[Analysis of the personnel development in anesthesiology over the last two decades with special attention to gender aspects]. / Eine Analyse der Personalentwicklung in der Anästhesiologie unter besonderer Berücksichtigung von Gender-Aspekten.

Skills shortage of nursing staff and physicians is a "hot topic" in health politics. For the future recruitment of medical staff in anesthesiology, an analysis of the staff development during the last decades considering gender aspects seems to be important. Therefore, the authors conducted a comparative analysis of data from the "Statistisches Bundesamt" (Fachserie 12 Reihe 7.3.1 and Fachserie 12 Reihe 6.1.1.) from 1994 until 2015. The analysis compared the development of anesthesiological staff (physicians) with the overall development of medical staff (physicians) in respect of the number of residents, consultants and department chairs. There are two major differences between the development of medical staff in anesthesiology and the overall development of medical staff: (1) in anesthesiology there is a high percentage of consultants without management tasks, (2) though the percentage of female colleagues is increasing both in anesthesiology and overall, the percentage of female colleagues in management or chair positions is lower in anesthesiology compared to the other disciplines, altogether. Anesthesiology is a discipline in which both the number of tasks and personnel have risen over the last two decades. The comparatively huge increase in the number of residents and consultants without management tasks suggests that the number of tasks in daily routine has substantially increased for anesthesiologists. The comparatively low percentage of female colleagues in chair positions should give an impulse to improve the compatibility of family and working live both for clinical and scientific careers.

[Informal care for dementia according to type of service]. / Informelle Pflege bei Demenz nach Leistungsarten.

BACKGROUND: Dementia is a major challenge for society and its impact will grow in the future. Informal care is an essential part of dementia care. Previous studies considered informal care as a whole and not by its components. OBJECTIVE: We aimed to assess the degree of association between specific informal care services and dementia. MATERIAL AND METHODS: This analysis is based on data from the seventh wave of the AgeCoDe/AgeQualiDe study. Dementia was diagnosed based on the DSM-IV criteria. Severity of dementia was assessed and categorized by means of the Clinical Dementia Rating and eight individual informal care services were considered. Logistic regression models were used to assess associations. RESULTS: Of the 864 participants 18% suffered from dementia (very mild: 4%; mild: 6%; moderate: 5%; severe: 3%). All informal care services were significantly associated with dementia, with an emphasis on "supervision", "regulation of financial matters" and "assistance in the intake of medication". Considering different degrees of dementia severity, similar results arose from the analyses. All three aforementioned services showed a pronounced association with all degrees of dementia severity, except for supervision and very mild dementia. CONCLUSION: The provision of all types of informal care services is associated with dementia. The association is pronounced for services that can be more easily integrated into the daily routines of the informal caregiver. Policy makers who plan to integrate informal care into the general care arrangements for dementia should consider this.

[Quo vadis Therapeutic Health Care Professionals--What do Occupational and Physical Therapists Think about their Future? Results of a Survey throughout Germany]. / Quo vadis Therapieberufe--wie sehen Physio- und Ergotherapeuten die Zukunft ihrer Berufe? Ergebnisse einer deutschlandweiten Befragung.

BACKGROUND: The introduction of occupational and physical therapy as academic disciplines is evidence of radical changes in the therapeutic health care professions. Therapists' professional associations are planning and negotiating both with health insurance companies and with other branches of the health care professions concerning future spheres of activity. In order to find out what the therapists in these professions think about their future, we conducted a survey of physical and occupational therapists through-out Germany. Our findings regarding professional life, job satisfaction, competition and cooperation have already been published. This article presents therapists' assessments of the future of their professions. METHOD: From May until December 2008 we performed a cross-sectional survey, interviewing physical and occupational therapists throughout Germany. Statements were answered on a 6-step Likert scale; open questions were answered in free-text fields. The evaluation was performed quantitatively; the free texts were also evaluated qualitatively. RESULTS: A total of 3,506 questionnaires were evaluated; 1,273 were completed by occupational therapists and 2,233 by physical therapists. Nearly half of the therapists (n=1,687; 48.4%) used the opportunity to emphasise the need for change. We identified 4,026 statements about 8 general topics: remuneration, employee co-determination, professional recognition, continuing education, cooperation, initial access to the professions, and their academic status. Therapists illustrated certain items in the questionnaire with examples from their professional experience, suggested additional topics, and proposed concrete changes. We document a broad range of opinions and concerns, especially in regard to such subjects concerning the future of the professions as their new academic status and initial access. CONCLUSION: Physical and occupational therapists are concerned about the future development of their professions. They see a need for change in the following areas: remuneration, employee co-determination, initial access and cooperation as well as in the development of their profession as an academic discipline. Policy makers need to heed therapists' assessments of the state of their professions and their calls for its increased professionalisation.

