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schiwagos's BLOG - Erzählungen aus dem rotarischem Universum
Dienstag, 30. Dezember 2008
Zwischen den Jahren...
Schattenreich der Stämme
Hingeworfene Sonnenstrahlen
Zwischen stummen Riesen...
Eiskristalle krallen sich
An kleine Äste
Murmelnd wirbelnd
Klarer Bach vorbei am
Hingestreckten Weggefährten
Sturmgeborstene Splitter
Schreien himmelwärts
Stille dennoch allerorts
Gehst du Schritt für Schritt...
Walter Frank
Zwischen den Jahren
Montag, 29. Dezember 2008
Minimal-Invasive Chirurgie bei Dickdarmkrebs
Laparoscopic colectomy: lessons learned and future prospects
Laparoscopic colectomy, or minimally invasive surgery for colon cancer, is now considered an acceptable alternative to standard open colectomy. The COlon cancerLaparoscopic or Open Resection (COLOR) trial, reported in this month’s issue of The Lancet Oncology (1) refutes previous observations of increased rates of wound tumour implants and lays to rest the concern that laparoscopic techniques are dangerous in the setting of cancer. The level one data from this trial suggest that laparoscopic colectomy is not an inferior oncological procedure to open colectomy; it neither predisposes to surgical shortcuts nor to unique mechanisms of tumour dissemination.
This is a major step forward for laparoscopic oncological surgery and future patients should benefit from the knowledge gained from this trial.To a non-surgeon, this might seem like the end of the story. In fact, to someone not involved directly in the field, it might seem that a great deal of attention has been placed on the testing of a single new procedure (2–5). However, to reduce this story to such a simple conclusion would not do justice to the many lessons learned along the way and to how such lessons will affect the future of surgery. Consider, for example, what has been learnt about the patient’s perspective on surgery. The fact that more than 1765 patients with colon cancer have participated in laparoscopic trials has taught us a great deal about the relative importance of pain, scars, quality of life, and duration of recovery in patient decision-making (6). In order to have less postsurgical pain and discomfort, patients readily accepted the risk that laparoscopic colectomy might offer them an inferior oncological result to open colectomy. The willingness of patients to accept the tradeoff between cancer outcomes andpostoperative outcomes has encouraged surgeons tocontinue to explore new methods for further decreasing postsurgical pain.
Indeed, trials are underway to test the role of laparoscopic proctectomy in patients with rectal cancer, such as the phase III trials being run by both theCOLOR and Clinical Outcomes of Surgical Therapy (COST) groups (now part of the American College of Surgeons Oncology Group) (7). These new trials place less emphasis on concerns specific to abdominal insufflation and atypical tumour seeding and more emphasis on whether complex oncological pelvic resection of the rectum can be achieved. If the extent of resection achieved with open techniques, measured by pathological margins and rates of local relapse, can be replicated with laparoscopic techniques, further steps to achieving natural-orifice surgery might not be so distant. Indeed, some would argue that natural-orifice surgery is the logical extension of current laparoscopic and endoscopic colon and rectal surgery, because the target organ—the bowel—and the natural orifice—the anus—are continuous structures. Although the realisation of natural-orifice surgery is not expected for several years, we are substantially closer to this reality as a result of lessons learned from these laparoscopic trials in colon cancer.
From the surgeon’s perspective, we have learned that complex minimally invasive procedures can be done in diverse practices, by surgeons with diverse training, and in multinational environments. The feasibility of laparoscopic colectomy in practice is confirmed by the findings reported by the COLOR group, with perioperative death and complication rates as low as 1% and 21%, respectively (1). We might never know if these findings are due to the technical standards, credentialing processes, or the positive feedback effects of audits. What we do know, however, is that these trials and the capacity to video-record surgery has ushered in new opportunities to measure, monitor, and safely introduce new surgical procedures. Laparoscopic video recording has aided, for the first time, the ability of surgeons to witness the surgical techniques of another surgeon. Historically, it was almost prohibitive for surgeons to spend time reviewing the procedure of another surgeon at a different institution. The opportunity to review video-recorded operative details allows a new level of surgical standardisation, dialogue, and innovation. As mentioned previously, technical dialogue will certainly speed the development of the instrumentation and techniques needed to achieve natural-orifice surgery in this setting.
Lastly, the Barcelona, COLOR, Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer(CLASICC), and COST trials have assuredly dispelled the concept that randomised trials are inappropriate for surgical procedures; a long and steadfast perception (8). Arguably, it is the systematic knowledge obtained during the laparoscopic trials that has enhanced the feasibilityof complex surgery, set new surgical standards (9) and allowed a smooth and measured transition of this new technology into practice.
Heidi NelsonMayo Clinic and Foundation, Rochester, MN 55905, USAnelsonh@mayo.edu
The author declared no confl icts of interest.
1 Colon Cancer Laparoscopic or Open Resection Study Group. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 2008; 10: 44–52.
2 Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet 2002; 359: 2224–29.
3 Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med2004; 350: 2050–59.
4 Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomized trial.Lancet Oncol 2005; 6: 477–484.
5 Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer(MRC CLASICC trial): multicentre, randomized controlled trial. Lancet 2005;365: 1718–26.
6 Bonjer HJ, Hop WC, Nelson H, et al. Laparoscopically assisted versus open colectomy for colon cancer. Arch Surg 2007; 142: 298–303.
7 Soop M, Nelson H. Laparoscopic-assisted proctectomy for rectal cancer:on trial. Ann Surg Oncol 2008; 15: 2418–25.
8 Bonchek LI. Are randomized trials appropriate for evaluating new operations? N Engl J Med 1979; 301: 44–45.
9 Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectalsurgery. J Natl Cancer Inst 2001; 93: 583–96.
The Lancet Oncology Volume 10, Issue 1, Pages 1-96 (January 2009
Laparoscopic colectomy, or minimally invasive surgery for colon cancer, is now considered an acceptable alternative to standard open colectomy. The COlon cancerLaparoscopic or Open Resection (COLOR) trial, reported in this month’s issue of The Lancet Oncology (1) refutes previous observations of increased rates of wound tumour implants and lays to rest the concern that laparoscopic techniques are dangerous in the setting of cancer. The level one data from this trial suggest that laparoscopic colectomy is not an inferior oncological procedure to open colectomy; it neither predisposes to surgical shortcuts nor to unique mechanisms of tumour dissemination.
This is a major step forward for laparoscopic oncological surgery and future patients should benefit from the knowledge gained from this trial.To a non-surgeon, this might seem like the end of the story. In fact, to someone not involved directly in the field, it might seem that a great deal of attention has been placed on the testing of a single new procedure (2–5). However, to reduce this story to such a simple conclusion would not do justice to the many lessons learned along the way and to how such lessons will affect the future of surgery. Consider, for example, what has been learnt about the patient’s perspective on surgery. The fact that more than 1765 patients with colon cancer have participated in laparoscopic trials has taught us a great deal about the relative importance of pain, scars, quality of life, and duration of recovery in patient decision-making (6). In order to have less postsurgical pain and discomfort, patients readily accepted the risk that laparoscopic colectomy might offer them an inferior oncological result to open colectomy. The willingness of patients to accept the tradeoff between cancer outcomes andpostoperative outcomes has encouraged surgeons tocontinue to explore new methods for further decreasing postsurgical pain.
Indeed, trials are underway to test the role of laparoscopic proctectomy in patients with rectal cancer, such as the phase III trials being run by both theCOLOR and Clinical Outcomes of Surgical Therapy (COST) groups (now part of the American College of Surgeons Oncology Group) (7). These new trials place less emphasis on concerns specific to abdominal insufflation and atypical tumour seeding and more emphasis on whether complex oncological pelvic resection of the rectum can be achieved. If the extent of resection achieved with open techniques, measured by pathological margins and rates of local relapse, can be replicated with laparoscopic techniques, further steps to achieving natural-orifice surgery might not be so distant. Indeed, some would argue that natural-orifice surgery is the logical extension of current laparoscopic and endoscopic colon and rectal surgery, because the target organ—the bowel—and the natural orifice—the anus—are continuous structures. Although the realisation of natural-orifice surgery is not expected for several years, we are substantially closer to this reality as a result of lessons learned from these laparoscopic trials in colon cancer.
From the surgeon’s perspective, we have learned that complex minimally invasive procedures can be done in diverse practices, by surgeons with diverse training, and in multinational environments. The feasibility of laparoscopic colectomy in practice is confirmed by the findings reported by the COLOR group, with perioperative death and complication rates as low as 1% and 21%, respectively (1). We might never know if these findings are due to the technical standards, credentialing processes, or the positive feedback effects of audits. What we do know, however, is that these trials and the capacity to video-record surgery has ushered in new opportunities to measure, monitor, and safely introduce new surgical procedures. Laparoscopic video recording has aided, for the first time, the ability of surgeons to witness the surgical techniques of another surgeon. Historically, it was almost prohibitive for surgeons to spend time reviewing the procedure of another surgeon at a different institution. The opportunity to review video-recorded operative details allows a new level of surgical standardisation, dialogue, and innovation. As mentioned previously, technical dialogue will certainly speed the development of the instrumentation and techniques needed to achieve natural-orifice surgery in this setting.
Lastly, the Barcelona, COLOR, Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer(CLASICC), and COST trials have assuredly dispelled the concept that randomised trials are inappropriate for surgical procedures; a long and steadfast perception (8). Arguably, it is the systematic knowledge obtained during the laparoscopic trials that has enhanced the feasibilityof complex surgery, set new surgical standards (9) and allowed a smooth and measured transition of this new technology into practice.
Heidi NelsonMayo Clinic and Foundation, Rochester, MN 55905, USAnelsonh@mayo.edu
The author declared no confl icts of interest.
1 Colon Cancer Laparoscopic or Open Resection Study Group. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 2008; 10: 44–52.
2 Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet 2002; 359: 2224–29.
3 Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med2004; 350: 2050–59.
4 Veldkamp R, Kuhry E, Hop WC, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomized trial.Lancet Oncol 2005; 6: 477–484.
5 Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer(MRC CLASICC trial): multicentre, randomized controlled trial. Lancet 2005;365: 1718–26.
6 Bonjer HJ, Hop WC, Nelson H, et al. Laparoscopically assisted versus open colectomy for colon cancer. Arch Surg 2007; 142: 298–303.
7 Soop M, Nelson H. Laparoscopic-assisted proctectomy for rectal cancer:on trial. Ann Surg Oncol 2008; 15: 2418–25.
8 Bonchek LI. Are randomized trials appropriate for evaluating new operations? N Engl J Med 1979; 301: 44–45.
9 Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectalsurgery. J Natl Cancer Inst 2001; 93: 583–96.
