Multiple giant coronary artery aneurysms: a case report.

BACKGROUND: Coronary artery aneurysm is defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. Giant aneurysms are those aneurysms that measure greater than 2cm in diameter. There have been many pathologic diseases, including atherosclerosis, that have been implicated in the development of coronary artery aneurysms. MATERIALS AND METHODS: We report a case of a 61-year-old African American male with multiple comorbidities including hypertension, congestive heart failure, abdominal aortic aneurysm, and bilateral iliac aneurysms, who was admitted to our hospital with exacerbation of congestive heart failure. Less than 2weeks after admission, the patient suffered cardiac arrest while receiving dialysis and was unresponsive to resuscitative measures. FINDINGS: Autopsy was performed and revealed significant cardiomyopathy and giant coronary artery aneurysms involving the left anterior descending, left circumflex, and right coronary arteries. Both ventricles showed hypertrophy and dilation with multifocal areas of chronic myocardial scarring. CONCLUSIONS: Coronary artery aneurysms and giant coronary artery aneurysms are an uncommon. As there are few reported cases in the literature, the cause, detection, and treatment of this disease are still largely unknown.

[The ICF in use: testing of a new concept in four clinics]. / Praktische Nutzung der ICF: Erprobung eines neuen Ansatzes in vier Kliniken.

The International Classification of Functioning, Disability and Health (ICF) consists of more than 1 400 items. Due to its size and complexity, using the ICF is hardly feasible in practice. Moreover, the severity of problems is given only on a five-point scale (qualifiers), which seems too insensitive for measurement of changes. Thus, in cooperation with four rehabilitation hospitals, Jacobi, Urban & Kaluscha have identified 148 relevant items for musculoskeletal diseases. For easier usage we assigned mnemonic three letter codes to these items, e. g. WAL for the item "Walking" (ICF d450). Then the physician assigns those few items which he and/or the patient consider most important. The severity of the problem is judged on a scale from 0 (no restriction) to 100 (maximum restriction) for each item. By drawing a bar on the scale the physician gives an interval instead of just a single point (fuzzy judgement). The centre of the interval represents the severity of the problem and the width represents the uncertainty of judgement, e. g. when there is no gold standard for measurement or when the problem varies with time. As both the assignment of descriptors from an item pool and the fuzzy judgements are a new approach to medical documentation, we carried out this pilot study to examine acceptance and feasibility of the approach. In the pilot study, 264 in-patients in four rehabilitation clinics have been included. 138 (94%) of the 148 descriptors in the item pool have been used. Altogether there were 1,764 single judgements. On average six descriptors per patient have been assigned, giving an efficient and precise individual documentation. This is an advantage of the documentation principle called combination of terms compared to the principle of classification. In contrast to the ICF core sets patients may get individual sets of descriptors as appropriate. On discharge, the judgements were about 25 points better compared to admission. During treatment the fluctuations of disorders decreased and the certainty of the judgements increased, resulting in reduction of interval width of 2.8 points. The feedback of the rehabilitation clinics involved showed good acceptance and feasibility. Our data can easily be mapped into the ICF. In addition to ICF core sets, our approach could facilitate the use of the ICF in practical settings.

[Decisions in case of "problematic" cost-effectiveness ratios based on the example of a clinical trial in rehabilitation care]. / Entscheidungen bei "schwierigen" Kosteneffektivitätsrelationen am Beispiel eines klinischen Versuchs aus der Rehabilitation.

