[Hypersalivation - inauguration of the S2k Guideline (AWMF) in short form]. / Hypersalivation - Ersterstellung der S2k-Leitlinie (AWMF) in gekürzter Darstellung.

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This reduces social interaction chances and burdens daily care. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, and saliva aspiration. Therefore, a multidisciplinary S2k guideline was developed. Diagnostic tools such as fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing studies generate important data on therapy selection and control. Especially traumatic and oncologic cases profit from swallowing therapy programmes in order to activate compensation mechanisms. In children with hypotonic oral muscles, oralstimulation plates can induce a relevant symptom release because of the improved lip closure. In acute hypersalivation, the pharmacologic treatment with glycopyrrolate and scopolamine in various applications is useful but its value in long-term usage critical. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Surgical treatment should be reserved for isolated cases. External radiation is judged as ultima ratio. Therapy effects and symptom severity has to be followed, especially in neurodegenerative cases. The resulting xerostomia should be critically evaluated by the responsible physician regarding oral and dental hygiene.

[Splitting of supplemental revenues in intensive care medicine]. / Erlöszuordnung von Zusatzentgelten in der Intensivmedizin.

In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs.

Randomized placebo-controlled study of recombinant human interleukin-11 to prevent chemotherapy-induced thrombocytopenia in patients with breast cancer receiving dose-intensive cyclophosphamide and doxorubicin.

PURPOSE: Thrombocytopenia may compromise cancer treatment, causing chemotherapy dose reductions, schedule alterations, or the need for platelet transfusions. We evaluated the efficacy and safety of recombinant human interleukin-11 (rhIL-11; Neumega, Genetics Institute, Inc, Cambridge, MA), a novel thrombopoietic growth factor, in reducing the need for platelet transfusions in patients who undergo dose-intensive chemotherapy. PATIENTS AND METHODS: Women with advanced breast cancer received cyclophosphamide (3,200 mg/m2) and doxorubicin (75 mg/m2) plus granulocyte colony-stimulating factor (G-CSF; 5 microg/kg/d). Patients were randomized to blinded treatment with placebo or 50 microg/kg/d rhIL-11 subcutaneously for 10 or 17 days after the first two chemotherapy cycles. RESULTS: Seventy-seven patients were randomized and constitute the intent-to-treat (ITT) population. Sixty-seven patients (the assessable subgroup) either completed both cycles without a major protocol violation (n = 62) or received a platelet transfusion before treatment was discontinued after the first cycle. In the ITT population, rhIL-11 significantly decreased the requirement for platelet transfusions; 27 of 40 (68%) patients who received rhIL-11 did not require transfusions, compared with 15 of 37 (41%) in the placebo group (P = .04). Treatment with rhIL-11 significantly reduced the total number of platelet transfusions required in the assessable subgroup (P = .03) and the time to platelet recovery to more than 50,000/microL in the second cycle (P = .01). Most adverse events associated with rhIL-11 were reversible, mild to moderate in severity, and likely related to fluid retention. CONCLUSION: rhIL-11 is safe and effective in reducing treatment-associated thrombocytopenia and the need for platelet transfusions in patients who undergo dose-intensive chemotherapy, and thus may permit chemotherapy to be administered as planned at intended doses and thereby maximize the potential for a successful outcome.

Improving the quality of healthcare for children: implementing the results of the AHSR research agenda conference.

OBJECTIVE: To describe the rationale, development, content, and results of the AHSR-sponsored conference on developing a research agenda focused on improving the quality of care for children. DATA SOURCES AND METHODS: Planning documents, background papers, and conference proceedings. PRINCIPAL FINDINGS: The conference developed the research agenda focused on (1) monitoring the health of children; (2) evaluating the efficacy and effectiveness of health services for children; (3) assessing the quality of healthcare provided to children; (4) improving the quality of healthcare within health systems; (5) assessing the performance of community systems for children; (6) exploring the impact of different financial incentives on the provision of pediatric healthcare; and (7) developing and disseminating clinical practice guidelines and other information to physicians, families, and consumers. Specific issues and research questions in each area are also presented. Strategies for implementing the research agenda are presented and include: (1) expanding the child health services research workforce; (2) developing child healthcare quality improvement research centers; (3) conducting research in specific high-priority areas; (4) focusing research on improving the health of vulnerable populations; (5) improving child health data and collection systems at the national level; (6) developing better community health monitoring for children; (7) building and supporting research networks and a consortium of research users; and (8) developing a coordinated interagency federal effort to advance this agenda and to provide accountability for its completion. CONCLUSION: The proposed research agenda should be a national priority so that all Americans can be assured that children are receiving the best quality of care that the United States can provide.