The Lancet Oncology Volume 10, Issue 1, Pages 1-96 (January 2009
Anstand...
...Bescheidenheit, Maß und Glaubwürdigkeit...
fordert Bundespräsident Köhler von uns ein...
Also - strengen wir uns an!
fordert Bundespräsident Köhler von uns ein...
Also - strengen wir uns an!
Sonntag, 28. Dezember 2008
Coca Cola und Verhütung...
4)Contraception doesn't go better with Coca-cola(Feature: Coca-Cola douches and contraception) http://www.bmj.com/cgi/doi/10.1136/bmj.a2873
One of the reasons why Coca-cola is not an effective spermicide is because sperm are faster and may reach an egg in time to fertilise it, says an expert in the Christmas issue published on bmj.com today.
The author, Deborah Anderson, a professor in obstetrics and gynaecology at Boston University and Harvard Medical School, writes that Coca-cola douches were allegedly used during the 1950s and 60s as a contraceptive when other methods were not easily available. The acidity alledgedly worked as spermicide to kill sperm and the classic coke bottle shape lent itself to a "shake and shoot" applicator!
In this analysis, Professor Anderson provides eight reasons why you're better off not reaching for a Coca-cola after sex, unless you want to drink it:
1. Coca-cola is not very effective in killing sperm. 2. Sperm are faster than Coca-cola and could escape douching and reach the cervical canal.3. Coca-cola may be good for tenderising steaks and removing corrosion from car bumpers but is not good news for vaginal tissue. Coca-cola damages the top layers of cells and could make a woman more prone to sexually transmitted infections.4. The good bacteria that keep vaginas healthy could be adversely affected by coke and this could result in fungal and bacterial infections. 5. Douching could lead to pelvic inflammatory disease and ectopic pregnancy. 6. The Coca-cola formula is a secret so this means no research has been done on whether it would cause birth defects. 7. You need skill to douche effectively with Coca-cola - not practical, especially in the dark when bottle caps can go dangerously astray. 8. There are much more effective and easy to use methods of contraception around.
Contact: Dr Deborah Anderson, Boston University, Boston, USAEmail: Deborah.Anderson@BMC.org
One of the reasons why Coca-cola is not an effective spermicide is because sperm are faster and may reach an egg in time to fertilise it, says an expert in the Christmas issue published on bmj.com today.
The author, Deborah Anderson, a professor in obstetrics and gynaecology at Boston University and Harvard Medical School, writes that Coca-cola douches were allegedly used during the 1950s and 60s as a contraceptive when other methods were not easily available. The acidity alledgedly worked as spermicide to kill sperm and the classic coke bottle shape lent itself to a "shake and shoot" applicator!
In this analysis, Professor Anderson provides eight reasons why you're better off not reaching for a Coca-cola after sex, unless you want to drink it:
1. Coca-cola is not very effective in killing sperm. 2. Sperm are faster than Coca-cola and could escape douching and reach the cervical canal.3. Coca-cola may be good for tenderising steaks and removing corrosion from car bumpers but is not good news for vaginal tissue. Coca-cola damages the top layers of cells and could make a woman more prone to sexually transmitted infections.4. The good bacteria that keep vaginas healthy could be adversely affected by coke and this could result in fungal and bacterial infections. 5. Douching could lead to pelvic inflammatory disease and ectopic pregnancy. 6. The Coca-cola formula is a secret so this means no research has been done on whether it would cause birth defects. 7. You need skill to douche effectively with Coca-cola - not practical, especially in the dark when bottle caps can go dangerously astray. 8. There are much more effective and easy to use methods of contraception around.
Contact: Dr Deborah Anderson, Boston University, Boston, USAEmail: Deborah.Anderson@BMC.org
Samstag, 27. Dezember 2008
Susanne erzählt...
Treffen sich zwei Planeten...
"Na, wie geht es dir?"
"Ganz gut. Und wie geht es dir?"
"Nicht so gut. Ich habe mir den Homo sapiens gefangen. Aber das geht schnell vorbei".
"Na, wie geht es dir?"
"Ganz gut. Und wie geht es dir?"
"Nicht so gut. Ich habe mir den Homo sapiens gefangen. Aber das geht schnell vorbei".
Einige lernen es nie...
Bischof Huber hat das Renditeziel von 25 Prozent der Deutschen Bank kritisiert... Der Sprecher der Bank findet diese Kritik am Vorstandsvorsitzenden Josef Ackermann unangebracht...
Da kann man nur noch sagen - manche lernen es nimmermehr!
Da kann man nur noch sagen - manche lernen es nimmermehr!
Krieg und Medizin
War: what is it good for?
Colin Martin, independent consultant in healthcare communication, London
Colin Martin applauds an exhibition whose theme is the constantly evolving relation between warfare and medicine
"As mankind’s capacity to maim and kill has increased, our desire to repair and heal has always struggled hard to keep pace," say those responsible for an exhibition surveying war and medicine over the past 150 years. Jointly curated by the Wellcome Collection in London and the Deutsches Hygiene-Museum in Dresden, it shows the pity of war for fighters and medical staff in conflicts from the Crimea to present day Afghanistan and Iraq.
Killing and curing are ethically incompatible bedfellows. The priority of military doctors and nurses is to maintain the fighting capabilities of the armed forces, saving the lives of wounded soldiers, sailors, and air crew so that they can fight another day. Military healthcare professionals are seldom able to observe or participate in the long term physical and mental rehabilitation of their patients, as is usual in conventional civilian health care. Like the battle victims they treat, the armed services’ doctors and nurses operate in a military microcosm.
Ethics aside, the exhibition shows that wars have always provided an impetus for rapid developments in medical science and practice. The organisational chaos of the Crimean war (1854-6) provoked Florence Nightingale to improve military and then civilian nursing. On the opposing side, the Russian army surgeon Nikolai Pirogov devised the system of triage, prioritising the treatment of the wounded in five categories. The British trained New Zealand surgeon Harold Gillies pioneered plastic surgery when trench warfare in the first world war increased the incidence of head and neck injuries. The second world war catalysed the Allies’ development of penicillin and its manufacture for supply to armed forces. Other wars represented in the exhibition are Vietnam (1959-75), the Falklands (1982), Afghanistan (2001 to present) and Iraq (2003 to present). All have brought new medical challenges.
The exhibition’s three major themes of organisation, body, and mind are reflected in the German architect Hans Dieter Schaal’s logical layout, bringing clarity to a potentially chaotic subject. His clean, almost aseptic design contrasts with the filth and sepsis encountered in warfare.
"Organisation" considers the logistics of providing medical care on the battlefield, beginning with the Crimean war. But two installations by the artist David Cotterrell are bang up to date. In November 2007 he spent four weeks observing the work of military medical staff at Camp Bastion, a tactical field hospital in Helmand Province, Afghanistan.
Cotterrell’s triple channel video 9-Liner presents three aspects of the dramatic recovery of a wounded soldier from a forward operating base. The three monitors evoke a painted triptych. Silently scrolling codified text fills the central one, tracking the operation’s progress. The left monitor shows the "watch keeper" at Camp Bastion, monitoring computer screens and answering telephones. The right monitor shows the medical emergency response team’s journey in a Chinook helicopter as they bring in the casualty.
The night-time evacuation of a stabilised patient from Camp Bastion to Kandahar is represented in Cotterrell’s panoramic five channel, high definition video projection, Theatre. The hypnotic drone of the Hercules’ engines and calm efficiency of medical staff working within its dimly lit belly create a mesmerising, digital tapestry. At Kandahar the sedated patient is transferred to a waiting C-17 airlifter and flown to Birmingham, for further treatment at Selly Oak Hospital.
"Body" presents artefacts, photographs, and film relating to wartime medical care and the physical rehabilitation of the injured. A long slab, inset with six glazed vitrines and four visual display units, leads visitors towards irregularly shaped white forms. Asymmetrically arranged, they resemble an opera set inspired by Caspar David Friedrich’s paintings of ice floes. Or the arrangement could be seen as a sacrificial altar or memorial to the slaughtered.
The London based artist Paddy Hartley is inspired by historical rather than current conflicts. Spreckley documents reconstructive facial surgery by Harold Gillies on a wounded soldier, whose jacket is inscribed and stitched to record the sequence of operations carried out. Unlike surgeons at the front line, Gillies managed his patients for years. With inspired empathy he found jobs as cinema projectionists for some who remained shy of being seen in public.
The first world war resulted in more than 80 000 British cases of "shell shock." "Mind" examines how our understanding of the importance of psychological support developed throughout the conflicts of the 20th century. A much higher number of civilians were injured in the second world war than previously. At the end of the exhibition a five screen video wall shows extracts from films, including interviews with survivors of the Dresden fire bombings in February 1945 and the atomic bombing of Hiroshima and Nagasaki in August 1945—people who still bear psychological scars today.
Estimates of the number of Iraqi civilian deaths are hotly debated in medical journals. A year after returning from Afghanistan, Cotterrell remains angry that the news media focus on deaths, obscuring the extent and human cost of casualties. "The incongruity between what I had seen and what was presented as the public face of conflict was, and continues to be, profound and irreconcilable."
War and Medicine offers much more than the expected historical overview, strongly advocating peace in a world that continues to be bereaved and burdened by war.
Cite this as: BMJ 2008;337:a2783
War and Medicine Wellcome Collection, London, until 15 February 2009 and Deutsches Hygiene-Museum, Dresden, 4 April to 9 August 2009
Freitag, 26. Dezember 2008
Musik
- Secret life of a girl von Christine Tobin, Babel Import
- Lookout mountain, lookout sea von Silver Jews, Drag City/Rough Trade
- Arnold Schönberg&Jean Sibelius: Violinkonzerte, DG/Universal
- Joseph Haydn: Symphonien, Sony
- La Brass Banda: Habediehre, Trikont
- Igor Strawinsky: L'oiseau de feu, Le sacre du printemps, RCO Live/Codaex
- Charles Ives: Psalms, Hänssler/Naxos
- Charlie Haden: Rambling Boy, Emarcy/Universal
- Karan Casey: Ships in the forest, Crow Valley Records/Pool Music
- Neil Diamond: Home Before Dark, Columbia/Sony
- David Oistrach: The Complete EMI Recordings
- Lied:gut! Deutsche Volkslieder, edition chrismon
- Take me to the river - A southern Soul Story 1961-1977, Ace Records/Soulfood Music
Donnerstag, 25. Dezember 2008
Rasul Allah – der Gesandte Gottes
Zwischen Islam und Christentum gibt es zahlreiche Unterschiede. Aber es gibt auch Gemeinsamkeiten. So kommt Jesus im Islam eine bedeutende Rolle zu. Aiman Mazyek über den islamischen Propheten, der im Koran Isa heißt.
