Hintergrund: In der Bundesrepublik Deutschland stehen Personen, die medizinisch als Notfall klassifiziert werden, mehrere Versorgungswege offen - die Konsultation eines Haus- oder Facharztes zu seinen Sprechstundenzeiten, des Kassenärztlichen Notdienstes über die Rufnummer 116 117 bzw. in einer Bereitschaftsdienstpraxis, einer Notaufnahme in einem Krankenhaus oder des Rettungsdienstes über die Rufnummer 112 bei höchster Dringlichkeit eines medizinischen Problems und unter akuter Lebensbedrohung. In den vergangenen Jahren wurde in verschiedenen Stellungnahmen postuliert, dass Notärzte vermehrt Aufgaben der ambulanten Regelversorgung außerhalb von lebensbedrohlichen Notfällen übernehmen. Vor diesem Hintergrund überprüft die vorliegende Arbeit folgende Hypothesen:1. Übernimmt der Notarzt Teilaufgaben der hausärztlichen Versorgung zu den Regelöffnungszeiten der Arztpraxen? 2. Übernimmt der Notarzt Teilaufgaben des kassenärztlichen Bereitschaftsdienstes? 3. Zeigt die Art der Tätigkeit (niedergelassen / angestellt) des Notarztes durch den Anteil an ambulant behandelten Patienten im Notarztdienst, dass es zu einer gehäuft nicht gerechtfertigten Inanspruchnahme des Notarztes kommt? 4. Gibt es Hinweise auf eine gehäufte, nicht gerechtfertigte Inanspruchnahme des Notarztes in Pflegeheimen? Methodik: Die Überprüfung der Hypothesen wurde anhand der statistischen Auswertung aller 3.860 Notarzteinsätze bei gesetzlich versicherten Patienten am Notarztstandort Hoyerswerda im Kalenderjahr 2011 durchgeführt. Neben demografischen Daten, klinischen Parametern und organisatorischen Aspekten sollten so Hinweise gefunden wer-den, die Rückschlüsse auf die tatsächliche Aufgabenwahrnehmung durch den Rettungsdienst zulassen. Ein Bezug zwischen den Einsatzparametern und deren Einfluss auf die o.g. Fragestellungen wurde mittels SPSS unter Anwendung des Chi-Quadrat-Tests analysiert. Für alle Berechnungen wurde die Signifikanz auf dem 5% Niveau (p≤0,05) festgelegt. Ergebnisse: Anhand der untersuchten Einsätze bestätigt sich, dass durch den Notarzt Aufgaben des kassenärztlichen Bereitschaftsdienstes mit übernommen werden. Hinweise darauf, dass der Notarzt Aufgaben der hausärztlichen Versorgung zu den Regelöffnungszeiten der Praxen übernimmt, finden sich nicht. Zusätzlich ergibt sich kein Anhalt dafür, dass spezifische Anstellungsverhältnisse einen Einfluss auf die Anteile an ambulant versorgten Patienten im Notarztdienst haben. Es lassen sich auch keine Hinweise darauf finden, dass die notärztliche Versorgung von Notfallpatienten in Pflegeheimen häufiger nicht indiziert ist, als bei Patienten, die nicht in Pflegeheimen leben. Insgesamt zeigt sich, dass fast jeder fünfte Notarzteinsatz nicht mit einem Transport in die Klinik abgeschlossen wird. Schlussfolgerungen: Strukturen der Notfallversorgung sollten Notfälle versorgen - in den Zeiten des kassen-ärztlichen Bereitschaftsdienstes sollte eine enge Abstimmung über den Einsatz eines Notarztes zwischen den Leitstellen der Notfallrettung und des Bereitschaftsdienstes erfolgen. Bei einem hohen Anteil von ambulant behandelten Patienten im Notarztdienst stellt dieser Bereich ein eigenes Qualitätsmerkmal dar und sollte zukünftig regelhaft erfasst werden.:Abbildungsverzeichnis V Tabellenverzeichnis VI Abkürzungsverzeichnis VII 1 Einleitung 1 2 Stand der Forschung 4 2.1 Organisatorisch-rechtliche Aspekte der Notfallversorgung in Deutschland 4 2.2 Abgrenzung und Nutzung der bestehenden Strukturen 5 2.2.1 Notfallversorgung durch niedergelassene Ärzte 5 2.2.2 Notfallversorgung im Rahmen des kassenärztlichen Bereitschaftsdienstes 8 2.2.3 Notfallversorgung durch Notaufnahmen in Krankenhäusern der Akutversorgung 10 2.2.4 Notfallversorgung durch rettungsdienstliche Strukturen 12 2.3 Aktuelle Entwicklungen in der Nutzung von Notfallstrukturen 20 3 Fragestellung und Hypothesen 23 4 Material und Methoden 26 4.1 Datenquellen 26 4.2 Umfang des Datenmaterials 26 4.3 Ethikkommission 27 4.4 Genutzte Software und statistische Auswertungsmethoden 27 4.4.1 Statistische Grundannahmen 27 4.4.2 Kolmogorow-Smirnow-Test 28 4.4.3 χ²-Test 28 5 Ergebnisse der Vollerhebung 29 5.1 Beschreibung der Patientenstichprobe 29 5.1.1 Geschlechtsverteilung 29 5.1.2 Altersverteilung der Gesamtstichprobe 30 5.1.3 Altersverteilung mit Bezug auf Pflegeeinrichtungen 30 5.2 Analysen in Bezug auf die beteiligten Notärzte 32 5.2.1 Anzahl der Notärzte und Einsatzhäufigkeit 32 5.2.2 Qualifikation und Beschäftigungsform der Notärzte 32 5.2.3 Einsatzzahlen der Notärzte 33 5.3 Organisatorische Einsatzaspekte 35 5.3.1 Verteilung: Notarzteinsätze nach Uhrzeit 35 5.3.2 Anzahl der Notarzteinsätze pro Tag 35 5.3.3 Verteilung: Notarzteinsätze nach Wochentag 36 5.3.4 Verteilung: Notarzteinsätze nach Monat 36 5.3.5 Verteilung: Notarzteinsätze pro Quartal und Halbjahr 37 5.3.6 Verteilung: Einsätze in bestimmten Zeitkategorien 38 5.4 Medizinische Einsatzaspekte 43 5.4.1 Diagnoseübersichten 43 5.4.2 Verbleib der Patienten 49 5.4.3 Ambulant behandelte Patienten nach Notärzten 51 5.4.4 Ambulant behandelte Patienten nach Einsatzzeiten 54 5.4.5 Ambulant behandelte Patienten nach Orten 57 5.4.6 Anzahl ambulant behandelter Pflegeheimpatienten 58 5.4.7 Anteil ambulant behandelter Patienten nach Altersgruppen 59 5.4.8 Anteil ambulant behandelter Patienten nach Diagnosen 60 5.5 Überprüfung der Forschungsfragen 64 5.5.1 Hypothese 1 64 5.5.2 Hypothese 2 66 5.5.3 Hypothese 3 69 5.5.4 Hypothese 4 70 6 Diskussion 71 6.1 Konsequenzen für die Forschungshypothesen 73 6.1.1 Hypothese 1 73 6.1.2 Hypothese 2 73 6.1.3 Hypothese 3 73 6.1.4 Hypothese 4 74 6.2 Kritische Reflexion einsatzorganisatorischer Aspekte 75 6.2.1 Entwicklung der Einsatzzahlen für die untersuchte Region 75 6.2.2 Entwicklung der Einsatzzahlen in Deutschland 77 6.2.3 Der ambulant behandelte Patient im Rettungsdienst 78 6.3 Kritische Reflexion zu demografischen und klinischen Aspekten 80 6.3.1 Vergleich der demografischen Daten der vorliegenden Untersuchung mit denen von Sefrin et al. (2015) 80 6.3.2 Vergleich der Diagnosedaten der vorliegenden Untersuchung mit denen von Sefrin et al. (2015) 82 6.4 Limitationen der vorliegenden Arbeit 84 7 Ausblick 86 Zusammenfassung 88 Abstract 90 Literaturverzeichnis 92 Erklärung zur Eröffnung des Promotionsverfahrens 101 Erklärung zur Einhaltung rechtlicher Vorschriften 103