PURPOSE: Economic assessment of an additional psychological intervention in the rehabilitation of patients with chronic low-back pain and evaluation of results by decision makers. METHODS: Piggy-back cost-utility analysis of a randomised clinical trial, including a bootstrap analysis. Costs were measured by using the cost accounting systems of the rehabilitation clinics and by surveying patients. Health-related quality of life was measured using the EQ-5D. Implications of different representations of the decision problem and corresponding decision rules concerning the cost-effectiveness plane are discussed. RESULTS: As compared with the 126 patients of the control arm, the 98 patients in the intervention arm gained 3.5 days in perfect health on average as well as 1219 euro cost saving. However, because of the uncertainty involved, the results of a bootstrap analysis cover all quadrants of the cost-effectiveness plane. Using maximum willingness-to-pay per effect unit gained, decision rules can be defined for parts of the cost-effectiveness plane. These have to be aggregated in a further valuation step. CONCLUSIONS: Study results show that decisions on stochastic economic evaluation results may require an additional valuation step aggregating the various parts of the cost-effectiveness plane.

Unexpected hospital-acquired bacteraemia in patients at low risk of bloodstream infection: the role of a heparin drip.

Following a cluster of cases of unexpected hospital-acquired bacteraemia suspected to be related to an intravenous (iv) heparin drip, all cases of hospital-acquired primary bloodstream infection (BSI) in patients at low risk of bacteraemia were analysed over a four-year period. Ninety-six bacteraemic patients (6%) from 1618 episodes of hospital-acquired bacteraemia had a peripheral iv line as the only risk factor. These patients were divided into two groups: 60 patients with phlebitis and 36 without local signs of inflammation. Baseline features of the two groups were comparable, but in univariate and multivariate analysis, a significant association was found between iv heparin use, predominance of Gram-negative organisms (especially Klebsiella, Serratia and Enterobacter species), and absence of phlebitis. In spite of clear statistical association, however, the means by which the heparin solution became contaminated with Gram-negative organisms remained unknown. Following implementation of infection control methods concerning heparin handling, no more cases occurred. Unexpected hospital-acquired Gram-negative bacteraemia in patients with peripheral iv lines should prompt investigation of potential infusate-related infection, especially in patients without phlebitis and those receiving iv heparin.

[The patient's signature of the physician's report at discharge from rehabilitation]. / Die Patientenunterschrift im ärztlichen Reha-Entlassungsbericht.

What follows for the outcome of rehabilitation, patients' satisfaction and work organisation in a rehabilitation hospital if the patients obtain their discharge reports for signature before they leave? This has been investigated in a pilot study at the University Rehabilitation Hospital in Bad Wurzach, Germany. The pilot study was so successful that the hospital continued to use the new procedure. Only very few refused their signature, most patients were happy to obtain their discharge reports immediately and to have the opportunity to discuss the report with their physician if desired. Physician judged patients' participation slightly more pointly while the known discrepancies between physicians' and patients' point of view remained, i. e. the physician doesn't "touch up" knowing the patient will read his report. Integrating the patient in the process is a major step towards patients' empowerment. Both the influence on patients' satisfaction and changes in work organisation are discussed in the paper. A timely discharge examination and an optimised computer-supported workflow, transformation of loosely coupled activities in a process managed by time frames are preconditions for being able to have the discharge report ready before the patients leave. Monitoring the timely delivery then becomes obsolete.

[The prognostic value of variables from the quality assurance program and of the rehabilitation-discharge report of the LVA Baden-Württemberg for early retirement: results of a retrospective cohort-study]. / Die prognostische Bedeutung von Variablen aus dem Qualitätssicherungsprogramm und dem Reha-Entlassungsbericht der LVA Baden-Württemberg für die Erwerbs- oder Berufsunfähigkeit: Ergebnisse einer retrospektiven Kohortenstudie.