Mehr...
Mehr...
Medizinisches Rätsel - Die Antwort
The medical mystery in the October 30 issue1 concerned a 71-year-old man with a 10-day history of dizziness, progressive lethargy, and confusion. A complete blood count showed pancytopenia (white-cell count, 2900 per cubic millimeter [normal range, 4000 to 11,000]; hemoglobin, 5.5 g per deciliter [normal range, 14 to 18]; hematocrit, 14.5% [normal range, 40 to 52]; and platelets, 56,000 per cubic millimeter [normal range, 150,000 to 440,000]) as well as macrocytosis (mean cell volume, 118 µm3 [normal range, 82 to 98], with a red-cell distribution width of 22,300 per cubic millimeter [normal range, 10,500 to 15,500]) and a reticulocyte count of 0.4% (normal range, 1.2 to 3.2). The patient reported occasional alcohol use, and there was no evidence of a toxic ingestion or nutritional deficiencies. He had no known autoimmune disease or endocrinopathies. Additional laboratory work showed a vitamin B12 deficiency (B12, 75 pg per milliliter [normal range, 240 to 900]; folate, 6.2 ng per milliliter [normal range, 2.0 to 20]). His peripheral-blood smear showed macroovalocytes (Figure 1A, arrowheads) and hypersegmented neutrophils (Figure 1A, arrow). A bone marrow aspirate, performed to evaluate pancytopenia, showed megaloblastic erythroid precursors (Figure 1B, arrowheads) and giant bands (Figure 1B, arrow). The patient was treated with folic acid, 5 mg daily by mouth for 2 months, and vitamin B12 replacement. A complete blood count obtained 7 months later showed a normalization of the red-cell count indexes. Pernicious anemia is suspected but has not been confirmed.
NEJM Volume 359:2845-2846 December 25, 2008 Number 26
Büchertisch für Kinder
- Dinge geregelt kriegen - ohne einen Funken Selbstdisziplin von Kathrin Passig, Rowohlt
- Sagen des Altertums. Das Hausbuch der griechischen Sagen von Edmund Jacoby, Gerstenberg Verlag
- Fünf Hunde erben 1 Million von Hans Traxler, Edition Buntehnde
- Heine für Kinder. Lebet wohl, wir kehren nie, Nie zurück von Bimini von Peter Härtling, Insel Verlag
Perchtenläufer in den Rauhnächten - Als Gott eine Frau war...
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Drudenhax und Teufelsfratz
Ein Röcheln und rasseln, ein Scheppern und Schreien, ein höllisches Spektakel. Das ist sie, die andere, die dunkle Seite der bayerischen Art, schrecklich und schaurig. Ein lautstarkes Echo dieser geheimnisvollen Seelenlandschaft ist die Rauhnacht. In ihr vereinen sie sich, die Kräfte des Unterbewussten, die Mächte der Nacht.Rauh- oder Rauchnächte, das war im Alpenraum früher die Zeit zwischen der Thomasnacht am 21. Dezember und dem Dreikönigstag am 6. Januar. Später wurde sie je nach Region erweitert oder auch eingeengt, zumal auf die Zeit zwischen Weihnachten und Heiligdreikönig. Der Begriff Rauh oder Rauch leitet sich vom ursprünglichen Wortsinn ab, von "rauch", das heißt haarig, behaart. Nicht von ungefähr werden heute noch Pelze auch Rauchwaren genannt. Pelze und Felle tragen seit alters her auch die Perchten, die besonders in den Rauhnächten umtreiben, da und dort werden sie auch Pelzer genannt. Einen doppelten Wortsinn bekam die Rauhnacht schließlich durch den Brauch, in diesen Nächten, vor allem an Dreikönig, Haus und Hof mit Weihrauch auszuräuchern, damit die bösen Geister keinen Einlass fanden. Woher aber dieser Brauch, der sich ja in vielerlei Formen von der Schweiz bis Böhmen, von Südtirol bis zur Oberpfalz erhalten hat. Wer sich da auf die Spuren des Ursprungs macht, taucht ein in tiefe Seelenschichten, in das zweite ICH des Menschen. Nun ist bekannt, dass das Christentum bei seinem Vordringen in die germansichen Länder sich mit alteingewurzelten Riten auseinander zusetzen hatte. Der Kernkonflikt war, dass das Christentum eine monotheistische Religion ist mit absolutem, alleinigen Heilsanspruch, also nur einen einzigen Gott verehrt, während für die germanischen Stämme und selbst noch für die römischen Kolonisatoren der frühen Jahre die ganze Welt beziehungsweise der Himmel von einer Vielzahl von Göttern beherrscht war, zumal von Naturgöttern. Im Kampf um die Vorherrschaft über die Seelen obsiegte das Christentum nicht nur, weil es mit einem alleinigen Gott mehr Kraft, mehr Überzeugung durchsetzen könnte - nein, es nahm durchaus geschickt auch Aspekte der heidnischen Religion mit auf, besetzte auch deren Kultstätten. Ein schönes Beispiel dafür ist das Kircherl von Seebruck am Chiemsee, dessen Grundmauern auf einen römischen Göttertempel verweisen, der hier einst stand. Überhaupt sind in derselben Gegend noch manche Wegkreuze zu finden, die auf heidnischen Gedenksteinen stehen.
Als Gott eine Frau war
Je weiter in die Berge, desto mehr solcher vom Christentum adaptierten Kultplätze gibt es. Der Tiroler Volkskundler Hans Hais hat in seinem überaus aufschlussreichen Buch "Mythos und Kult in den Alpen" Dutzende von bislang unbekannten Kultstätten und Opferplätzen mit Steinkreis und heiligen Quellen, mit heidnischen Wallfahrten zur Mutter Erde und Rutschsteinen zur Fruchtbarkeit aufgespürt. Ein besonders lesenswertes Kapitel darin heiß denn auch "Als Gott eine Frau war" ...Dass der Urgott auch im Alpenraum eine Göttin war, ist inzwischen ebenso hinlänglich gesichert. Noch heute werden, zuletzt in Niederbayern, bei archäologischen Grabungen kleiner, dralle Figurinen entdeckt - keine Ebenbilder von Germanenfrauen sind das, sondern von Göttinen. Die Münchner Ethnologin Luisa Francia, die durchaus auch als Hexe im modernen Sinne ("keine schwarze Magie", "sich besinnen auf seine eigene Kraft") bezeichnet werden darf, schlägt hier eine Brücke vom Alpenraum bis weit in den Kaukasus: Die Frau Percht und die Babuschka, das sind im europäischen Raum, die beiden einzigen Begriffe, die heute noch auf weibliche Gottheiten zurückweisen. Und wer großes Glück hat, stößt in abseits gelegenen Bergbauernhöfen noch auf einen Herrgottswinkel, in dem unter dem Gekreuzigten eine mordsdicke Puppe aus Stroh oder Holz steht. Oft auch als Kinderspielzeug verwendet, erinnert sie dennoch an weibliche Gottheiten - schaut sie doch ähnlich wie kleine Statuetten afrikanischer Göttinen aus, nur nicht aus schwarzem Ebenholz, sondern hellem Weidenstamm. Nicht zuletzt ist die Urgöttin auch im Märchen verewigt, dort heißt sie Frau Holle. Sie zählt zu den Lichtgestalten, die in der Zeit, da die Tage kürzer werden und die Nächte schrecklich lang, Zuversicht und Geborgenheit vermitteln soll. Die Perchta dagegen ist doppeldeutig, sowohl Sinnbild der Sünde, als auch der Sühne. Diese wechselnde Symbolik, hier die Frau Percht als die Böse, dort als die Gute, hat sich bis heute erhalten. In manchen Orten in Österreich, Bayern und der Schweiz geht in der dunklen Zeit die "Schiachpercht" um, in anderen wiederum die "Schönpercht". Finster, wild und zottelig die eine, hell und lieblich anzusehen die andere. Dass nun ausgerechnet die Frau Percht gar nicht heidnischen, sondern rein christlichen Ursprungs sein soll, ein Symbol der Sünde und eigentlich nur ein paar Jahrhunderte alt, wie dies eine jüngere Forschungsarbeit glauben machen will - das scheint beinah unhistorisch und arg am Volksglauben vorbei.
Den Ängsten Herr werden
Wo doch die Kirche seit Menschengedenken diese Perchtenumtriebe alles andere als freudig stützt und schützt, wo doch alle Mummenschanzereien und Maskeraden, alle rituellen Derbheiten und Frechheiten von der Geistlichkeit wahrlich nicht begeistert begrüßt wurden. Und wo doch perchtenähnliche Umtriebe oder gar die Wilde Jagd - als Mythos oder zuweilen auch leibhaftig - lange schon vor der Christianisierung verbreitet waren. Als ob Menschen in der Zeit davor kein Seelenleben, kein Über-Ich gehabt hätten, keine Ängste und Alpträume - und keine Ahnung, wie man diesen mit Personifizierungen, mit Allegorien auch Herr werden kann.Zumal in der finstersten Zeit des Jahres, die meist auch noch mit rauhem Wetter einhergeht, dachten sich unsere Ahnen die Welt von Unholden und Hexen beherrscht, die von Haus zu Haus schlichen, um Unheil zu stiften. Das erinnert stark an die germansiche Mythologie, in der Gott Wotan auf einem Schimmel zur Walstatt reitet, gefolgt von Kriegern, Schlachtjungfrauen, begleitet von Wölfen, Hunden, Katzen und fürchterlichem Sturm. Das ist sie, die Wilde Jagd. Es ist ja kein Wunder, dass die Vorfahren auf solche Gedanken kommen konnten. Man muss sich nur einmal vorstellen, wie sie im tiefsten Winter in ihren Häusern und Hütten hockten, die Stuben nur vom Herdfeuer oder vom Kienspan erhellt, keine andere Unterhaltung und Tröstung als die eigene Gegenwart, umgeben vom Toben des Sturms und dem Wüten der Elemente, begleitet von Einsamkeit und Stille. Natürlich besaßen die Alten Kenntnisse von den Vorgängen am Himmel und in der Natur, und das Verschwinden des Tageslichts, dem sie ja Gottgestalt gegeben hatten, beunruhigte sie sehr. Immer wieder von neuem musste deshalb die Wiederkehr der Sonne und die von ihr allein genährte Fruchtbarkeit und Lebendigkeit der Erde beschworen werden. Fruchtbarkeit ist hier nicht nur als Kindersegen und damit als Vorsorge fürs Alter zu verstehen, sondern ganz elementar das Wachsen in Feld und Flur, das Gedeihen von Vieh, Getreide und Früchten, das heißt die Sorge um das tägliche Brot. Dieser Winter- und Dunkelheitsangst, die die heutigen Menschen dank des elektrischen Stroms einfach gar nicht mehr so empfinden können, ließ die Vorfahren überall unheimliches Volk und drohende Wesen sehen.