As a therapist within the multi-disciplinary setting, one is confronted with a wide array of pathology and diagnoses. Care is taken to optimize treatment outcomes and overall return of function to every patient admitted to the various rehabilitation facilities. Treatment is often standardized to ensure quality care benchmarked against outcome parameters. The aforementioned is also true for medical practitioners, pharmacists and other auxiliary service providers. Research is aimed at improving quality of care, finding and establishing the best practises through all hospitals and care facilities. Medical care has undergone a transformation over the past few decades with a strong emphasis being placed on protocols and procedures. Through applying standardized care, protocols and procedures, the researcher have come to realize that certain denominators within patient care have no prediction or outcome control. After more than a decade of treating patients in various rehabilitation settings the researcher have come to realize that one complaint exists with each and every patient under my care – pain. This was even more evident within the group of joint replacement patients. No two patients presented with the exact same pain profile or pain reports despite various commonalities such as anthropometric data (age, gender, length, mass), surgical procedure, attending physician, care facility, pathway exposure, diagnosis, radiographic findings and pharmaceutical intervention. If all the obvious factors were identical – what accounted for the different pain reports? This question is at the heart of the study – why do pain reports differ in the presence of so many similarities between patients? It soon became apparent that pain is recognized in the organic form. Organic pain can be measured and is expected with injury, illness or surgical intervention. The entire multi-disciplinary team is aware of organic pain and ready to intervene with medication, surgery and a pathway of care. All vigorously record organic pain and adapt treatment according to the pain levels as organic pain is real pain: real pain existing through exposure to real surgical intervention. Still the question remained: if all the factors prior to surgery, during surgery and after surgery were the same, why are patients experiencing and reporting very different pain levels? This question was the catalyst for the research and lead to keen focus during patient interviews. Every patient receiving an educational session prior to surgery had very vivid ideas about the pain they will experience post-operatively. The majority of patients formed pre-conceived notions about pain prior to undergoing surgery. They presented with a clear pain rating of what they expected to feel post-operatively. The pre-conceived pain rating was constructed in almost all the cases after some form of information obtained during consultation with their surgeon or a member of the multidisciplinary team. This pain notion existed as a tangible and measurable rating in the client’s mind prior to undergoing the knee replacement surgery. In select cases perceived pain was constructed as a result of information obtained from family or friends that underwent the same procedure while other clients constructed perceived pain due to a lack of information on the proposed surgery. It became evident that education or lack thereof on surgical interventions played a primary role in the construct of perceived pain. Patients were entering theatres for procedures and already experienced a form of perceived pain. If pain could be constructed prior to experiencing surgical intervention – can perceived pain then translate into actual organic pain and account for the variable pain reports post surgery? Against this backdrop, research was directed at understanding perceived pain and the factors that aid the construction of perceived pain. As education was found to be at the heart of every pain construct, the doctor-patient consultation was evaluated as a core component to ascertain the impact this relationship has on perceived pain. Measurement of perceived pain was also performed to conclude on the impact of this pain form on organic pain. The study is aimed at addressing the variant pain reports that no pathway or procedure can predict and provide for. It is an attempt to validate pain as constructed by the patient that impacts on their post-surgical pain ratings and behaviour. This research might contribute towards existing knowledge and understanding of the influence of doctor-patient interaction as well as the significance of this interaction on pain. As only scant research on perception of pain has been undertaken this research can prove insightful for further studies or as supplement to existing views and opinions. It can also serve as a foundation in developing practices that will manage pain by enhancing doctor-patient interaction in the health setting. / MA, Medical Sociology, North-West University, Vaal Triangle Campus, 2012

