[Health-care reforms and insurees' preferences: a cluster analysis with data from the representative KBV survey 2010]. / Gesundheitsreformen und Versichertenpräferenzen. Eine Clusteranalyse mit Daten der bevölkerungsrepräsentativen KBV-Befragung 2010.

This study examines insurees' knowledge of and attitudes towards a number of recent reforms of the German healthcare system (electronic health insurance card, reimbursement tariff, etc.). It further examines whether it is possible to identify groups of respondents with similar patterns of preferences and knowledge. The analysis draws on a representative survey conducted by the German National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV, 2010), in which 6 065 respondents aged between 18 and 79 years were interviewed. 4 groups of respondents can be distinguished: the "quality oriented," the "uninformed," the "internet savvy," and the "informed." The most striking finding is that members of the "uninformed" group, who knew the least about recent reforms, tended to be employed middle-aged men with a high level of formal education. To foster the successful implementation of reforms in the health-care system and their communication to specific target groups, it is recommended to take into account not only specific social determinants, but the full personal circumstances and situation of insurees.

[Do gatekeeping programs increase equality of health care in Germany? A comparison of the health care situation of participants and nonparticipants]. / Führt das Hausarztmodell zu mehr Gleichheit im Gesundheitssystem? Ein Vergleich der Versorgungssituation von Hausarztmodellteilnehmern und Nichtteilnehmern.

This article compares the health care situation of participants in programs of general practitioner-centered health care (gatekeeping) in Germany (participants) with that of statutory health insurance holders who are not participating in such programs (nonparticipants). Because a key objective of the general practitioner model is to reduce the number of visits to specialists, the article also examines factors influencing frequent utilization of specialists in both groups. The analysis draws on a survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, 2010) based on a sample representative of the German population. In this context, 5,232 holders of statutory health insurance aged between 18 and 79 years were interviewed on health care policy issues. The results show that regulating the utilization of specialists through the gatekeeping function of general practitioners succeeds in facilitating similar utilization rates across educational levels, between cities and towns, and between men and women. Thus, gatekeeping programs contribute to the reduction of health care inequalities.

[Knowledge and evaluation of health-system reforms as reflected in social determinants]. / Kenntnisstand und Bewertung gesundheitspolitischer Reformen im Spiegel sozialer Determinanten.

Significant reforms have been instituted in Germany's health system in recent years. Although a number of studies have examined the population's knowledge of and attitudes towards the new regulations, little information is available on status-specific differences. This article examines the extent to which knowledge and evaluation of health policy measures is influenced by social determinants. The analysis draws on a survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, 2009) based on a sample representative of the German population. In this context, 2 032 respondents aged between 18 and 79 years were interviewed on health-care policy issues. Results of bivariate analysis and logistic regression show that knowledge of the reform measures is significantly associated with educational level, age, and nationality. For example, respondents with the lowest level of formal education have an approximately four times higher risk as those with a higher level of formal education of not knowing about the health fund, and non-Germans have around twice the risk as Germans of not knowing about the reform measures. The main difference to emerge in respondents' EVALUATION of the reform measures is between East and West Germans. West Germans are significantly more likely than East Germans to evaluate the reform measures in negative terms. These status-specific differences in respondent knowledge can be attributed at least to some extent to the information asymmetry between patients and physicians/health-care providers. There is an urgent need for policy makers and care providers to render the reform measures transparent, accessible and comprehensible - especially to disadvantaged groups - to facilitate their effective implementation and positive evaluation.

[Women and smoking. A challenge for the tobacco control policy in Germany]. / Frauen und Rauchen. Herausforderung für die Tabakkontrollpolitik in Deutschland.