[Morbidity differences according to nursing stage and nursing setting in long-term care patients: Results of a claims data based study]. / Morbiditätsunterschiede bei Pflegebedürftigen in Abhängigkeit von Pflegesektor und Pflegestufe: Eine Untersuchung auf der Basis von Abrechnungsdaten der Gesetzlichen Krankenversicherung.

BACKGROUND: We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany. MATERIALS AND METHODS: The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated. RESULTS: In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs. CONCLUSION: Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.

[The professional and private situation of male and female physicians entering postgraduate medical education in Germany]. / Die berufliche und private Situation von Ärztinnen und Ärzten zu Beginn der fachärztlichen Weiterbildung.

AIM: This study investigated the professional and the private situation of medical interns at the onset of their postgraduate training in Germany. We analysed the contractual situation and the working hours in the hospital, the professional situation of the partner and the number of hours invested in private life with special reference to gender and children. METHOD: A standardised postal survey was conducted among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg after entering postgraduate training. 1 009 were contacted for a first follow-up one year later and 87% responded. Descriptive statistics and regression analysis were performed. RESULTS: The analysis shows that female physicians are disadvantaged compared to males with regard to various professional and private conditions relevant for career development, especially when children are present. We found a large number of hints pointing towards a persistence of traditional role patterns within the couple relationship. These conditions differed substantially between the regions of former German Federal and former German Democratic Republic. CONCLUSIONS: A growing number of children in the study population in the course of the longitudinal analysis will show if these gender-related differences persist in the course of the training period and which influences on career development can be observed.

[Use and potential risks of over-the-counter analgesics]. / Gebrauch und potenzielle Risiken durch nicht verschreibungspflichtige Schmerzmittel.

BACKGROUND AND AIM: We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities. METHODS: Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen. RESULTS: Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved. DISCUSSION: About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.

[The epidemiology of chronic diseases and long-term care: results of a claims data-based study]. / Die Epidemiologie von chronischen Krankheiten und Pflegebedürftigkeit : Eine Untersuchung auf der Basis von Abrechnungsdaten der gesetzlichen Krankenversicherung.

BACKGROUND: It is generally assumed that chronic diseases and multimorbidity increase the risk of long-term care. Nevertheless, a systematic study on the nature and the prevalence of those diseases associated with long-term care has not been yet undertaken in Germany. MATERIALS AND METHODS: The study was perfomed using claims data of one nationwide operating statutory health insurance company in 2006. Inclusion criteria were age ≥ 65 years, minimum of 1 out of 46 diagnoses in a minimum of three quarters of the year (n = 8,678). A comparison group was formed with n = 114,962. We calculated prevalences and relative risks -using nominal regression- to determine influential factors on long-term care. RESULTS: A small number of diseases (e.g. dementia, urinary incontinence, chronic stroke and cardiac insufficiency) show high prevalences (> 20%) among long-term care users and at the same time great prevalence differences between users and non-users CONCLUSION: These data are important for improving medical and nursing care of long-term care users. Further research is needed with regard to the question by which mechanisms those diseases produce disability and frailty, thus leading to long-term care requirements.

[Satisfied general practitioners and critical nursing staff - problems of interprofessional cooperation in the home care of dementia patients]. / Zufriedene Hausärzte und kritische Pflegende - Probleme der interprofessionellen Zusammenarbeit in der Versorgung zu Hause lebender Menschen mit Demenz.

AIM OF THE STUDY: Analysis of views of general practioners and nurses of interprofessional cooperation between general practititoners and nurses in the ambulatory care of dementia patients is presented. METHODS: A survey was carried out among general practitioners and nurses caring for community dwelling dementia patients in Hamburg. RESULTS: The majority of GPs and nurses consider interprofessional cooperation to be good and beneficial for their own work. GPs are generally more positive about the quality of cooperation than nurses. Joint sessions for planning and evaluation of care are seldom. Even so, more GPs than nurses evaluate the frequency of these meetings to be sufficient. Although nurses are more critical about the quality of the cooperation with the GPs, they seldom address the GP to express their criticism. CONSEQUENCES: To make cooperation work, the matter should be part of the training of both physicians and nurses and the hierarchy between the 2 groups should be reduced.

