. The aim of this observational study is to analyse the impact of written peer feedback on the performance of lecturers in an emergency medicine lecture series for undergraduate students.
In this prospective study, 13 lecturers in 15 lectures on emergency medicine for undergraduate medical students were videotaped and analysed by trained peer reviewers using a 21-item assessment instrument. The lecturers received their written feedback prior to the beginning of the next years’ lecture series and were assessed in the same way.
In this study, we demonstrated a significant improvement in the lecturers’ scores in the categories ‘content and organisation’ and ‘visualisation’ in response to written feedback. The highest and most significant improvements after written peer feedback were detected in the items ‘provides a brief outline’, ‘provides a conclusion for the talk’ and ‘clearly states goal of the talk’.
This study demonstrates the significant impact of a single standardized written peer feedback on a lecturer’s performance.
PMCID: PMC4264246  PMID: 25472430
Peer feedback; Lecture; Faculty development; Emergency medicine; Undergraduate education
3.  Unstable Intertrochanteric Femur Fractures: Is There a Consensus on Definition and Treatment in Germany? 
Extramedullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment.
We conducted a national survey of practicing chairpersons of German institutions to determine current perspectives and perceptions of practice in the diagnosis, management, and surgical treatment of unstable intertrochanteric fractures.
Between January and February 2010, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 26-question web-based survey regarding three broad domains: fracture classification and instability criteria, implants and surgical treatment algorithms, and timing of operations. Response rate was 42%.
There was a clear preference for use of the AO/OTA fracture classification with geographic variations. Absence of medial support was considered the main criterion for fracture instability (84%), whereas a broken lateral wall and detached greater trochanter were considered by 4% and 5% of the respondents, respectively, to determine instability. Two percent routinely fixed unstable intertrochanteric fractures with extramedullary devices. Ninety-eight percent of German hospitals reportedly perform surgery within 24 hours after admission. Time to surgery was dependent on hospital level, with more direct surgeries in Level I hospitals.
Despite varying opinions in the literature in recent years, we found some instability criteria (lateral wall breach, a detached greater trochanter) played a minor role in defining an unstable intertrochanteric fracture pattern. Despite recent meta-analyses suggesting clinical equivalence of intra- and extramedullary implants, few respondents routinely treat unstable intertrochanteric fractures with extramedullary plates. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures.
Level of Evidence
Level V, expert opinion. See the Instructions for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-013-2834-9) contains supplementary material, which is available to authorized users.
PMCID: PMC3734428  PMID: 23389806
4.  Can a Modified Anterior External Fixator Provide Posterior Compression of AP Compression Type III Pelvic Injuries? 
Current anterior fixators can close a disrupted anterior pelvic ring. However, these anterior constructs cannot create posterior compressive forces across the sacroiliac joint. We explored whether a modified fixator could create such forces.
We determined whether (1) an anterior external fixator with a second anterior articulation (X-frame) would provide posterior pelvic compression and (2) full pin insertion would deliver higher posterior compressive forces than half pin insertion.
We simulated AP compression Type III instability with plastic pelvis models and tested the following conditions: (1) single-pin supraacetabular external fixator (SAEF) using half pin insertion (60 mm); (2) SAEF using full pin insertion (120 mm); (3) modified fixator with X-frame using half pin insertion; (4) modified fixator using full pin insertion; and (5) C-clamp. Standardized fracture compression in the anterior and posterior compartment was performed as in previous studies by Gardner. A force-sensitive sensor was placed in the symphysis and posterior pelvic ring before fracture reduction and the fractures were reduced. The symphyseal and sacroiliac compression loads of each application were measured.
The SAEF exerted mean compressions of 13 N and 14 N to the posterior pelvic ring using half and full pin insertions, respectively. The modified fixator had mean posterior compressions of 174 N and 222 N with half and full pin insertions, respectively. C-clamp application exerted a mean posterior load of 407 N.
Posterior compression on the pelvis was improved using an X-frame as an anterior fixation device in a synthetic pelvic fracture model.
Clinical Relevance
This additive device may improve the initial anterior and posterior stability in the acute management of unstable and life-threatening pelvic ring injuries.
PMCID: PMC3734429  PMID: 23604604
5.  Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures? 
Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.
We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.
We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24–30 months).
We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.
Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3392400  PMID: 22311725
6.  A Novel Laser-Doppler Flowmetry Assisted Murine Model of Acute Hindlimb Ischemia-Reperfusion for Free Flap Research 
PLoS ONE  2013;8(6):e66498.
Suitable and reproducible experimental models of translational research in reconstructive surgery that allow in-vivo investigation of diverse molecular and cellular mechanisms are still limited. To this end we created a novel murine model of acute hindlimb ischemia-reperfusion to mimic a microsurgical free flap procedure. Thirty-six C57BL6 mice (n = 6/group) were assigned to one control and five experimental groups (subject to 6, 12, 96, 120 hours and 14 days of reperfusion, respectively) following 4 hours of complete hindlimb ischemia. Ischemia and reperfusion were monitored using Laser-Doppler Flowmetry. Hindlimb tissue components (skin and muscle) were investigated using histopathology, quantitative immunohistochemistry and immunofluorescence. Despite massive initial tissue damage induced by ischemia-reperfusion injury, the structure of the skin component was restored after 96 hours. During the same time, muscle cells were replaced by young myotubes. In addition, initial neuromuscular dysfunction, edema and swelling resolved by day 4. After two weeks, no functional or neuromuscular deficits were detectable. Furthermore, upregulation of VEGF and tissue infiltration with CD34-positive stem cells led to new capillary formation, which peaked with significantly higher values after two weeks. These data indicate that our model is suitable to investigate cellular and molecular tissue alterations from ischemia-reperfusion such as occur during free flap procedures.
PMCID: PMC3688775  PMID: 23840492
7.  Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial 
European Spine Journal  2012;21(5):992-998.
To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students.
In 2007–2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE).
Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts.
The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.
PMCID: PMC3337919  PMID: 22223196
Peer teaching; Gender differences; Randomised controlled trial; Complex motor skills; Spinal manipulative therapy
8.  Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial 
BMC Medical Education  2012;12:85.
The exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake.
Second-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student’s perceptions were evaluated using Likert scale-based items.
The ASK-group (n = 70, age 23.4 (20–36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20–53) yrs.) and the CON-group (n = 88, 22.8 (20–33) yrs.; p = 0.019). After an additional arthroscopy teaching 1% of students failed the MC exam, in contrast to 10% in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001).
The additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery.
PMCID: PMC3473305  PMID: 22958784
Arthroscopy; Education, Anatomic competence, Randomized controlled trial, Knee joint, Shoulder joint, Students; Medical, Musculoskeletal ultrasound

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