In Germany, smoking rates among women have been slightly declining since 2003. However, smoking rates among young women and girls are high and are reaching the smoking rates of their male counterparts. Only about half of pregnant smokers below the age of 25 stop smoking. Women and girls with low education and low level jobs, those who are unemployed, as well as single parents have the highest smoking rates. The tobacco industry promotes smoking behavior of women and girls through marketing campaigns, thus, systematically counteracting smoking prevention activities. Within the framework of the annual conference 2008 of the Federal Drug Commissioner on the theme of "Women and Smoking", recommendations for a gender-specific tobacco control policy in Germany were developed. The main demands relate to the necessity of a targeted policy approach which takes into account the needs and life circumstances of women and girls, the development of integrated prevention programs for pregnant women, improved medical and preventive care, the involvement of women from the media and culture, from health professions and politics to promote a smoke-free culture, gender-specific research, and the improvement of tobacco control legislation. FACT (Frauen aktiv contra Tabak e.V.) actively supports the implementation of these policy recommendations.

[Statutory ambulatory medical care through the eyes of the health insurance beneficiaries--methods and results of the 2006 NASHIP Health Insurance Beneficiary survey: care utilisation, primary care, and emergency medical services]. / Die ambulante vertragsärztliche Versorgung aus der Perspektive der Versicherten--Methodik und Ergebnisse der KBV-Versichertenbefragung 2006: Inanspruchnahme, Versorgung beim Hausarzt, Bereitschafts- und Notdienstpraxen.

OBJECTIVE: The aim of this study was to obtain valid information on the delivery of ambulatory medical care from the point of view of the health insurance beneficiaries. The National Association of Statutory Health Insurance Physicians (NASHIP) conducted in 2006 for the first time a nationally representative telephone survey. The survey set out to gather information on health care utilisation, patients' experiences and satisfaction with care delivery, and to provide an indication for the further development of the services offered. METHODS: Between 22 May and 8 June 2006, a random sample of 4 315 inhabitants from 18 to 79 years of age was interviewed using a computer-assisted telephone interview (CATI). The questionnaire included 51 questions relating to six topics, and consisted of a core set of questions and supplementary questions dealing with further details or special issues. One section of the 2006 survey focused on emergency medical services. In the analysis, samples were weighted to reflect the distribution of the population by age and sex. RESULTS: 82% of survey participants have visited a doctor's office in the last 12 months, and 93% indicated to have a regular general practitioner (GP) they consult for medical problems or health advice. Referring to all respondents, the mean number of consultations in a doctor's office was about 5 per year. Over 90% of respondents having a regular GP arrive at the office within 20 min, and for 61% home visits by their regular doctor are very important or important. 90% of respondents having seen the GP during the last 12 months assess the medical care received as very good or good. The places contacted when the regular office is closed are clearly varying by region and respondent's age. Whereas younger people primarily consult the hospital emergency department, the importance of the general practitioner in the case of an emergency increases with age. Overall, 29% preferentially turn to a hospital or hospital emergency department, another 25% to outpatient emergency medical services, and scarcely 16% to their regular GP. 61% of survey participants or their close relatives have already utilised emergency medical services (EMS). Regarding the last case of a medical emergency, in 3 out of 5 cases patients went themselves to the emergency service. A total of 74% of patients assess the care received by the emergency medical service as very good or good. Evaluations are less favourable in the event of prolonged waiting time for the emergency medical doctor at home or in the EMS office. CONCLUSION: The NASHIP health insurance beneficiary survey reflects a broadening patient and service orientation and provides valid information on ambulatory medical care through the eyes of the insurance beneficiaries. The survey depicts high overall satisfaction with primary care, a high degree of trust in the doctor's medical competence, and easily accessible services. Patient evaluations of outpatient emergency medical care are mainly positive, but still show room for improvement.

Accumulation of iron and arsenic in the Chandina alluvium of the lower delta plain, Southeastern Bangladesh.