This text describes different aspects of the design of a Doctor-on-a-Chip device. Doctor-on-a-Chip is a DNA analysis system integrated on a single chip, which should provide all of the advantages that stem from the system integration, such as small sample volume, fast and accurate analysis, and low cost. The text describes all of the steps of the on-chip sample analysis, including DNA extraction from the sample, purification, PCR amplification, novel dielectrophoretic sorting of the DNA molecules, and finally detection. The overview is given of the technologies which are available to make the integration on a single chip possible. The microfluidic technologies that are used to manipulate the sample and other chemical reagents are already known and in this text they are analyzed in terms of their feasibility in the on-chip system integration. These microfluidic technologies include, but are not limited to, microvalves, micromixers, micropumps, and chambers for PCR amplification. The novelty in the DNA analysis brought by Doctor-on-a-Chip is the way in which the different DNA molecules in the sample (for example, human and virus DNA) are sorted into different populations. This is done by means of dielectrophoresis – the force experienced by dielectric particles (such as DNA molecules) when subject to a non-uniform electric field. Different DNA molecules within a sample experience different dielectrophoretic forces within the same electric field, which makes their separation, and therefore detection, possible. In this text, the emphasis is put on numerical modelling of the dielectrophoretic effect on biological particles. The importance of numerical modelling lies in the fact that with the accurate model it is easier to design systems of microelectrodes for dielectrophoretic separation, and tune their sub-micrometre features to achieve the maximum separation efficacy. The numerical model described in this text is also experimentally verified with the novel microelectrodes design for dielectrophoretic separation, which is successfully used to separate the mixture of different particles in the micron and sub-micron range.