Since 1997 the LVA Baden-Württemberg pension insurance agency has implemented an instrument to measure the outcome quality of in-patient rehabilitation. The objective of this study was to evaluate the prognostic value of various short-term rehabilitation success markers and of variables of the quality assurance program and the rehab-discharge report of the LVA Baden-Württemberg on early retirement by means of a retrospective cohort study. The analysis was based on routinely registered data of patients who underwent in-hospital rehabilitation in a hospital accredited by the LVA Baden-Württemberg between June 1997 and June 1999. Baseline data included information from medical discharge reports and from the quality assurance programme. Follow-up information with regard to disability was collected until July 2000. The prognostic value of the quality assurance programme and of 4 standardized documented items from the medical discharge report was estimated by proportional hazards regression. In this analysis 6,823 patients aged 30-59 years who underwent an in-patient rehab programme between June 1997 and July 1999 in 5 of 6 LVA rehab clinics were included. During follow-up (mean duration: 1.8 years) 908 (13.3%) patients retired because of health-related disability. The variables with the strongest prognostic values were the evaluation of the patient health status by the physician and the patients themselves and the capacity to work. The variables with the highest prognostic value were the evaluation on a 1-6 visual analogue scale; a better assessment by one mark of the health status by physician and patient himself, respectively, was associated with a 53% and 40% reduced risk of disability. Fitness for work at discharge was the most prognostic variable from the discharge report. Patients who were able to work had a 78% reduced risk of disability compared to patients unable to work. Also of prognostic relevance were a positive performance and the duration of the inability to work the year before rehabilitation. The variables of the newly developed quality assurance programme of the LVA clearly demonstrated a prognostic value in terms of risk for subsequent early retirement. It should be considered to include the ability to work at discharge in the programme to further improve its prognostic value.

[Cost evaluation by a patient questionnaire: pilot study of a weekly cost diary]. / Kostenmessung durch Patientenbefragung: Pilotstudie zu einem Kostenwochenbuch.

Weekly cost diaries are instruments to measure direct and indirect costs prospectively by using patient data. First we searched MEDLINE for information concerning the use of diaries in health care and their methodological evaluation. Based on a Dutch weekly cost diary we developed an instrument for patients with acute or chronic back pain to be completed following participation in an inpatient rehabilitation measure. Its use was tested in an explorative pilot study. We asked for all costs and resource use due to back pain (all direct medical and non medical costs as well as indirect costs) occurring in a 4-week follow-up period, irrespective of the cost carrier. The total response rate was 58%. Patients spent an average 13 minutes a week for completing the questionnaire, without reporting any major methodological difficulties. Some 30% percent of overall costs were direct costs, the majority being non-recurring costs for assistive devices such as mattresses and mattress frames. Excluding these, monthly direct costs per patient were 270 DM on average. Indirect costs, mainly due to absence from salaried work, amounted to an average 1634 DM per patient, with marked variation. Our study results show that this instrument is basically useful and feasible in this indication. Further studies with larger and representative samples are needed to evaluate data quality. It is suggested that weekly cost diaries can be useful tools in particular in decentralized health care systems to measure costs from the societal perspective.

[Economic rehabilitation management among patients with chronic low back pain]. / Okonomisches Rehabilitationsmanagement bei chronischen Rückenschmerzen.

BACKGROUND AND STUDY PURPOSE: Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care. METHODS: The concept development consists of a theoretical and an empirical part. The method of the theoretical part is based on a systematic literature review on managed care (not included in this article), health systems research and the analysis of economic incentives. For the empirical investigation, long term effects and costs were calculated. For the evaluation of effects, we psychometrically tested and used the EuroQol (EQ-5D) as a measure of health-related quality of life (HRQL). The calculation of costs (both direct and indirect) is based on routine data of payers, a cost diary and the internal cost accounting systems of rehabilitation clinics. We statistically analysed the cost distribution and identified predictors of the management targets (e.g., costs of care) by means of regression analyses. RESULTS: The market-driven managed care approach is based on three tools: (1) a primary care system with case management and gatekeeping, (2) direct influence on providers by utilisation review and setting guidelines, and (3) indirect influence by setting supply-side economic incentives via the remuneration mode. The third managed care tool is most important when managing the rehabilitation of working age patients with chronic low back pain from an economic point of view. This concept consists of three components: (1) a case-based budget for direct costs; this is a prospective remuneration mode for an integrated primary care network including a rehabilitation facility, (2) retrospective bonus payments which are related to savings of indirect costs, and (3) retrospective bonus payments which are related to the effectiveness of rehabilitation, i.e. gains in HRQL. Common features of the three management components are a long-term perspective (e.g., from admission to a rehabilitation clinic until six months after discharge) and risk-adjustment of the three management targets (i.e., direct and indirect costs and gains in HRQL) in order to avoid selection and to limit the financial risk for providers. The EuroQol instrument shows acceptable psychometric properties in the rehabilitation setting for back pain patients. This instrument may yield two kinds of preference-based index values, one reflecting the preferences of the general population and one those of the patient. The Pearson correlation of these two approaches is fair, but there is a systematic difference. Empirical investigation shows that the distribution of both direct and indirect costs is skewed to the right. Statistically relevant predictors of the management targets are incapacity to work and HRQL at admission. CONCLUSIONS: Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.