Accumulations of iron, manganese, and arsenic occur in the Chandina alluvium of southeastern Bangladesh within 2.5 m of the ground surface. These distinctive orange-brown horizons are subhorizontal and consistently occur within 1 m of the contact of the aerated (yellow-brown) and water-saturated (gray) sediment. Ferric oxyhydroxide precipitates that define the horizons form by oxidation of reduced iron in pore waters near the top of the saturated zone when exposed to air in the unsaturated sediment. Hydrous Fe-oxide has a high specific surface area and thus a high adsorption capacity that absorbs the bulk of arsenic also present in the reduced pore water, resulting in accumulations containing as much as 280 ppm arsenic. The steep redox gradient that characterizes the transition of saturated and unsaturated sediment also favors accumulation of manganese oxides in the oxidized sediment. Anomalous concentrations of phosphate and molybdenum also detected in the ferric oxyhydroxide-enriched sediment are attributed to sorption processes.

Cytokine profile of bronchoalveolar lavage-derived CD4(+), CD8(+), and gammadelta T cells in people with asthma after segmental allergen challenge.

T cell-derived cytokines play an important role in the pathogenesis of allergic asthma, but little is known about the cytokine profile of their different subsets. The aim of the present study was to investigate the cytokine production potential of CD4(+), CD8(+), or gammadelta(+) T cells derived from the bronchoalveolar space of mild atopic asthmatic subjects (n = 11) and nonatopic control subjects (n = 9) before and 24 h after segmental allergen challenge. The cytokine production was determined using the technique of intracellular cytokine detection by flow cytometry. Comparing asthmatic with control subjects we found no difference in the percentage of CD4(+), CD8(+), or gammadelta T cells in the bronchoalveolar lavage fluid before and after allergen challenge. Before allergen challenge the proportion of cells producing the cytokines interferon (IFN)-gamma, interleukin (IL)-2, IL-4, IL-5, and IL-13 was not different in CD4(+) and CD8(+) cells. The major difference between the groups was an increased percentage of positive-staining cells for the T helper-(Th)2-cytokines IL-5 and IL-13 in the gammadelta T-cell subset. After allergen challenge, all T-cell subsets revealed a decreased proportion of cells producing the Th1-type cytokines IFN-gamma and IL-2. The percentage of IL-4- and IL-5-positive cells did not change in all subsets, and there was a decreased proportion of IL-13- positive cells in the CD4(+) subset. These findings indicate an increased Th2-cytokine profile in gammadelta T cells. After allergen challenge, the dysbalance between Th1 and Th2 cytokines was further accentuated by a reduction in Th1 cytokine-producing T cells.

Interleukin 16 and T-cell chemoattractant activity in bronchoalveolar lavage 24 hours after allergen challenge in asthma.

IL-16 has been shown to be one of the earliest CD4(+) cell chemoattractants present in BAL 4-6 h after antigen challenge but little is known about its persistence and biological activity after 6 h. We determined the concentration of IL-16 using ELISA and the T-cell chemoattractant activity using a modified Boyden chamber assay in unconcentrated BAL fluid from 13 patients with mild asthma and 9 nonatopic control subjects at baseline and 24 h after segmental allergen or saline challenge. Furthermore, the percentage of IL-16-producing T cells was determined in the different samples of BAL fluid using a flow cytometric intracellular cytokine assay. Although no substantial levels of IL-16 protein were detectable in BAL fluid from control subjects and patients with asthma at baseline and after saline challenge, IL-16 concentrations were significantly elevated in patients with asthma after allergen challenge (median, 97 pg/ml; range, 38-362 pg/ml; p < 0.01). Furthermore, there was an increased T-cell chemoattractant activity after allergen challenge in patients with asthma (p < 0.01), which could be blocked by preincubation with anti-IL-16 antibodies and which correlated significantly with the IL-16 protein levels (R = 0.90, p < 0.01) and with the level of Fas ligand expression on BAL CD4(+) cells (R = 0. 80, p < 0.05). A high percentage (mean 70-90%) of CD4(+) and CD8(+) cells stained positively for IL-16 in both patients with asthma and control subjects without differences after allergen or saline challenge. These data demonstrate that the increased chemotactic activity for T cells in patients with asthma is mainly attributable to IL-16. Although T cells by themselves are able to produce IL-16, other cells, such as epithelial cells, have to be considered as further sources for this cytokine in patients with asthma.