Doctor en Ciencias con mención en Biología

Doctor en Ciencias con mención en Microbiología

The purpose of my thesis is to analyse criminal aspects of the relationship between a doctor and an patient. The reason for my research is that I think this topic does not recive enough attention in Czech republic as it deserves. The thesis is composed of five chapters, each of them dealing with different aspects of doctors criminal lability. I dedicated m attention only to doctors criminal lability, not to the criminal liability of patient. Chapter One is introductory and defines basic terminology used in the thesis as types of lability, basic aspects of relatinship between doctor and patient, medical experiment, specific aspects of criminal lability in medicine and another terminology which is often used in medical law. The chapter is devided in nine parts. Chapter Two is dedicated to crimes which are usually committed by doctors practising their profession. The chapter is divided five parts, using the same system and order as in czech Penal Code. Chapter Three is subdivided in two parts. Part one is dedicated to euthanasia and legal problems which are united with euthanasia. Chapter three examines relevant czech legislation and problems in czech legislation united with euthanasia. This part of chapter also deals with advantages and disadvantages of euthanasia. Part two is dedicated to assisted...

Doctor en Ciencias con mención en Química

The increased influence of digitalizing in the Swedish healthcare is a change that some people find it hard to adapt to. For most youths and people from the younger generations this is not considered a problem, since they have been exposed to different aspects of digitalization throughout their lives. However, how do older people and especially older people with chronic diseases feel about the digitalization and the changes it brings? The purpose of this study is to explore how people with chronic diseases experience this progresses in the society that has contributed to the digitalization within healthcare and the increased utilization of digital platforms. Previous studies indicate that both the change in the doctor-patient relationship and the increased possibilities for patient to access health information from their homes, is an effect of the digitalization. In this study, which is conducted with a qualitative method, we come to understand that older people with chronic diseases find it difficult to adapt to the digitalization. None of the participants are opposing it, rather they experience the changes as complicated. Furthermore, the participants stress the prerequisite of the physical contact with a doctor to enable a correct medical assessment. Whether or not this means that health centers will be dismantled is still unknown. However, our study shows that there is no resistance to digitalization among the participants, provided it is executed in a correct and trustworthy manner.

The discipline of orthopaedic surgery is a fast growing surgical specialty directed at the diagnosis and management of disorders of the musculoskeletal system e.g. acute trauma, fractured or dislocated joints, elective reconstructive surgery as well as related research. The standard of care in orthopaedic surgery treatment reflects the status of its evolution and what is currently available in terms of the knowledge, surgical expertise, orthopaedic implant materials, and equipment. It is the duty of the orthopaedic surgeon to live up to the promise as best he or she can to heal when it is possible to heal and to provide the level of care expected that transcends simple surgical expertise and bio-technological intervention. The informed consent process is an often neglected but vital component of the standard of care which has to satisfy prescribed ethical and legal requirements. This research is focused on how to heighten the awareness of, and to encourage engagement within the orthopaedic surgery fraternity with the informed consent process. If the informed consent is given more recognition within this group, it will benefit the potentially vulnerable orthopaedic patient, protect the orthopaedic surgeon against litigation, and importantly, contribute to the ethical imperatives bound in a doctor-patient relationship. For this research, a vast search of the available local and international literature has been perused and my finding is that the application of Ethics and recognition of the informed consent concept within the medical community in general is gathering momentum and it must be both supported and internalized by those in orthopaedic surgical practice.

This study employs conversation analysis (CA) and membership categorization analysis (MCA) in an exploration of the interactional organization of talk between doctors and the mothers (or the female guardians acting as “proxy mothers”) of HIV-positive child patients being treated at a paediatric hospital in the Western Cape, South Africa, in 2003. The analysis focuses on how the HIV paediatric consultation is co-constructed between the doctor and the mother/guardian, and how interactional choices on the part of the participants shape the course of the consultation. Specific attention is placed on how participants orient to, hear, respond to and coconstruct the category of “mother”, along with the emergent inferences of what constitutes “good mothering” in the context of pursuing the wellbeing of the HIV-positive child who - as it emerges in certain cases - has evidently been infected by the mother in the first instance. As its core focus, this study examines how orienting to “good mothering” is done - in a moment-bymoment, collaborative and co-constructed manner – in the immediate course of the doctor/mother/guardian consultation. This involves considering the interplay of shifts in orientations to “motherly responsibility” and “doctorly responsibility”, and how these shifts are collaboratively activated, negotiated and responded to, as the consultation proceeds.