Kinder d´Luz geht um
Da ist die Luz, auch sie wieder in zweierlei Gestalt, einmal die Heilige Luzia, einmal als furchterregender Kinderschreck. Vor drei, vier Generationen noch glaubten Dorfkinder, wenn sie am 13. Dezember, dem Tag der Luzia, etwas Weißes huschen sahen, das war ganz bestimmt die Luz gewesen. Wenn sie nicht einschlafen wollten, mahnte die Mutter "d`Luz geht um", dann verschloffen sie sich in ihr Federnest. Mit einem Korb am Arm, aus dem ein hölzernes Messer ragte, hinkte die Luz von Haus zu Haus auf der Suche nach Kindern, die in der Dunkelheit noch auf der Gasse waren. Sie schnitt ihnen, so will es der Volksglauben, mit ihrem Messer den Bauch auf."An Luzier geht der Tag irr", weil er, im alten Kalender auf den 23. Dezember fallend, die längste Nacht erreicht, diese Nachtlänge eine Zeitlang stehen bleibt. In dieser Nacht treibt alles Unheimliche auf Teufel komm raus sein Unwesen, sie galt von jeher als die unheilvollste, als Hexen- und Drudennacht aller ersten Ranges, wie der Hilferuf an die Heilige Luzia besagt: "Vorn Drudndrucka, vor Hexenhaxn - vorn Teifisbratn und Zauberfaxn - beschützt mi du, heilige Luz - bis i morgn Früah aufsteh".
Von gewissen Weibspersonen
Wer oder was die Drud oder Trud ist, das beschäftigte auch den großen bayerischen Sprachforscher Andreas Schmeller. In seinem unereichtem Bayerischen Wörterbuch aus dem Jahr 1872 schreibt er über die Trud: "Nach dem Wahn des großen Haufens: eine jene Art Hexen oder Unholdinnen, deren besondere Liebhaberei es ist, sich schlafenden Personen in allerlei furchtbaren Gestalten recht breit und schwer auf die Brust zu setzen und ihnen die ängstlichen Empfindungen zu verursachen, die man anderswo den Alp oder das Alpdrücken nennt. Dieser an sich gleichgültige Wahn hatte früher das Bedenkliche, dass der gemeine Mann nicht selten bestimmte, besonders ältere Weibspersonen aus seiner Gegend für Truden zu halten und als solche anzufeinden beliebte.Und im Deutschen Wörterbuch der Brüder Jacob und Wilhelm Grimm heißt es: "Trud bezeichnet ein gespenstisches Wesen, gewöhnlich ein Nachtgespenst, das das Alpdrücken verursacht." Um nun die Drud von der Liegestatt abzuwehren, zeichnete man mit geweihter Kreide auf das Brett am Fußende der Bettstatt einen Drudnhax, das fünfeckige Pentagramm, steckte außerdem in den aufgezeichneten Drudenfuß ein feststehendes Messer, denn Eisen wehrt die bösen Geister ab. Den Drudnhax in Gestalt von geflochtenen Zweigen sieht man zuweilen noch immer überm Eingang zu Almhütten. Und alte Bauersleut schaun heut noch drauf, dass in der Nacht zum 24. Dezember alle Besen mit dem Stiel nach unten im Türeck stehen - damit die Drud und mit ihr alle bösen Geister in den Kehrreisern hängen bleiben. Es ist nun bezeichnend und geradezu ein Grundkurs in Tiefenpsychologie, wie sich die Altvorderen gegen die Heerschar böser Geister wehrten, obwohl sie doch noch keine Feiung durch eine Christliche Erlösungsreligion hatten. Sie versuchten, die Hexen gleichsam zu verhexen, die Unholde durch noch mehr Unholdsein zu beeindrucken. Den Teufel mit dem Belzebub austreiben - diese Sentenz hat hier ihre Wurzeln. Also noch wilder als die Wilde Jagd, noch schrecklicher als das ganze Getöse und Geheule am Nachthimmel - in diesem Bestreben entwickelten sich die furcheinflössenden Masken der Perchtenläufer in den Rauhnächten, denen man im Voralpenland wie in den tiefsten Bergdörfern noch immer begegnen kann und denen selbst die christliche Religion nicht den Garaus machen konnte, sie allenfalls überlagert hat.
Das stärkt den aufrechten Gang
In uralter Zeit war das Auftreten der Perchten, dieser menschlichen Projektion übermenschlicher Mächte, etwas sehr Ernstes und Wichtiges: Vermummte Menschen konnten sich also nicht nur vor ihresgleichen verbergen, sondern auch vor den Geistern, konnten sie mit grauenhaften Fratzen und wildem Fell, mit viel Getöse und Katzenmusik gleichsam zur Hölle jagen. Besser ließ sich das Böse nicht bannen, waren Ängste nicht zu bewältigen, Alpträume nicht zu verarbeiten. So sind die Rauhnächte auch eine Reise ins Unterbewusste, ein Spiegel der Seele.Kurzum, es ist dies ein ziemlich sinnvolles Brauchtum. Also Brauch in seinem Wortsinne: es brauchen, es nötig haben. Das vor allem, um eines zu stärken - das Selbstbewusstsein, den aufrechten Gang. Max Königsdorfer Scharivari |
Die Juden...
Volk, Kultur, Religions- oder Schicksalsgemeinschaft. Es gibt viele Begriffe, mit denen sich das Judentum und seine über 3000 Jahre währende Geschichte bezeichnen lassen. Geeint wurde das "auserwählte Volk" durch den Glauben an den einen Gott. Verstärkt wurde diese Verbundenheit noch durch Jahrhunderte voller Verfolgung und Diskriminierung. Doch trotz aller Widrigkeiten haben die reiche jüdische Kultur und ihre Traditionen bis heute überlebt.
Mehr gibt es bei Planet Wissen....unter dem Stichwort Juden
Mehr gibt es bei Planet Wissen....unter dem Stichwort Juden
Mittwoch, 24. Dezember 2008
Weihnachten
Uns erscheint Weihnachten als das eigentlich christliche Fest. Gott wird Mensch, er erbarmt sich der Sünder, er ist solidarisch mit den Armen. Ist unsere Rettung nicht schon geschehen, wenn die Hirten das Kind in der Krippe verehren und die drei Weisen aus dem Morgenland, im Traum durch einen Engel gewarnt, Herodes den Aufenthaltsort des Kindes nicht verraten?
In den Evangelien finden sich die Berichte und theologischen Aussagen, die bis heute dem Weihnachtsfest seine innere Kontur geben. Am meisten hat der Evangelist Lukas den Charakter des Festes mit folgenden Erzählungen geprägt. - Verkündigung des Engels Gabriel an Maria - Besuch Marias bei Elisabeth - Herbergssuche - Geburt im Stall - Verkündigung an die Hirten - Beschneidung und Darstellung Jesu im Tempel - Der Zwölfjährige im Tempel.
Der Weihnachtsbaum ist nicht nur deshalb zum Zentrum des Weihnachtszimmers geworden, weil das Grün im Winter symbolisiert, daß das Leben trotz der Kälte weiter geht, er ist auch das Gegenbild zum Paradiesesbaum, von dem das Unheil ausgegangen ist, aus dem das Kind die Menschheit erretten wird. Das Kind wird mit ausgebreiteten Armen in die Krippe gelegt, weil so auf die Kreuzigung hingedeutet wird. Ein Charakteristikum der Predigt Jesu klingt bei der Geburt schon an: Die kleinen Leute, die Hirten, werden als erste auf die Geburt hingewiesen, die Mächtigen in der Gestalt des Herodes reagieren mit Angst und daraus folgender Gewalt. Trotz allen Konsums, trotz Wintersport und andere heutigen Arrangements um das Weihnachtsfest herum dringt die Botschaft des Kindes aus der Krippe weiterhin bis in die Herzen der Menschen.
www.kath.de
In den Evangelien finden sich die Berichte und theologischen Aussagen, die bis heute dem Weihnachtsfest seine innere Kontur geben. Am meisten hat der Evangelist Lukas den Charakter des Festes mit folgenden Erzählungen geprägt. - Verkündigung des Engels Gabriel an Maria - Besuch Marias bei Elisabeth - Herbergssuche - Geburt im Stall - Verkündigung an die Hirten - Beschneidung und Darstellung Jesu im Tempel - Der Zwölfjährige im Tempel.
Der Weihnachtsbaum ist nicht nur deshalb zum Zentrum des Weihnachtszimmers geworden, weil das Grün im Winter symbolisiert, daß das Leben trotz der Kälte weiter geht, er ist auch das Gegenbild zum Paradiesesbaum, von dem das Unheil ausgegangen ist, aus dem das Kind die Menschheit erretten wird. Das Kind wird mit ausgebreiteten Armen in die Krippe gelegt, weil so auf die Kreuzigung hingedeutet wird. Ein Charakteristikum der Predigt Jesu klingt bei der Geburt schon an: Die kleinen Leute, die Hirten, werden als erste auf die Geburt hingewiesen, die Mächtigen in der Gestalt des Herodes reagieren mit Angst und daraus folgender Gewalt. Trotz allen Konsums, trotz Wintersport und andere heutigen Arrangements um das Weihnachtsfest herum dringt die Botschaft des Kindes aus der Krippe weiterhin bis in die Herzen der Menschen.
www.kath.de
Montag, 22. Dezember 2008
1. Tag Chanukka
Chanukka erinnert an die Wiedereinweihung des zweiten jüdischen Tempels in Jerusalem im jüdischen Jahr 3597 (164 v. Chr.) nach dem erfolgreichen Makkabäeraufstand der Juden Judäas gegen hellenisierte Juden und makedonische Syrer, wie er im Ersten Buch der Makkabäer und auch im Talmud überliefert ist. Die Makkabäer beendeten die Herrschaft des Seleukidenreiches über Judäa, beseitigten den im jüdischen Tempel von Griechen errichteten Zeus-Altar, und führten den jüdischen Tempeldienst wieder ein.