[Development and validation of a prognosis model for predicting work capacity after rehabilitation based on routinely collected parameters]. / Entwicklung und Validierung eines Prognosemodells zur Vorhersage der Arbeitsfähigkeit nach Rehabilitation anhand routinemässig erhobener Parameter.

For efficient rehabilitation it is important to identify, as early as possible, the patients likely to be successfully returned to work after rehabilitation. The aim of this pilot study was to develop a statistical model for predicting this return as reliably as possible. The model uses only information readily available at the beginning of rehabilitation. A multiple regression analysis with backward elimination was used from a routine data base and identified 8 variables of prognostic value. The model offers a comfortable possibility to predict the probability of return to work of a patient on the basis of routinely registered data. The prognosis was found correct in 68% of those returning to work after rehabilitation (sensitivity) and in 80% of those who did not (specificity). Further work to improve the model for prognosis in rehabilitation research is considered reasonable.

[Developing a rehabilitation databank for Germany--conceptional considerations exemplified by UDSMRSM (Uniform Datasystem of Medical Rehabilitation)]. / Entwicklung einer Rehabilitationsdatenbank für Deutschland--konzeptionelle Uberlegungen am Beispiel der UDSMRSM.

Current research in medical rehabilitation lacks well designed clinical studies to demonstrate the efficacy, effectiveness and efficiency of rehabilitation interventions. Randomized controlled studies (RCTs) are difficult to conduct in rehabilitation research because of multiple variables and difficulties to include appropriate control groups. Therefore, we propose the development of a rehabilitation database and network for Germany to allow data collection from daily rehabilitation practice in the three areas medical-objective, perceptive-subjective and economical-social, designed after the example of the Uniform Datasystem of Medical Rehabilitation (UDSMRSM). This American database uses the Functional Independence Measure (FIM) to monitor functional changes in medical rehabilitation patients. Quarterly reports are sent out to participating institutions and allow comparisons with other regional, national and international institutions. The database demonstrates an initial step towards the concept of "evidence-based rehabilitation" by defining a common rehabilitation outcome and it allows benchmarking with other rehabilitation facilities. This permits the development of quality standards, cost analyses, payment systems and a new research methodology that can identify the most effective rehabilitation method through statistical analysis for focused clinical trials.

[Databank-oriented physician generated medical record as the basis for outcome quality in rehabilitation medicine]. / Datenbankorientierte Arztbriefschreibung als Grundlage der Ergebnisqualität in der Rehabilitationsmedizin.

A new approach is presented for the medical reports in rehabilitation medicine. It is realized with the integration of formatted textblocks into a client-server based workflow. This technology is able to reduce hardware and costs. The data material, extracted from the daily routine of the hospital, is characterized by high quality and it supports statistics and quality management. It is a uniform database for rehabilitation medicine and for rehabilitation research. Since 1996 the medical report software has been established in all rehabilitation hospitals accredited by the LVA Württemberg pension insurance agency.

A uniform database of rehabilitation as a basis for evaluating the outcome quality.