Dysfunction of pulmonary surfactant in asthmatics after segmental allergen challenge.

Increased airway resistance in asthma may be partly due to poor function of pulmonary surfactant. This study investigated the inflammatory changes of bronchoalveolar lavage fluid (BALF) and the performance of BALF surfactant in healthy control subjects (n = 9) and patients with mild allergic asthma (n = 15) before and after segmental challenge. BALF was obtained for baseline values, and 24 h after challenge with saline solution in one lung segment and with allergen in another. Cell counts, phospholipid and protein concentrations, and ratios of small to large surfactant aggregates (SA/LA) were analyzed. Surface tension was determined with a pulsating bubble surfactometer, and the ability of the BALF surfactant to maintain airway patency was assessed with a capillary surfactometer. Baseline values of control subjects and asthmatics were not different. Challenge with saline and antigen raised total inflammatory cells in both control subjects and asthmatics. Allergen challenge of asthmatics, but not of healthy volunteers, significantly increased eosinophils, proteins, SA/ LA, and surface tension at minimum bubble size, and diminished the time the capillary tube is open. In conclusion, allergen challenge in asthmatics induced surfactant dysfunction, probably mainly because of inhibiting proteins. During an asthma attack, narrow conducting airways may become blocked, which might contribute to an increased airway resistance.

Enhanced expression of fas ligand (CD95L) on T cells after segmental allergen provocation in asthma.

BACKGROUND: Little is known about the termination of the T-cell driven inflammation found in patients with allergic asthma. OBJECTIVE: Because signals delivered through Fas/Fas ligand can lead to T-cell apoptosis, we investigated the expression of Fas and Fas ligand on peripheral blood- and bronchoalveolar lavage fluid (BALF)-derived T cells and the percentage of apoptotic BALF cells in asthma. METHODS: Nine atopic subjects with mild asthma and 9 control subjects underwent segmental sham and allergen challenge. Flow cytometry was used to determine the T-cell expression of Fas and Fas ligand, and the terminal dUTP nick end labeled technique was applied to detect apoptotic BALF cells. RESULTS: In asthmatic and control subjects almost all T cells in the BALF expressed Fas antigen without changes after saline or allergen challenge. A small percentage of T cells in BALF expressed the Fas ligand. In asthmatic subjects, but not in control subjects, there was a significant increase in Fas ligand after allergen challenge (CD3: 0.8% +/- 0.6% [baseline] vs 3.2% +/- 1.2% [allergen challenge]; CD4: 1.8% +/- 0.0% vs 4.3% +/- 1.8%; CD8: 2.8% +/- 2.4% vs 9.1% +/- 4.8%) but not after saline challenge, with a significant correlation to the percentage of BALF eosinophils. Apoptotic BALF cells were localized exclusively in macrophages at a very low frequency (0.03% to 0.15%) and without changes after saline or allergen challenge in both groups. CONCLUSION: In asthma there is an upregulation of Fas ligand on T cells in BALF after allergen challenge. Because there is no evidence for increased apoptosis, this phenomenon may reflect antigen-induced T-cell activation rather than apoptosis.

[Status of health policy and possible support to self-help groups]. / Gesundheitspolitischer Stellenwert und Unterstützungsmöglichkeiten von Selbsthilfegruppen.

Self-help groups strengthen an individual's sense of autonomy and self-determination, and help to recover from diseases and other health-related problems. Participants mutually support each other within the group to promote a healthier approach to socio-psychological issues; they also conduct activities outside the group, especially counselling services for peers dealing with similar problems. In recent years, the number of groups throughout Germany rosen to approximately 60,000. The groups are mainly supported by self-help clearinghouses which have sprung up in many regions of western and eastern Germany over the last few years. This paper provides an overview of the development of self-help groups as well as the current state of support and funding in this area. Furthermore, it describes in detail the work performed by clearinghouses and the possibilities for cooperation with these new "liaison institutions".