Die Menora war ein Leuchter, welcher im Tempel niemals erlöschen sollte. Nach der Überlieferung war aufgrund der Eroberung der Syrer nur noch ein Krug geweihtes Öl vorzufinden. Dieses Öl reichte für gerade mal einen Tag. Für die Herstellung neuen geweihten Öls werden aber acht Tage benötigt. Durch ein Wunder hat das Licht jedoch acht Tage gebrannt, bis neues geweihtes Öl hergestellt worden war. Daran erinnern die acht Lichter des Chanukka-Leuchters. Jeden Tag wird ein Licht mehr angezündet, bis am Ende alle acht brennen.
www.wikipedia.de
Die Menora war ein Leuchter, welcher im Tempel niemals erlöschen sollte. Nach der Überlieferung war aufgrund der Eroberung der Syrer nur noch ein Krug geweihtes Öl vorzufinden. Dieses Öl reichte für gerade mal einen Tag. Für die Herstellung neuen geweihten Öls werden aber acht Tage benötigt. Durch ein Wunder hat das Licht jedoch acht Tage gebrannt, bis neues geweihtes Öl hergestellt worden war. Daran erinnern die acht Lichter des Chanukka-Leuchters. Jeden Tag wird ein Licht mehr angezündet, bis am Ende alle acht brennen.
www.wikipedia.de
Sonntag, 21. Dezember 2008
Freitag, 19. Dezember 2008
Karl-Ludwig
War es gestern erst
Als wir beschlossen
gemeinsam zu kämpfen?
Gemeinsam zu kämpfen
um deine Lebenszeit...
und jetzt stehe ich
an deinem Grab im Grau des
Winters - Diamantklare
Wassertropfen an nackten Stäuchern...
Eine Schale Erde links neben mir
und plötzlich - ein Sonnenstrahl
läßt Blütenblätter leuchten...
Walter Frank
Als wir beschlossen
gemeinsam zu kämpfen?
Gemeinsam zu kämpfen
um deine Lebenszeit...
und jetzt stehe ich
an deinem Grab im Grau des
Winters - Diamantklare
Wassertropfen an nackten Stäuchern...
Eine Schale Erde links neben mir
und plötzlich - ein Sonnenstrahl
läßt Blütenblätter leuchten...
Walter Frank
Donnerstag, 18. Dezember 2008
Warum ist Gesundheit ein Menschenrecht?
The Lancet Volume 372 Issue 9655 13 December 2008-19 December 2008, Page 2010
Why and how is health a human right?
Amartya Sen,
Harvard University, Cambridge, MA 02138, USA
In doing a special issue on the right to health, The Lancet is helping to draw attention to an extraordinarily important subject that does not get as much attention as it deserves. There are understandable reasons why the perspective of the right to health seems to many to be remote. First, there is what we might call the legal question: how can health be a right since there is no binding legislation demanding just that? Second, there is the feasibility question: how can the state of being in good health be a right, when there is no way of ensuring that everyone does have good health? Third, there is the policy question: why think of health, rather than health care, as a right, since health care is under the control of policy making, not the actual state of health of the people?
The legal question assumes that the idea of right has to be inescapably legal. Indeed, Jeremy Bentham described the 1789 French declaration of the rights of man (what rights every human being has) as “nonsense”, since a right had to be, he argued, legislated and must be a “child of law”.1 But there is a long tradition of thinking of rights in terms of social ethics: what a good society must have. Indeed, when the American Declaration of Independence invoked “certain inalienable rights” that everyone had, the idea of human rights served not as a “child of law” but more as a “parent of law” in guiding legislation.2 In seeing health as a human right, there is a call to action now to advance people's health in the same way that the 18th-century activists fought for freedom and liberty.
The feasibility question is based on a common confusion about what can or cannot be a right. If feasibility were a necessary condition for everyone to have any right, it would be nonsensical to say that everyone has the right to liberty, in view of the difficulty in ensuring the life and liberty of all against transgression. We cannot prevent the occurrence of murder somewhere or other every day. Nor, with the best of efforts, can we stop all mass killings. The acceptance of health as a right of all is a demand to take action to promote that goal, going beyond what is sometimes called the first-generation rights that involve personal liberties and political entitlements such as the right to vote (none of these rights are completely realisable).
The policy question points to the important fact that good health depends on health care, and health care is something that we can legislate about. But good health does not depend only on health care. It also depends on nutrition, lifestyle, education, women's empowerment, and the extent of inequality and unfreedom in a society. A human right can serve as a parent not only of law, but also of many other ways of advancing the cause of that right. Even the fulfilment of the first-generation rights (such as religious liberty, freedom from arbitrary arrest, the right not to be assaulted and killed)3 depends not only on legislation but also on public discussion, social monitoring, investigative reporting, and social work.4
The right to health has similarly broad demands that go well beyond legislating good health care (important as that is). There are political, social, economic, scientific, and cultural actions that we can take for advancing the cause of good health for all.[5], [6], [7], [8], [9] and [10] Indeed, this special issue, which is aimed at knowledge and understanding of the parameters of the right to health, is itself a contribution to that splendid cause. In seeing health as a right, we acknowledge the need for a strong social commitment to good health. There are few things as important as that in the contemporary world.
Why and how is health a human right?
Amartya Sen,
Harvard University, Cambridge, MA 02138, USA
In doing a special issue on the right to health, The Lancet is helping to draw attention to an extraordinarily important subject that does not get as much attention as it deserves. There are understandable reasons why the perspective of the right to health seems to many to be remote. First, there is what we might call the legal question: how can health be a right since there is no binding legislation demanding just that? Second, there is the feasibility question: how can the state of being in good health be a right, when there is no way of ensuring that everyone does have good health? Third, there is the policy question: why think of health, rather than health care, as a right, since health care is under the control of policy making, not the actual state of health of the people?
The legal question assumes that the idea of right has to be inescapably legal. Indeed, Jeremy Bentham described the 1789 French declaration of the rights of man (what rights every human being has) as “nonsense”, since a right had to be, he argued, legislated and must be a “child of law”.1 But there is a long tradition of thinking of rights in terms of social ethics: what a good society must have. Indeed, when the American Declaration of Independence invoked “certain inalienable rights” that everyone had, the idea of human rights served not as a “child of law” but more as a “parent of law” in guiding legislation.2 In seeing health as a human right, there is a call to action now to advance people's health in the same way that the 18th-century activists fought for freedom and liberty.
The feasibility question is based on a common confusion about what can or cannot be a right. If feasibility were a necessary condition for everyone to have any right, it would be nonsensical to say that everyone has the right to liberty, in view of the difficulty in ensuring the life and liberty of all against transgression. We cannot prevent the occurrence of murder somewhere or other every day. Nor, with the best of efforts, can we stop all mass killings. The acceptance of health as a right of all is a demand to take action to promote that goal, going beyond what is sometimes called the first-generation rights that involve personal liberties and political entitlements such as the right to vote (none of these rights are completely realisable).
The policy question points to the important fact that good health depends on health care, and health care is something that we can legislate about. But good health does not depend only on health care. It also depends on nutrition, lifestyle, education, women's empowerment, and the extent of inequality and unfreedom in a society. A human right can serve as a parent not only of law, but also of many other ways of advancing the cause of that right. Even the fulfilment of the first-generation rights (such as religious liberty, freedom from arbitrary arrest, the right not to be assaulted and killed)3 depends not only on legislation but also on public discussion, social monitoring, investigative reporting, and social work.4
The right to health has similarly broad demands that go well beyond legislating good health care (important as that is). There are political, social, economic, scientific, and cultural actions that we can take for advancing the cause of good health for all.[5], [6], [7], [8], [9] and [10] Indeed, this special issue, which is aimed at knowledge and understanding of the parameters of the right to health, is itself a contribution to that splendid cause. In seeing health as a right, we acknowledge the need for a strong social commitment to good health. There are few things as important as that in the contemporary world.
Mittwoch, 17. Dezember 2008
Globale Ethik
Das Wittenberg-Zentrum für Globale Ethik hat es sich zum Ziel gesetzt, heutigen und künftigen Entscheidungsträgern aus Politik, Wirtschaft und Gesellschaft Kompetenzen in ethischen Fragen zu vermitteln. Anliegen ist es, den Blickwinkel für gesellschaftliche Probleme zu erweitern, die Fähigkeiten zur sachgerechten Diskussion zu verbessern und Wege für verantwortungsvolles Handeln in der modernen Gesellschaft aufzuzeigen. Mit Hilfe einer fundierten wirtschaftsethischen Konzeption werden Möglichkeiten gesucht, wie Moral in der Marktwirtschaft und unter Wettbewerbsbedingungen zur Geltung kommen kann.
Mehr
Mehr
Dienstag, 16. Dezember 2008
Montag, 15. Dezember 2008
Immer mehr - für wen eigentlich?
Ein weiteres bestimmendes Moment kapitalistischer Gesellschaften, das die Triebfeder des widersprüchlichen - schöpferischen wie destruktiven – "Wirtschaftswachstums" darstellt, scheint ebenfalls an seine Grenzen zu stoßen, wie der Guardan bemerkt:
Tatsächlich ist das Wachstum, das nur der volkswirtschaftlich sichtbare Ausdruck der ![[extern]](https://lh3.googleusercontent.com/blogger_img_proxy/AEn0k_tANhUXrBFAssGt77Lydzot8zhWGl3U8DP4IYYvLxUQKoKxt_7T-mIlUBMO0-VqKH_hMMH1LRfhRKVwvL9Xe88EtaLK1Jo7DSLdAlg55YmP1K1F30A=s0-d)
Ein weiteres Problem im Zuge der Akkumulation von Kapital ergibt sich aus der herrschenden Definition von "Nachfrage". Für das Kapital wie auch die gängige Betriebswirtschaftslehre gibt es nur dort Nachfrage nach einer Ware, wo es auch die Mittel gibt, diese zu erwerben. So kann ein jeder BWLer ruhigen Gewissens feststellen, dass am Horn von Afrika, wo sich gerade eine Hungersnot anbahnt, keine Nachfrage nach Lebensmitteln herrscht.
Sonntag, 14. Dezember 2008
Das Zeitalter des Verfalls...
Peak Everything
Note: This issue is an edited version of the Introduction to Peak Everything: Waking Up to the Century of Declines.