Central pontine myelinolysis despite slow sodium rise in a case of severe community-acquired hyponatraemia.

The management of severe hyponatraemia is a challenging task for intensivists. It should be based on underlying pathophysiology, especially the duration of hyponatraemia (acute vs. chronic) and the presence or absence of severe neurologic symptoms. We describe a case of severe community-acquired hyponatraemia in which central pontine myelinolysis developed several days after discharge from the intensive care unit, despite a gradual increase of plasma sodium levels during the intensive care unit stay.

[Therapy for unilateral vocal fold palsy]. / Therapie der einseitigen Stimmlippenparese.

The main symptom of unilateral vocal fold palsy is hoarseness, which can cause considerable disturbance to the patient depending on its extent and the patient's individual situation. Therapy aims at the restitution of a tuneful and resilient voice, which can be achieved by surgical or conservative means, improving the glottal closure and synchronizing the vocal fold vibrations during phonation. Vocal therapy is a common conservative method that may be supported by psychotherapeutic or physical procedures. In surgical therapy, there is a distinction between techniques of endoscopic augmentation by injecting different materials into the vocal folds and transcutaneous laryngeal framework surgery, i.e., transferring the paralyzed vocal fold to the glottal midline. Particularly apt for injection are biocompatible materials amount and position whose can easily be controlled. However, the inevitable resorption of many materials causes deterioration in voice quality. Furthermore, the change of vocal fold morphology obstructs regular phonatory vibration. On the other hand, medialization thyroplasty leads to permanent voice amelioration without a substantial complication rate when performed by experienced surgeons.

[Does patient satisfaction correlate with pain level during patient-monitored epidural analgesia. Evaluation of data from postoperative pain service]. / Korreliert die Patientenzufriedenheit mit dem Schmerzniveau bei der Anwendung von patientenkontrollierter Epiduralanalgesie?Evaluation der Daten eines postoperativen Schmerzdienstes.

INTRODUCTION: The evaluation of patients' satisfaction and outcome after surgery is of increasing importance. An optimized postoperative pain management may contribute substantially to this important goal. METHODS: After approval of the local ethics committee and written informed consent, 150 adult patients receiving epidural catheters for postoperative pain management were evaluated over 1 week postoperatively with respect to their satisfaction with the pain therapy and incidence of side effects. All patients received a continuous epidural infusion with ropivacaine 0.2% plus sufentanil 0.5 microg/ml via a PCEA pump (basal rate 6-8 ml/h, bolus 2 ml, lockout time 5 min). For assessment of pain the VAS scale (0-100 mm) was used, and patients' satisfaction was evaluated using a numeric rating scale (1-6, 1=very good, 6=very dissatisfied). RESULTS: Of the patients, 95 were operated in general surgery, 32 in orthopedics, and 23 in gynecology. Time of treatment with epidural catheters (71% thoracic, 29% lumbar catheters) was 5.1 +/- 2.9 days. Of the patients, 87.8% evaluated the postoperative pain service as very good or good, and 89% of the patients would choose the same pain therapy again. Side effects mainly consisted in bladder dysfunction (19%) and intermittent motor blockade (18%) especially with lumbar catheters. Correlation between patient satisfaction and the remembered maximum pain levels was low ( r=0.266). CONCLUSION: Evaluation of patients' satisfaction with postoperative epidural pain therapy resulted in a high degree of satisfaction without correlation between patients' satisfaction and recalled maximum pain levels. These results, including side effects and special problems during pain therapy, provide motivation to further improve postoperative pain management.