[Potentially inappropriate medication in elderly primary care patients : A retrospective, longitudinal analysis]. / Potenziell inadäquate Medikamente bei älteren hausärztlich versorgten Patientinnen und Patienten : Eine retrospektive Längsschnittanalyse.

BACKGROUND: Elderly people are often burdened by several diseases. This accounts for a higher medication intake and increases the risk of adverse drug events. To minimize this risk, several lists (Beers, PRISCUS) have been published of drugs that elderly patients should not take. We present a longitudinal analysis of the use of potentially inappropriate medication (PIM) over a period 4.5 years in a cohort of patients aged 75 years or more. METHODS: Data were collected from the prospective, multicenter, observational study "German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)," initially enrolling 3,327 patients. We investigated the prevalence of PIM by checking medications during visits to patients' homes. Furthermore, we analyzed the use of individual PIM agents over time. RESULTS: At baseline, we found a PIM prevalence of 29 % according to the PRISCUS list, which decreased to 25.0 % 4.5 years later (χ(2): 7.87, p = 0.004). The Beers list yielded a prevalence of 21 % at baseline, decreasing after 4.5 years to 17.1 % (χ(2): 10.77, p = 0.000). A time-dependent multilevel model confirmed these results. Older age, depression, and the use of numerous prescribed agents are independent risk factors for using a PRISCUS-PIM. CONCLUSION: Our results seem to support a trend toward a more rational drug therapy because fewer patients were prescribed PIM. Thus, for the individual patient, the risk of adverse effects and side effects is reduced as are the costs of these effects.

A genome-wide survey of human short-term memory.

Recent advances in the development of high-throughput genotyping platforms allow for the unbiased identification of genes and genomic sequences related to heritable traits. In this study, we analyzed human short-term memory, which refers to the ability to remember information over a brief period of time and which has been found disturbed in many neuropsychiatric conditions, including schizophrenia and depression. We performed a genome-wide survey at 909 622 polymorphic loci and report six genetic variations significantly associated with human short-term memory performance after genome-wide correction for multiple comparisons. A polymorphism within SCN1A (encoding the α subunit of the type I voltage-gated sodium channel) was replicated in three independent populations of 1699 individuals. Functional magnetic resonance imaging during an n-back working memory task detected SCN1A allele-dependent activation differences in brain regions typically involved in working memory processes. These results suggest an important role for SCN1A in human short-term memory.

[General practitioner or specialist at home or abroad?]. / Hausarzt oder Spezialist im In- oder Ausland?

This study investigated the career preferences of medical graduates in Germany with regard to discipline, place and position after the completion of postgraduate training. We also investigated differences in career options according to gender and region of study (former German Federal Republic vs. former German Democratic Republic).The study is based on a standardised postal survey among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2 107 persons were contacted and 1 012 (48%) participated in the survey.96% of participants stated their intention to pursue a postgraduate training in a medical discipline, and only 0.4% denied such an objective. 7% of the graduates preferred a career towards general practice, and a similar percentage preferred general internal medicine which usually also leads to a primary care activity. 84% aimed at becoming a medical specialist. In total, 28% intended to work in a specialist practice, and 10% in a general practice. Only one-fifth of the latter aimed at working in a countryside setting. 7% aimed at starting postgraduate training outside of Germany, and 8% preferred to work outside Germany after completion of the postgraduate training. In both cases, Switzerland was by far the most preferred country.The results contradict the thesis that young graduates are reluctant to enter clinical medicine. Working abroad is within the scope of less than 10% of the graduates. A dramatic difference between the demand for general practitioners and the career intentions of medical graduates is observed. Measures to increase the attractiveness of primary care, especially in the countryside, are urgently needed.

Net costs of dementia by disease stage.