During the past few years the phrase Peak Oil has entered the global lexicon. It refers to the moment in time when the world will achieve its maximum possible rate of oil extraction; from then on, for reasons having mostly to do with geology, the amount of petroleum available to society on a daily or yearly basis will begin to dwindle. Most informed analysts agree that this will happen during the next two or three decades; an increasing number believe that it is happening now - that conventional oil production peaked in 2005–2006 and that the flow to market of all hydrocarbon liquids taken together will start to diminish around 2010.1 The consequences, as they begin to accumulate, are likely to be severe: the world is overwhelmingly dependent on oil for transportation, agriculture, plastics, and chemicals; thus a lengthy process of adjustment will be required. According to one recent U.S. government-sponsored study, if the peak does occur soon replacements are unlikely to appear quickly enough and in sufficient quantity to avert what it calls "unprecedented" social, political, and economic impacts.2
This book is not an introduction to the subject of Peak Oil; several existing volumes serve that function (including my own The Party's Over: Oil, War and the Fate of Industrial Societies).3 Instead it addresses the social and historical context in which the event is occurring, and explores how we can reorganize our thinking and action in several critical areas in order to better navigate this perilous time.
Samstag, 13. Dezember 2008
Als das Mondschaf Halme zupfte...
Christian Morgenstern's Mondschaf zupfte Halme, als wir uns aufmachten zum Westfalenstadion...
Zwiebelschalentechnik war angesagt, sprich lange Unterhosen etc...
Also - mit dem Auto fahre ich so schnell nicht mehr vom Ambiente zum Stadion, mit Glück ergatterten wir in der Nähe einen Parkplatz.
Das Stadion mit 79400 Zuschauern fast ausverkauft. Bevor wir zum Block 14 gehen, gibt es eine warme, große Brezel!
Auf der Südtribüne meinte dann Magdalena, dass man gar nicht frieren kann, weil die Menschen so dicht gedrängt stehen...
Die Gladbacher in blauem Trikot.
M: "In so einem Babyblau würde ich niemals spielen!"
34. Min. - M: "Ein ziemlich langweiliges Spiel..." Vereinzelt fielen schon Pfiffe auf der Südtribüne.
Zidan erlöste uns dann kurz darauf mit einem fulminanten Schuß vom 16er aus. Dann wurde es interessant - Hajnal flog wegen wiederholtem Fouls, zum Schluß gegen den Torwart, mit Rot vom Platz, das konnte heiter werden...
In der Pause gab es denBVB-Schneewalzer - und die Südtribüne schunkelte...
In der zweiten Hälfte eine Überraschung - Sahin schießt das 2 : 0! Toll herausgespielt! Zum Schluß hin ein zerfahrenes Spiel.
W: "Pass auf, gleich gibt es das 3 : 0"
M: " Ich glaube, eher das 2 : 1"
Wie immer bekommt sie recht, Gladbach gelingt gleich darauf das 2 : 1.
Beim Verlassen des Stadions kaufen wir eine Bratwurst...schmeckt richtig gut, für Bier ist es zu kalt - und Bratwurst mit Glühwein (den gibt es tatsächlich auch) geht nicht.
Und dann eine Überraschung - im Ambiente feiert die Knappschaft Weihnachtsfeier - Wiedersehen mit Frau Trapp, Frau Hartmann und KollegenInnen...
Herr Bauer: "Wiedersehen mit der alten Heimat..."
In gewisser Weise kann man das sagen.
Weihnachtsmarkt Dortmund - Beim Karstadt Sport erhalten wir als Zugabe einen BVB-Adventskalender, in der Mayer'schen Buchhandlung ist der Teufel los - aber da fühlt man sich trotzdem gut aufgehoben, zum Abschluß gibt es Westfälischen Grillschinken, als "Nachtisch" Reibekuchen mit Apfelmus...
Impressionen gibt es hier.
Zwiebelschalentechnik war angesagt, sprich lange Unterhosen etc...
Also - mit dem Auto fahre ich so schnell nicht mehr vom Ambiente zum Stadion, mit Glück ergatterten wir in der Nähe einen Parkplatz.
Das Stadion mit 79400 Zuschauern fast ausverkauft. Bevor wir zum Block 14 gehen, gibt es eine warme, große Brezel!
Auf der Südtribüne meinte dann Magdalena, dass man gar nicht frieren kann, weil die Menschen so dicht gedrängt stehen...
Die Gladbacher in blauem Trikot.
M: "In so einem Babyblau würde ich niemals spielen!"
34. Min. - M: "Ein ziemlich langweiliges Spiel..." Vereinzelt fielen schon Pfiffe auf der Südtribüne.
Zidan erlöste uns dann kurz darauf mit einem fulminanten Schuß vom 16er aus. Dann wurde es interessant - Hajnal flog wegen wiederholtem Fouls, zum Schluß gegen den Torwart, mit Rot vom Platz, das konnte heiter werden...
In der Pause gab es denBVB-Schneewalzer - und die Südtribüne schunkelte...
In der zweiten Hälfte eine Überraschung - Sahin schießt das 2 : 0! Toll herausgespielt! Zum Schluß hin ein zerfahrenes Spiel.
W: "Pass auf, gleich gibt es das 3 : 0"
M: " Ich glaube, eher das 2 : 1"
Wie immer bekommt sie recht, Gladbach gelingt gleich darauf das 2 : 1.
Beim Verlassen des Stadions kaufen wir eine Bratwurst...schmeckt richtig gut, für Bier ist es zu kalt - und Bratwurst mit Glühwein (den gibt es tatsächlich auch) geht nicht.
Und dann eine Überraschung - im Ambiente feiert die Knappschaft Weihnachtsfeier - Wiedersehen mit Frau Trapp, Frau Hartmann und KollegenInnen...
Herr Bauer: "Wiedersehen mit der alten Heimat..."
In gewisser Weise kann man das sagen.
Weihnachtsmarkt Dortmund - Beim Karstadt Sport erhalten wir als Zugabe einen BVB-Adventskalender, in der Mayer'schen Buchhandlung ist der Teufel los - aber da fühlt man sich trotzdem gut aufgehoben, zum Abschluß gibt es Westfälischen Grillschinken, als "Nachtisch" Reibekuchen mit Apfelmus...
Impressionen gibt es hier.
Freitag, 12. Dezember 2008
Villa Bonn
Die diesjährige Abschlußfeier mit Preisverleihung und Jahresvortrag der Rhein-Main-Arbeitsgemeinschaft für Gastroenterologie fand in der Villa Bonn statt - einem stattlichen Haus mit einer bemerkenswerten Historie...
Stefan Zeuzem stellte zunächst den Preisträger Herrn OA Dr. Mönch, Mitarbeiter von Prof. Bechstein vor. Herr Mönch berichtete danach von seiner Arbeit, die belegen konnte, dass es nach Lebertransplantation möglich ist, auf die Steroidmedikation zu verzichten. Wer klinische Forschung kennt, muß einfach anerkennend sagen: "Chapeau!".
Professor Riemann, aus der Schule von Demling, den ich selber noch in Erlangen erleben durfte, berichtete dann, nachdem er zuvor mit großen Respekt von Stefan Zeuzem vorgestellt wurde, vom
Kolorektalen Karzinom - eine Erkrankung, die vermeidbar ist...wenn man zur Vorsorgekoloskopie geht!
Man merkte Professor Riemann an, mit welcher Leidenschaft ihn dieses Thema bewegt. Herzlichen Dank für diesen überzeugenden Vortrag!
Impressionen vom Abend gibt es hier...
Stefan Zeuzem stellte zunächst den Preisträger Herrn OA Dr. Mönch, Mitarbeiter von Prof. Bechstein vor. Herr Mönch berichtete danach von seiner Arbeit, die belegen konnte, dass es nach Lebertransplantation möglich ist, auf die Steroidmedikation zu verzichten. Wer klinische Forschung kennt, muß einfach anerkennend sagen: "Chapeau!".
Professor Riemann, aus der Schule von Demling, den ich selber noch in Erlangen erleben durfte, berichtete dann, nachdem er zuvor mit großen Respekt von Stefan Zeuzem vorgestellt wurde, vom
Kolorektalen Karzinom - eine Erkrankung, die vermeidbar ist...wenn man zur Vorsorgekoloskopie geht!
Man merkte Professor Riemann an, mit welcher Leidenschaft ihn dieses Thema bewegt. Herzlichen Dank für diesen überzeugenden Vortrag!
Impressionen vom Abend gibt es hier...
Donnerstag, 11. Dezember 2008
Übergewicht und Gene...
NEJM Volume 359:2603-2604 December 11,2008 Number 24
Energy In, Energy Out, and the Effects of Obesity-Related Genes
Rudolph L. Leibel, M.D.
More than 100 genes have been implicated in the determination of body weight. These genes, acting primarily in or through the central nervous system (primarily the hypothalamus and brain stem), affect conscious and unconscious aspects of food intake and energy expenditure. They include genes mediating brain sensing of fat stores, calorie flux in the gut, hedonic responses to specific foods, rates of energy expenditure, and even inclination to physical activity.1,2,3 In some populations, mutations in one of these genes — the melanocortin 4 receptor (MC4R), which conveys hypothalamic signals suppressing food intake and increasing energy expenditure — can account for 3 to 5% of severe obesity (body-mass index [BMI] >40, with BMI defined as the weight in kilograms divided by the square of the height in meters).4 Other quantitatively significant single genes have been hard to identify. Possible reasons for this failure may be that obesity is so physiologically complex that no single gene or even handful of genes is likely to have a dispositive role, that examining gene–gene interactions is difficult without large numbers of subjects, and that variations among current candidate genes are not the most important contributors to human adiposity.
Enter the genomewide association study,5 which uses large numbers of common single-nucleotide polymorphisms (SNPs) in DNA spaced more or less evenly across the human genome to identify genetic variation associated with ordinal or cardinal phenotypes. Unlike the candidate-gene approach, the genomewide association study is genetically agnostic: it looks for genetic intervals associated with the phenotype or phenotypes; the constituent genes are "discovered" after the fact by examining those in the implicated interval. The fat mass and obesity–associated gene (FTO) examined in the article by Cecil et al. in this issue of the Journal6 was previously identified as a new obesity candidate by a genomewide association study.7
Frayling et al.7 found a strong association between SNPs (e.g., rs9939609) and adiposity in the first intron of FTO. This association has been replicated in several additional studies, using data on more than 80,000 adults and children. The statistical power of the association (P=~1.2x10–29) in the aggregate data is much higher than for any previous candidate-gene association study.