To make it possible to benefit from patient data recorded in rehabilitation clinics, with regard to outcome quality and scientific investigation, the Rehabilitation Research Centre at the University of Ulm has created a rehabilitation register, a database based on ORACLE, into which the relevant patient data is transferred, having been made anonymous via an SQL archiving program. The archived data includes the clinical parameters, the running text of the discharge report, and the doctor's and patient's assessment of the rehabilitation outcome. It can be automatically searched for structured data, according to every conceivable criterion and in every conceivable combination, also in combination with a text search in the running text of the admission and discharge reports and the rehabilitation outcome. With the aid of the rehabilitation register and thanks to the possibilities of EDP (Electronic Data Processing), in future it will be possible to make much more differentiated comments on the rehabilitation outcome than would be the case if the search were restricted to structured data alone. This is essential in order to be able constantly to improve outcome quality and to verify the economic benefit of rehabilitation medicine.

Criteria for prosthetic provision: "he who pays the piper calls the tune".

Previously instituted policies regarding prosthetic limb provision had been deemed dependable. A follow-up home visit study showed that 18 of 60 patients that had been provided with prostheses, did not make use of them. Analysis showed that three categories of patients made up the large majority of the non-users; double amputees, blind persons and those with psychiatric disorders. In order to attempt to eliminate the wastage of prosthetic provision to non-ambulators a new policy decision was made. Doubtful ambulators and those from the three aforementioned categories will be initially provided with temporary prostheses. Only after a period of months of temporary prosthetic usage at home will a decision be made as to whether a permanent prosthesis will be issued.

[Ulm Scientific Rehabilitation Research Group--"building blocks in rehabilitation"]. / Rehabilitationswissenschaftlicher Forschungsverbund Ulm--"Bausteine der Reha".

The Rehabilitation Research Network of Ulm on "Bausteine der Reha" consists of several departments of the University of Ulm, and various rehabilitation hospitals and cooperates with a pension insurance institute (LVA Wuerttemberg). The aim of this interdisciplinary approach is to evaluate process and outcome of rehabilitation measures considering specific clinical and rehabilitative questions with main emphasis on epidemiological and economic aspects. The Rehabilitation Research Nétwork of Ulm is subdivided into clinical projects and cross-sectional subjects. The clinical studies deal with cardiovascular and neurological rehabilitation and rehabilitation in disorders of the musculoskeletal system. The cross-sectional topics contain special fields such as biometry, health economics, epidemiology and occupational rehabilitation. All participating institutions have access to a central database with uniform structure of the data.

[Epidemiology of rheumatic complaints in Germany. Data on the prevalence and physical and psychosocial disability]. / Epidemiologie rheumatischer Beschwerden in der Bundesrepublik Deutschland. Daten zur Prävalenz und zur körperlichen und psychosozialen Beeinträchtigung.

Because of their considerable socioeconomic costs rheumatic symptoms are a major concern in industrialized nations. Our study provides data on the prevalence of rheumatic symptoms in the general population and on their physical and psychosocial impact. We performed a survey of 1814 randomly selected non institutionalized persons, aged 40 to 69 years, living in the Federal Republic of Germany. The selected subjects were asked whether they had pain in one or more of the following sites: neck/back, joints of upper extremities, joints of lower extremities. Physical and psychosocial disability was assessed using a multidimensional questionnaire that included a German version of the Arthritis Impact Measurement Scales (AIMS) and validated instruments concerning psychosocial dimensions of health status. The prevalence of rheumatic symptoms increases between 40 and 59 years and decreases thereafter. Rheumatic symptoms are more frequent in women than in men. The predominant pain localization is the back. Individuals reporting pain in one region (back, upper and lower extremities) often feel pain in other areas as well and often suffer from additional symptoms such as weakness and sleep disturbance. We found significant disabilities in physical (mobility, activities of daily living, physical activities) and psychosocial (depression, anxiety, exhaustion, family problems) dimensions of health status in subjects reporting rheumatic symptoms.