OBJECTIVE: To estimate net costs of dementia by degree of severity from a societal perspective, including a detailed assessment of costs of formal and informal nursing care. METHOD: In a cross-sectional study, costs of illness were analysed in 176 dementia patients and 173 matched non-demented control subjects. Healthcare resource use and costs were assessed retrospectively by means of a questionnaire. Dementia patients were classified into three disease stages, and linear regression models were applied to estimate net costs of dementia by degree of severity. RESULTS: Annual net costs of dementia by stage were approximately €15 000 (mild), €32 000 (moderate) and €42 000 (severe), corresponding to US-$21 450, 45 760 and 60 060 respectively. Across disease stages, nursing care accounted for approximately three-quarters of total costs, of which half resulted from informal care. In sensitivity analyses using different valuation methods for nursing care, total costs decreased or increased by more than 20%. CONCLUSION: Net costs more than double across stages of dementia. Informal care accounts for a considerable share of nursing care costs, and the approach to valuation of informal care has a large impact on cost-of-illness estimates.

[The joint research project "Comorbidity and multimorbidity in primary care" (MultiCare)]. / Das Verbundvorhaben "Komorbidität und Multimorbidität in der hausärztlichen Versorgung" (MultiCare).

MultiCare is the acronym for a multidisciplinary and multicenter research network on multimorbidity and comorbidity in the primary care/family medicine setting, which is coordinated by the Institute of Primary Medical Care of the University Medical Center Hamburg-Eppendorf. Multimorbidity is one of the most difficult problems in primary medical care as little is known about the interaction of several diseases in a person with regard to etiology and disease progress. Also, guidelines for the treatment of multimorbid patients are largely lacking. Therefore, the aims of the MultiCare network include: the identification of multimorbidity patterns in the elderly primary care population, analysis of incidence and prevalence and of interactions within clusters, the investigation of severity and consequences for patients, as well as trials to improve physician-patient interaction in the case of multimorbidity. During the first funding period (2008-2010) the network consisted of two observational and two interventional studies. Their results as of summer 2011 are presented in the following article.

Risk factors for incident mild cognitive impairment--results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe).

OBJECTIVES: To provide age- and gender-specific incidence rates of MCI among elderly general practitioner (GP) patients (75+ years) and to identify risk factors for incident MCI. METHOD: Data were derived from the longitudinal German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). Incidence was calculated according to the 'person-years-at-risk' method. Risk factors were analysed using multivariate logistic regression models. RESULTS: During the 3-year follow-up period, 350 (15.0%) of the 2331 patients whose data were included in the calculation of incidence developed MCI [person-years (PY) = 6198.20]. The overall incidence of MCI was 56.5 (95% confidence interval = 50.7-62.7) per 1000 PY. Older age, vascular diseases, the apoE epsilon4 allele and subjective memory complaints were identified as significant risk factors for future MCI. CONCLUSION: Mild cognitive impairment is frequent in older GP patients. Subjective memory complaints predict incident MCI. Especially vascular risk factors provide the opportunity of preventive approaches.

[Stigma and taboo in dementia care - does continuing education for GPs and nurses contribute to destigmatisation]. / Tabu und Stigma in der Versorgung von Patienten mit Demenz: Kann ein Fortbildungsangebot für Hausärzte und ambulante Pflegedienste zur Destigmatisierung beitragen?

One of the main reasons for deficits in the care of patients with dementia is the taboo on the disease and the stigma of the people suffering from the disease, also from the side of the professional caregivers. The aim of the project was to find out whether a continuing education program for GPs and for nurses in ambulatory care was able to increase the skills of professionals to better communicate with patients and relatives on the taboo topic of dementia. The program was developed with a multi-professional team and tested with 53 GPs and 54 nurses in ambulatory care. The evaluation was performed with a 39-item questionnaire administered before and after the training. Also, to test the stability of the outcomes, the same questionnaire was administered to the GPs after one year and after two months for the nurses. The process quality of the training was evaluated very positively in both groups. Outcome quality was also very positive. Many attitudes of the GPs changed in a positive way and this change was still present after one year. This was the case for their general attitude towards caring for people with dementia, their view on therapeutic possibilities, their willingness to support relatives, to refer them to the Alzheimer Society and to suggest to them participation in a self-help group. Results for the nurses pointed in the same direction. However, with regard to diagnosis disclosure and informing the patient, no effect of the training could be shown in the GP sample.

[CERAD-NP battery: Age-, gender- and education-specific reference values for selected subtests. Results of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)]. / CERAD-NP-Testbatterie: Alters-, geschlechts- und bildungsspezifische Normen ausgewählter Subtests. Ergebnisse der German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe).