Cecil et al. studied the effects of genetic variation in the region around SNP rs9939609 in children. The major effect appears to be on energy intake and preference for foods of high caloric density. The magnitude of the increase in energy intake correlated with the A allele of this SNP is high enough to account for some or all of the differences in adiposity. No effect of genotype at rs9939609 on resting energy expenditure (corrected for body size) was detected, and physical activity was actually estimated to be increased in these children. Given the findings of studies of the molecular physiology of weight regulation, excess intake (rather than reduced basal energy expenditure) is probably the major mechanism for obesity in humans. Conducting studies of the contributions of genetic variation to the risk of obesity during the dynamic process of weight gain is crucial, because once a stable weight is reached, energy intake per unit of metabolic mass does not differ between obese and lean people.8
Two known genes lie within the implicated genetic interval. One is FTO (a locus associated with fat mass and obesity), which has been implicated in nucleic acid demethylation and is highly expressed in the arcuate nucleus of the hypothalamus; the other, called fantom, or FTM (KIAA1005 or RPGRIP1L), begins transcription at a location only 200 base pairs upstream from the 5' end of FTO. FTM is a structural component of the ciliary body, present on all cells, that plays a role in a wide range of cellular and organ functions.9 Elements of the cilium are mutant in Bardet–Biedl syndrome, which includes obesity among its characteristic phenotypes.10
Fasting decreases the expression of both FTO and FTM in the hypothalamus in murine models, suggesting that these molecules may function to suppress energy intake. One SNP (rs8050136) in intron 1 of FTO, which is located near rs9939609, encodes for a binding site for a transcription factor, cut-like 1 (CUTL1). Experimental reduction of CUTL1 transcript in human fibroblasts is associated with reduced expression of both FTO and FTM, consistent with their joint regulation in vivo.11 Both genes are plausible candidates for influencing energy homeostasis. It is possible, of course, that both genes are involved in conveying the strong statistical association of this genetic interval with obesity. In fact, a genomewide association study is inherently biased toward the discovery of intervals containing several contributing genes.
In the original genomewide association study conducted by Frayling et al.,7 the frequency of the rs9939609 A allele (increased obesity risk) was 0.45 in Europeans, 0.52 in West Africans, and 0.14 in Chinese. In their meta-analysis of available genomewide association study data (primarily in whites), the odds ratio for the A allele was 1.31 for obesity and 1.18 for overweight. Although the variance in BMI accounted for by rs9939609 was only 1%, the population attributable risks for overweight and obesity were 12.7% and 20.4%, respectively. Hence, although this locus accounts for only a small proportion of differences in the BMI in the entire population, it plays a substantial role — in these people, in these environments — in conveying the risk of actually becoming overweight or obese. In the Avon longitudinal study of parents and children (7477) in the United Kingdom, cited in Frayling et al.,7 each A allele increased BMI by about 0.4 by the age of 11 years, increasing the relative risk of obesity by 35% and overweight by 16%. The effect was not seen at birth but was apparent by 7 years and was due to increases in body fat alone.
The population attributable risk for obesity conveyed by the FTO–FTM region is high but probably not sufficient to support its use as a clinical screening tool, since the gene or genes responsible are not yet known, and no specific prophylactic or therapeutic intervention is yet apparent for this or other common genetic variants contributing to obesity (e.g., MC4R). However, the day is not too far off when we will, by "scoring" alleles of perhaps 15 to 20 such genes, be able to predict individual risk of type 2 diabetes, obesity, and other diseases. The important role that environment plays in enabling or resisting such susceptibility is clear evidence that such risk can be modified.
References
Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human adiposity. Behav Genet 1997;27:325-351. [CrossRef][ISI][Medline]
Mutch DM, Clément K. Unraveling the genetics of human obesity. PLoS Genet 2006;2:e188-e188. [CrossRef][Medline]
Rankinen T, Bouchard C. Genetics of food intake and eating behavior phenotypes in humans. Annu Rev Nutr 2006;26:413-434. [CrossRef][ISI][Medline]
Farooqi IS, Keogh JM, Yeo GS, Lank EJ, Cheetham T, O'Rahilly S. Clinical spectrum of obesity and mutations in the melanocortin 4 receptor gene. N Engl J Med 2003;348:1085-1095. [Free Full Text]
Pearson TA, Manolio TA. How to interpret a genome-wide association study. JAMA 2008;299:1335-1344. [Erratum, JAMA 2008;299:2150.] [Free Full Text]
Cecil JE, Tavendale R, Watt P, Hetherington MM, Palmer CNA. An obesity-associated FTO gene variant and increased energy intake in children. N Engl J Med 2008;359:2558-2566. [Free Full Text]
Frayling TM, Timpson NJ, Weedon MN, et al. A common variant in the FTO gene is associated with body mass index and predisposes to childhood and adult obesity. Science 2007;316:889-894. [Free Full Text]
Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. N Engl J Med 1995;332:621-628. [Erratum, N Engl J Med 1995;333:399.] [Free Full Text]
Singla V, Reiter JF. The primary cilium as the cell's antenna: signaling at a sensory organelle. Science 2006;313:629-633. [Free Full Text]
Ansley SJ, Badano JL, Blacque OE, et al. Basal body dysfunction is a likely cause of pleiotropic Bardet-Biedl syndrome. Nature 2003;425:628-633. [CrossRef][Medline]
Stratigopoulos G, Padilla SL, LeDuc CA, et al. Regulation of Fto/Ftm gene expression in mice and humans. Am J Physiol Regul Integr Comp Physiol 2008;294:R1185-R1196. [Erratum, Am J Physiol Regul Integr Comp Physiol 2008;295:R1360-R1363.] [Free Full Text]
Energy In, Energy Out, and the Effects of Obesity-Related Genes
Rudolph L. Leibel, M.D.
More than 100 genes have been implicated in the determination of body weight. These genes, acting primarily in or through the central nervous system (primarily the hypothalamus and brain stem), affect conscious and unconscious aspects of food intake and energy expenditure. They include genes mediating brain sensing of fat stores, calorie flux in the gut, hedonic responses to specific foods, rates of energy expenditure, and even inclination to physical activity.1,2,3 In some populations, mutations in one of these genes — the melanocortin 4 receptor (MC4R), which conveys hypothalamic signals suppressing food intake and increasing energy expenditure — can account for 3 to 5% of severe obesity (body-mass index [BMI] >40, with BMI defined as the weight in kilograms divided by the square of the height in meters).4 Other quantitatively significant single genes have been hard to identify. Possible reasons for this failure may be that obesity is so physiologically complex that no single gene or even handful of genes is likely to have a dispositive role, that examining gene–gene interactions is difficult without large numbers of subjects, and that variations among current candidate genes are not the most important contributors to human adiposity.
Enter the genomewide association study,5 which uses large numbers of common single-nucleotide polymorphisms (SNPs) in DNA spaced more or less evenly across the human genome to identify genetic variation associated with ordinal or cardinal phenotypes. Unlike the candidate-gene approach, the genomewide association study is genetically agnostic: it looks for genetic intervals associated with the phenotype or phenotypes; the constituent genes are "discovered" after the fact by examining those in the implicated interval. The fat mass and obesity–associated gene (FTO) examined in the article by Cecil et al. in this issue of the Journal6 was previously identified as a new obesity candidate by a genomewide association study.7
Frayling et al.7 found a strong association between SNPs (e.g., rs9939609) and adiposity in the first intron of FTO. This association has been replicated in several additional studies, using data on more than 80,000 adults and children. The statistical power of the association (P=~1.2x10–29) in the aggregate data is much higher than for any previous candidate-gene association study.
Cecil et al. studied the effects of genetic variation in the region around SNP rs9939609 in children. The major effect appears to be on energy intake and preference for foods of high caloric density. The magnitude of the increase in energy intake correlated with the A allele of this SNP is high enough to account for some or all of the differences in adiposity. No effect of genotype at rs9939609 on resting energy expenditure (corrected for body size) was detected, and physical activity was actually estimated to be increased in these children. Given the findings of studies of the molecular physiology of weight regulation, excess intake (rather than reduced basal energy expenditure) is probably the major mechanism for obesity in humans. Conducting studies of the contributions of genetic variation to the risk of obesity during the dynamic process of weight gain is crucial, because once a stable weight is reached, energy intake per unit of metabolic mass does not differ between obese and lean people.8
Two known genes lie within the implicated genetic interval. One is FTO (a locus associated with fat mass and obesity), which has been implicated in nucleic acid demethylation and is highly expressed in the arcuate nucleus of the hypothalamus; the other, called fantom, or FTM (KIAA1005 or RPGRIP1L), begins transcription at a location only 200 base pairs upstream from the 5' end of FTO. FTM is a structural component of the ciliary body, present on all cells, that plays a role in a wide range of cellular and organ functions.9 Elements of the cilium are mutant in Bardet–Biedl syndrome, which includes obesity among its characteristic phenotypes.10
Fasting decreases the expression of both FTO and FTM in the hypothalamus in murine models, suggesting that these molecules may function to suppress energy intake. One SNP (rs8050136) in intron 1 of FTO, which is located near rs9939609, encodes for a binding site for a transcription factor, cut-like 1 (CUTL1). Experimental reduction of CUTL1 transcript in human fibroblasts is associated with reduced expression of both FTO and FTM, consistent with their joint regulation in vivo.11 Both genes are plausible candidates for influencing energy homeostasis. It is possible, of course, that both genes are involved in conveying the strong statistical association of this genetic interval with obesity. In fact, a genomewide association study is inherently biased toward the discovery of intervals containing several contributing genes.
In the original genomewide association study conducted by Frayling et al.,7 the frequency of the rs9939609 A allele (increased obesity risk) was 0.45 in Europeans, 0.52 in West Africans, and 0.14 in Chinese. In their meta-analysis of available genomewide association study data (primarily in whites), the odds ratio for the A allele was 1.31 for obesity and 1.18 for overweight. Although the variance in BMI accounted for by rs9939609 was only 1%, the population attributable risks for overweight and obesity were 12.7% and 20.4%, respectively. Hence, although this locus accounts for only a small proportion of differences in the BMI in the entire population, it plays a substantial role — in these people, in these environments — in conveying the risk of actually becoming overweight or obese. In the Avon longitudinal study of parents and children (7477) in the United Kingdom, cited in Frayling et al.,7 each A allele increased BMI by about 0.4 by the age of 11 years, increasing the relative risk of obesity by 35% and overweight by 16%. The effect was not seen at birth but was apparent by 7 years and was due to increases in body fat alone.
The population attributable risk for obesity conveyed by the FTO–FTM region is high but probably not sufficient to support its use as a clinical screening tool, since the gene or genes responsible are not yet known, and no specific prophylactic or therapeutic intervention is yet apparent for this or other common genetic variants contributing to obesity (e.g., MC4R). However, the day is not too far off when we will, by "scoring" alleles of perhaps 15 to 20 such genes, be able to predict individual risk of type 2 diabetes, obesity, and other diseases. The important role that environment plays in enabling or resisting such susceptibility is clear evidence that such risk can be modified.