[Importance and value of roentgen studies as outcome criteria in rheumatoid arthritis]. / Wertigkeit und Aussagefähigkeit von Röntgenuntersuchungen als Outcome-Kriterium bei rheumatoider Arthritis.

In order to evaluate the objectivity and validity of radiographic parameters in rheumatoid arthritis (RA) we studied 56 patients with definite RA. Inter-observer variation was assessed comparing the scorings (Larsen classification) of two independent experienced observers. Total radiographic scores were highly significantly correlated (r = 0.89). Yet, we could not find relevant associations between radiographic findings and clinical outcome parameters (pain, morning stiffness, dexterity, grip strength, and patient's overall assessment). Thus, hand radiographs in RA provide highly reproducible results. Its validity concerning patient outcome, however, has to be interpreted very carefully.

Managing your academic career. Interview with a dean. Interview by Beverly Dillingham Lavenson.

Because the experience of others is often the best teacher, we periodically interview nurse educators who have advanced their careers successfully. In this article, Ms. Lavenson presents highlights from her interview with Eileen M. Jacobi, EdD, RN, FAAN. Former dean of the Adelphi University School of Nursing, Dr. Jacobi retired in 1986 as Dean and Professor of the College of Nursing and Allied Health, University of Texas at El Paso. She was a faculty member at Teachers' College, Columbia University and Executive Director of the American Nurses Association from 1970-1976. She received Boston University's merit award for Distinguished Service in Nursing and the outstanding graduate award from both Teachers' College and Adelphi University.

[Assessment of the effectiveness of inpatient rehabilitation measures in patients with chronic low back pain: a prospective, randomized, controlled study]. / Uberprüfung der Wirksamkeit stationärer Rehabilitationsmassnahmen bei Patienten mit chronischen Kreuzschmerzen: eine prospektive, randomisierte, kontrollierte Studie.

Chronic low-back pain is a frequent symptom causing considerable socioeconomic costs in many countries. Outpatient treatment of low-back pain often remains unsatisfactory. In our prospective study, one hundred patients on the five months waiting list were allocated randomly to attending the hospital either four months or six months later, the latter serving as a control group for those undergoing treatment. Health status was assessed using a multidimensional questionnaire, which had proven a reliable, valid and sensitive instrument in former studies. After four to six weeks of multidisciplinary inpatient treatment, a significant decrease in pain, anxiety and depression was found, whereas no improvement was observed in the control group. Multidisciplinary inpatient treatment therefore at least has short-term positive effects on patients' health status.

[Problems in implementing a pain management program for rheumatoid patients and studies of its effectiveness]. / Probleme bei der Durchführung eines Schmerzbewältigungsprogrammes bei Rheumapatienten und Untersuchungen zu seiner Effektivität.

A pain management program is presented which enables patients to reduce pain by means of relaxation and attention-diversion, etc. The problems arising from applying a psychological training to organic diseases, and the most favourable therapist's behaviour in facing these difficulties are elucidated. Finally, controlled studies are cited showing that pain can be reduced and the emotional state improved by pain management techniques.

[Intervertebral disk surgery and postoperative rehabilitation treatment: effect on health status]. / Bandscheibenoperation und Anschlussheilbehandlung: Einfluss auf den Gesundheitszustand.

There is an increasing frequency of lumbar disc surgery in many countries. In the Federal Republic of Germany, many patients are admitted to in-patient rehabilitation immediately after surgery, which causes additional socioeconomic costs. In order to assess the efficiency of this therapy approach, we used the MOPO Scales, a thoroughly evaluated instrument describing patient health status in both its physical and psychosocial dimensions. In 79 patients who had been followed-up over six months post-discharge from in-patient rehabilitation, a significant increase in mobility, physical activity, activities of daily living, household activities, and social activities was found, as well as a significant decrease in pain, depression and anxiety. These results prove lumbar disc surgery combined with immediate post operative rehabilitation to be efficient.