Students' acquisition and use of school condoms in a high school condom availability program.

OBJECTIVES: To determine what students know about a condom availability program in their high school, how they react to the program, whether they obtain condoms from it, and what they do with these condoms. DESIGN: Self-administered anonymous survey conducted 1 year after the program began. SETTING: An urban California school district. PARTICIPANTS: A total of 1112 students, 9th through 12th grade, 59% of eligible students present on the survey day. MAIN OUTCOME MEASURES: History of obtaining condoms from the program, use of these condoms, knowledge about the program, and attitudes toward the program. RESULTS: Forty-eight percent of students had personally taken school condoms, and another 5% had gotten them from someone else, for a total of 53% who had obtained school condoms. Seventy percent of nonvirgins and 38% of virgins obtained condoms. Males were more likely than females to have obtained condoms (60% vs 45%). Fifty-four percent of students who had obtained school condoms had used them for sexual activity: 52% had used them for vaginal intercourse, 7% for anal intercourse, and 4% for fellatio. Students also explored school condoms without having sex, eg, removing them from the packet, putting them on fingers, or putting them on their penis or a partner's penis. Thirty-four percent of students who had used a condom for vaginal intercourse during the previous year had obtained the condom they last used from school, with more males than females reporting the school as their source (41% vs 26%). Eighty-eight percent of students knew that all students were allowed to obtain condoms, and 74% knew that parental permission was not required. Students generally supported the condom program: 88% thought the school should give out condoms, and 79% thought that if the school were to require parental permission for students to get condoms, students would get them less often than with the present system (which does not require permission). Thirteen percent agreed and 71% disagreed that "having condoms available at school makes it harder for someone who doesn't want to have sex to say no." CONCLUSIONS: Providing high school students with direct access to condoms leads to widespread use of school condoms, both for sexual activity and for exploratory activities that familiarize students with condoms. Condoms are of interest to both students who have and students who have not engaged in sexual activities for which condoms are recommended.

Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention.

OBJECTIVE: To evaluate a case management/home visitation intervention to improve access to and utilization of well-child care (WCC) visits. STUDY DESIGN: Randomized, controlled trial with baseline and follow-up interview surveys. Mothers and infants in the intervention group were assigned to a case manager who made at least four home visits during the infant's first year of life. In addition, the case managers contacted clients by telephone and mail to see if they had kept their WCC appointments and to follow up on other issues. SAMPLE AND DATA COLLECTION: A population-based random sample of African-American mothers of newborns from South Central Los Angeles: 185 mothers in the intervention group and 180 in the control group completed both interview surveys. The principal outcome variable was number of WCC visits. Additional outcome variables included the child's type of insurance, the number of months with insurance coverage during the first year of life, age when first enrolled in Medi-Cal, age at the first WCC visit, usual source of WCC, travel time to the usual source of care, whether the child had a regular provider, and whether the child ever needed care but did not get it. RESULTS: There was little change in the overall distribution of number of WCC visits during the first year of life. Comparisons of the cumulative numbers of visits for each possible cutoff showed that children in the intervention group were more likely than children in the control group to have at least four visits (81% vs 70%). Because this split was identified empirically rather than through an antecedent hypothesis, we conducted a Smirnov test to account for multiple comparisons. This test showed a reduced level of significance. Other outcome variables did not show significant differences for the control and intervention groups. CONCLUSIONS: In light of the high expense of this intervention, our evaluation shows that our moderate-intensity case management and home visitation program is not an effective way to increase the number of WCC visits.

Promoting adolescent health: worksite-based interventions with parents of adolescents.

A promising public health approach for reducing adolescent risk behavior is to recognize and support the role of parents in promoting healthful behaviors. Although there are various settings where parents can be reached, this article focuses on one particular setting--the parent's place of employment. The article discusses the development and implementation of parenting programs for parents of adolescents. Such programs are new and should be evaluated to determine whether they are effective.