References
Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human adiposity. Behav Genet 1997;27:325-351. [CrossRef][ISI][Medline]
Mutch DM, Clément K. Unraveling the genetics of human obesity. PLoS Genet 2006;2:e188-e188. [CrossRef][Medline]
Rankinen T, Bouchard C. Genetics of food intake and eating behavior phenotypes in humans. Annu Rev Nutr 2006;26:413-434. [CrossRef][ISI][Medline]
Farooqi IS, Keogh JM, Yeo GS, Lank EJ, Cheetham T, O'Rahilly S. Clinical spectrum of obesity and mutations in the melanocortin 4 receptor gene. N Engl J Med 2003;348:1085-1095. [Free Full Text]
Pearson TA, Manolio TA. How to interpret a genome-wide association study. JAMA 2008;299:1335-1344. [Erratum, JAMA 2008;299:2150.] [Free Full Text]
Cecil JE, Tavendale R, Watt P, Hetherington MM, Palmer CNA. An obesity-associated FTO gene variant and increased energy intake in children. N Engl J Med 2008;359:2558-2566. [Free Full Text]
Frayling TM, Timpson NJ, Weedon MN, et al. A common variant in the FTO gene is associated with body mass index and predisposes to childhood and adult obesity. Science 2007;316:889-894. [Free Full Text]
Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. N Engl J Med 1995;332:621-628. [Erratum, N Engl J Med 1995;333:399.] [Free Full Text]
Singla V, Reiter JF. The primary cilium as the cell's antenna: signaling at a sensory organelle. Science 2006;313:629-633. [Free Full Text]
Ansley SJ, Badano JL, Blacque OE, et al. Basal body dysfunction is a likely cause of pleiotropic Bardet-Biedl syndrome. Nature 2003;425:628-633. [CrossRef][Medline]
Stratigopoulos G, Padilla SL, LeDuc CA, et al. Regulation of Fto/Ftm gene expression in mice and humans. Am J Physiol Regul Integr Comp Physiol 2008;294:R1185-R1196. [Erratum, Am J Physiol Regul Integr Comp Physiol 2008;295:R1360-R1363.] [Free Full Text]
Mittwoch, 10. Dezember 2008
Teaching on a ward round
Published 2 December 2008, doi:10.1136/bmj.a1930
Cite this as: BMJ 2008;337:a1930
Jean Ker1, Peter Cantillon2, Lucy Ambrose1
1 Clinical Skills Centre, University of Dundee, Ninewells Hospital, Dundee DD1 9SY , 2 Department of General Practice, National University of Ireland, Galway peter.cantillon@nuigalway.ie
Correspondence to: J Kerj.s.ker@dundee.ac.uk
A deliberate and planned approach to bedside teaching will make learning more effective
Teaching on a ward round has been compared to walking a tightrope. A clinical teacher has to balance the differing needs of undergraduate and graduate learners while providing a comprehensive and safe clinical service. Teaching in the presence of patients is an additional tension because the patient plays a central role and also is the most attentive member of the audience. Ward round teaching remains a powerful teaching context in medicine as it provides an authentic experience of the complexity of patient care and professional practice.1 2 The enduring value of the ward round lies in its potential to model professionalism, enhance clinical reasoning,3 and demonstrate the cultural norms of medical practice.4 5
We have developed six questions that can routinely be used to plan and deliver effective bedside teaching on ward rounds (fig 1
). The questions are derived from empirically based theories of experiential and situated learning.6 7 8
|
What is the plan (for teaching and learning)?
Most clinical teaching is done on the hoof, but ward based teaching is more effective if it is planned. This can be difficult on a busy ward. When the senior clinician arrives for a ward round, there is usually a brief conference with team members and then "off we go." However, taking five minutes at the start to think about the learners, the teaching opportunities, the teaching goals, and the tasks will increase the efficiency and effectiveness of teaching enormously.
It is important to consider what sort of ward round it is. For example, a ward round that follows a night when team members were on call (a post-take ward round) will be longer than usual but may offer more teaching opportunities. As a clinician you will be more focused on ensuring optimum patient care. Taking time in advance to think about how to share and distribute the teaching tasks would be well worth while.
Practical points
- Estimate the amount of time that you will need for listening to presentations, making decisions, and talking to patients. Then work out how much time you have for teaching. Remember that discussing the patients will usually take longer than you think.
- Speak to the on-call team before you start to identify patients for presentations that might allow focused teaching about history, physical examination, or patient management.
- Know who your learners are: use their names. This simple demonstration of respect from you will make a big difference to their self confidence.
- If time is short, send learners to assess a new admission ahead of the ward round team so that time can be spent on the detailed study of one patient’s case rather than a superficial skim through many patients.
- Alternatively, ask the learner(s) to stay behind after the ward round has moved on to stay with a patient so that they can explore this patient’s understanding of his or her condition and its management. Follow this up by offering to meet with the students at the end of the round to discuss the encounter.
What do the learners know?
Empirical educational theory has established that the quality of individuals’ learning depends to a great extent on what they already know.9 10 Learners make sense of new experiences by using their existing knowledge. Your role as a clinical teacher is to help learners build new understandings, elaborate their existing knowledge, and tackle misconceptions. Ward rounds provide opportunities for learners as apprentice practitioners to think about their knowledge in the context of patients.11
Practical points
- Identify learners’ level of clinical experience and knowledge by asking them about their stage of training, clinical rotations completed, and logged clinical experiences.
- Ask learners to summarise one or two patients from the last ward round they attended to get some sense of how sophisticated their understanding of patient care is.
- Ask learners if there are aspects of clinical practice that they find difficult to understand.
What can be achieved?
It is essential to agree in advance with learners what they need to learn. This provides a much needed focus to bedside teaching, which is often unpredictable. By using the learning needs that have been identified and taking cognisance of the learning opportunities that a ward round will offer, you can offer appropriate teaching for your learners.
Learning about team work
Ward rounds, whether conducted at the bedside or in the ward meeting room, provide opportunities for students to witness clinical teamwork and understand its value. Effective collaboration reduces hospital inpatient times and costs.12
Learning with and from documentation
Undergraduate students often have little understanding of how medical information is documented and stored. Preparing for and being involved in ward rounds gives them an opportunity to look through and understand healthcare records. You can ask students to write case notes based on their encounters with patients and give them feedback on the quality of their records.
Learning about safe decision making
Delivering care in a hospital setting has become more risky and complex in recent years.13 Ward rounds provide a powerful opportunity to both model and explain the risk assessments associated with every major decision.14
Learning professional behaviours
Clinical teachers should be aware that they are acting as role models for undergraduates and doctors in training as they work.15 16 Coaching, mentoring, and acting as a role model have been linked to error reduction and performance improvement within healthcare teams.17
Practical points
- Agree on the learning goals in advance. Aim to set a few, achievable goals, as less is more in clinical education.
- On the business ward round, set a theme to highlight, patient by patient. In this way, learning can be reinforced from patient to patient, maximising individuals’ learning.
Who will do the teaching?
It is essential to view the ward round as a unique opportunity for different teachers from different professions to participate in teaching. For example, including a pharmacist on the post-take ward round has been shown to be effective in improving the management of patients’ drugs.18 Including other health professionals as tutors reinforces learners’ sense of teamwork. By participating in this process, learners recognise the roles of different professional groups.
Practical points
- Before starting the ward round, agree to share your teaching role with other team members.
How can I help the students to learn?
The fifth question is deliberately worded to emphasise helping learners to learn, rather than the more traditional approach in which the teacher’s job was to transmit knowledge ("what do I want to teach?").
Directed observation
Rather than expecting students to know what to observe, tell them what to look for in clinical encounters: "Watch the way that I take a history from the next patient and tell me afterwards what you noticed." Experience has shown that this approach is especially useful with novice learners, who are often daunted by the ward round experience and do not know where to focus their attention.14 19
Give learners tasks
Medical students often feel "in the way" in clinical settings. Giving learners tasks that benefit the team makes them feel involved and engages them in purposeful activity.
Organise dedicated teaching rounds
Most clinical teams organise dedicated teaching rounds for undergraduate and postgraduate learners. Dedicated teaching rounds can be enhanced if the goals of the teaching round are made explicit in advance; patients are carefully selected (or even invited to attend from home) to match the learning needs and abilities of different grades of learner; and the teacher observes and provides feedback on learners’ performance.
Stop and summarise the learning
Learning opportunities on ward rounds can come thick and fast. Learners can become overwhelmed unless some effort is made to stop between patients to summarise what was learned.
Practical points
- Always attempt to observe what the learner does and provide timely feedback either at the bedside or in a suitable location immediately after the ward round.
- Wait for learners to answer your questions (count slowly to 10 in your head). Silence can be an effective tool in enabling learners to think and contribute to a discussion.
- Use validated checklists (examples are given by Caldwell14 and Norgaard et al20) to structure your evaluation of junior doctors’ performance on ward rounds.
How will I know what learning has been achieved?
Checking what has been learned is often the forgotten element of bedside teaching. It is vital to debrief learners after a ward round to highlight key points, uncover areas of uncertainty, and raise problems that could not be discussed at the bedside. It is also an important time to provide corrective feedback that might have been embarrassing to give in front of a patient.
Practical points
At the end of the ward round:
- Ensure that you or one of your fellow tutors reviews what has been learned with each group of learners. Use the learning summaries as your basis.
- Plan with learners what they need to look at or do before the next clinical encounter.
- Encourage learners to keep track of what they are learning by using a logbook or portfolio.
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Conclusion
Ward round teaching is here to stay, despite recent changes in doctors’ working patterns and the increasingly rapid turnover of patients occupying hospital beds. A deliberate and planned approach to bedside teaching will make effective learning much more likely. The critical success factors include establishing a safe learning environment, observing what learners do, and providing feedback in a timely fashion. Teachers should view each teaching ward round as an opportunity for both their learners’ and their own development.
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Cite this as: BMJ 2008;337:a1930
This series provides an update on practical teaching methods for busy clinicians who teach. The series advisers are Peter Cantillon, senior lecturer in the department of general practice at the National University of Ireland, Galway, Ireland, and Yvonne Steinert, professor of family medicine, associate dean for faculty development, and director of the Centre for Medical Education at McGill University, Montreal, Canada.
Contributors: All authors have given a substantial contribution to the conception and design of this article, drafted and revised the article, and have approved the final version of the article. JSK and LA are guarantors.
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
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