The CERAD-NP battery represents well-established tests for the neuropsychological diagnosis of characteristic cognitive deficits in Alzheimer's dementia. However, the use of neuropsychological tests requires reliable standard values for the population under consideration, taking sociodemographic characteristics like age, education and gender into account. This report presents age-, education- and gender-specific reference values for the subtests verbal fluency, word list memory, word list recall and word list recognition as well as the word list savings score of the CERAD-NP battery. The study sample consists of 2891 general practitioners' patients from Germany aged 75 years and older. The study participants had a mean age of 80.2 years (SD=3.6); thus, this report provides reliable reference values for the neuropsychological diagnosis of dementia in older age groups.

Longitudinal Analysis of Outpatient Physician Visits in the Oldest Old: Results of the AgeQualiDe Prospective Cohort Study.

OBJECTIVES: The aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally. DESIGN: Multicenter prospective cohort "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). SETTING: Individuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves). PARTICIPANTS: Primary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85-100 years). MEASUREMENTS: Self-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale). RESULTS: Fixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables. CONCLUSION: Our findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

[Which patients are (not) included in the DMP diabetes programme?]. / Welche Patienten werden (nicht) in das DMP Diabetes eingeschlossen?

AIM: The disease management programme for diabetes mellitus type 2 (DMP) is joined by many General Practitioners. Aim of the study is to compare patients included in this programme with patients not included and to explore reasons for the selection. METHODS: 10 GPs in Hamburg participated. From each patient list 10 participants in the DMP and the same number of non-participants were randomly selected. HbA1c before start of the programme, presence of insulin therapy, comorbidity and language skills were documented. GPs reported their estimation of the compliance and their reasoning in the selection process. The hypothesis for the primary endpoint was: Diabetics not included have a worse HbA1c value than those included in the DMP. RESULTS: The hypothesis was not confirmed. In both groups similarly good HbA1c values were observed (7.0 in DMP participants, 7.3 in non-participants). The included participants differed from those not included with respect to age (statistically significantly younger) and a better compliance. In the subgroup of patients younger than 70 years the patients included have a better HbA1c and get insulin more frequently (both n. s.). CONCLUSIONS: One part of the patients seems to be not included into the DMP for good reasons. Two questions should be further evaluated: To what extent are patients included although they already have a good metabolic situation? And to what extent are patients with a poor compliance not included, although they might benefit from participation?

[The new curriculum for surgery in Hamburg, Germany]. / Integrierte operative Medizin: Die studentische Ausbildung in der Chirurgie in Hamburg.

In October 2004, the medical faculty of Hamburg University started a program to restructure completely clinical teaching according to new state regulations of June 2002. In this new curriculum design, the surgical disciplines were horizontally and vertically interconnected and integrated, with a focus on practical training and problem-based teaching. This study describes the concept of clinical teaching and presents the student evaluation results of the first four blocks with a focus on performance in surgical disciplines. There was high student satisfaction with the new program, compared with results before October 2004 and also with respect to other disciplines within the new curriculum. This was especially true for the practical courses in the newly established skills lab. Future developments in e-learning and practical teaching in the skills lab are necessary to overcome restrictions on medical education due to changes in the German health care system.

Transdermal iontophoretic delivery of apomorphine in patients improved by surfactant formulation pretreatment.

The objective of the present study is to evaluate the efficacy and the safety of transdermal iontophoretic delivery of R-apomorphine, a potent dopamine agonist, in combination with surfactant pretreatment in patients with advanced Parkinson's disease. Iontophoresis patches were applied in 16 patients for 3.5 h, with 0.5 h of passive delivery followed by 3 h of current application at a current density of 250 microA/cm2. Eight of these patients were treated with a surfactant formulation prior to iontophoresis. The pharmacokinetics, pharmacodynamic effects, systemic and local side effects of R-apomorphine were assessed. The plasma concentration vs. time profiles upon iontophoresis of R-apomorphine were described successfully by a novel pharmacokinetic model. The model suggests that only 1.9% of the dose that has been released from the patch accumulated in the skin. The patients treated with the surfactant formulations showed a statistically significant increase of bioavailability (from 10.6+/-0.8% to 13.2+/-1.4%) and of the steady state input rate (from 75.3+/-6.6 to 98.3+/-12.1 nmol/cm2 h) compared to the control patients (iontophoresis without absorption enhancers). In five out of eight patients in the study group and in three out of eight patients in the control group, clinical improvement was observed.