[The Role of Preferences in the German Long-Term Care Insurance - Results from Expert Interviews]. / Die Rolle von Präferenzen für Langzeitpflege in der sozialen Pflegeversicherung ­ Ergebnisse von Experteninterviews.

BACKGROUND: As a result of population aging, the number of persons dependent on long-term care (LTC) is expected to increase considerably in Germany. Information about LTC preferences is important to decision-makers in future reforms. Taking into account the preferences of people can lead to a better congruence between desired and utilized LTC services. The aim of this study was to evaluate LTC preferences, their underlying reasons, and the potential to satisfy individual preferences within the German LTC insurance system. METHODS: Interviews with 20 LTC (insurance) experts in Germany between July and September 2014 were analyzed using qualitative content analysis methods. RESULTS: Irrespective of the care setting, people prefer flexible LTC (services), which allow for as much autonomy and independence as possible. Ideally, care is provided by close relatives at the dependent's home. Besides informal homecare, professional care at home is also (becoming increasingly) important, whereas inpatient LTC (nursing home) is rarely preferred over homecare arrangements. To most LTC dependents, interpersonal needs are more important than bodily and professional aspects of care. CONCLUSION: While the flexible choices and manifold options to combine services (high degree of person-centeredness) within the German LTC insurance constitute an important basis for the satisfaction of individual preferences, the widespread lack of information about entitlements, costs of services, and corresponding LTC options in the general population (future dependents) substantially hampers long-term care that is in line with preferences.

Miniaturized implantable sensors for in vivo localized temperature measurements in mice during cold exposure.

We report on in vivo temperature measurements performed in mice at two specific sites of interest in the animal body over a period of several hours. In particular, the aim of this work was to monitor mouse metabolism during cold exposure, and to record possible temperature differences between the body temperature measured in the abdomen and the temperature of the brown adipose tissue (BAT) situated in the interscapular area. This approach is of biological interest as it may help unravelling the question whether biochemical activation of BAT is associated with local increase in metabolic heat production. For that purpose, miniaturized thermistor sensors have been accurately calibrated and implanted in the BAT and in the abdominal tissue of mice. After 1 week of recovery from surgery, mice were exposed to cold (6 °C) for a maximum duration of 6 h and the temperature was acquired continuously from the two sensors. Control measurements with a conventional rectal probe confirmed good performance of both sensors. Moreover, two different mouse phenotypes could be identified, distinguishable in terms of their metabolic resistance to cold exposure. This difference was analyzed from the thermal point of view by computational simulations. Our simple physical model of the mouse body allowed to reproduce the global evolution of hypothermia and also to explain qualitatively the temperature difference between abdomen and BAT locations. While with our approach, we have demonstrated the importance and feasibility of localized temperature measurements on mice, further optimization of this technique may help better identify local metabolism variations.

Necrotizing pulmonary aspergillosis and ventricular assist device infection: case report and review of literature.

Necrotizing pulmonary aspergillosis and Aspergillus device infection are rare and have potentially fatal complications after left ventricular assist device (LVAD) implantation. To date, few cases of patients surviving Aspergillus device infection have been published, with survival reported only after device removal. We present a patient implanted with an LVAD in whom necrotizing pulmonary aspergillosis with device involvement was successfully treated by segmentectomy and prolonged antifungal treatment without device exchange or removal. Similar cases in the literature were searched for and are discussed in view of the severity of this complication.

Seventy kilovolt ultra-low dose CT of the paranasal sinus: first clinical results.

AIM: To evaluate the diagnostic image quality and radiation dose of low-dose 70 kV computed tomography (CT) of the paranasal sinus in comparison to 100 and 120 kV CT. MATERIALS AND METHODS: CT of the paranasal sinus was performed in 127 patients divided into three groups using different tube voltages and currents (70 kV/75 mAs, ultra-low dose protocol, n = 44; 100 kV/40 mAs, standard low-dose protocol, n = 42; 120 kV/40 mAs, standard protocol, n = 41). CT dose index (CTDIvol), dose-length product (DLP), attenuation, image noise and signal-to-noise ratio (SNR) were compared between the groups using Wilcoxon-Mann-Whitney U-test. Subjective diagnostic image quality was compared by using a five-point scale (1 = non-diagnostic, 5 = excellent, read by two readers in consensus) and Cohen's weighted kappa analysis for interobserver agreement. RESULTS: Radiation dose was significantly lower with 70 kV acquisition than 100 and 120 kV (DLP: 31 versus 52 versus 82 mGy·cm; CTDI 2.33 versus 3.95 versus 6.31 mGy, all p < 0.05). Mean SNR (70 kV: 0.37; 100 kV: 0.21; 120 kV: 0.13; p < 0.05) and organ attenuation increased significantly with lower voltages. All examinations showed diagnostic image quality. Subjective diagnostic image quality was higher with standard protocols than the 70 kV protocol (120 kV: 5.0; 100 kV: 4.5; 70 kV: 3.5, p < 0.05) without significant differences with substantial interobserver agreement (κ > 0.59). CONCLUSION: The ultra-low dose (70 kV) CT imaging of the paranasal sinus allowed for significant dose reduction by 61% and an increased attenuation of organ structures in comparison to standard acquisition while maintaining diagnostic image quality with a slight reduction in subjective image quality.

Non-linear image blending improves visualization of head and neck primary squamous cell carcinoma compared to linear blending in dual-energy CT.

AIM: To compare non-linear and linear image-blending post-processing techniques in dual-energy CT (DECT) of primary head and neck squamous cell carcinoma (SCC) regarding subjective and objective image quality. MATERIALS AND METHODS: Head and neck DECT studies from 69 patients (48 male, 21 female; mean age 62.3 years) were retrospectively evaluated. All tumour lesions were histologically confirmed SCC. Linearly blended 80/140 kVp images series with varying weighting factors of 0.3 (M_0.3), 0.6 and 0.8 were compared with non-linearly blended images. Attenuation of tumour lesion, various soft-tissue structures, the internal jugular vein, and image noise were measured, tumour signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Overall image quality, delineation of tumour lesion, image sharpness, and noise level were rated individually by three radiologists using five-point Likert scales. Interobserver agreement was calculated using intraclass correlation coefficient (ICC). RESULTS: Enhancement of tumour lesions (non-linear, 137.5 ± 20.1 HU; M_0.3, 92.7 ± 14.4 HU; M_0.6, 110 ± 15.4 HU; M_0.8, 123 ± 18.2 HU), CNR (non-linear, 12 ± 8; M_0.3, 4 ± 4.7; M_0.6, 7.5 ± 5.5; M_0.8, 8 ± 5.5), subjective overall image quality and tumour delineation were significantly increased (all p < 0.001) with the non-linear blending technique compared to all investigated linear blending weighting factors. Overall interobserver agreement was substantial (ICC 0.70; 95% CI: 0.66-0.73). CONCLUSION: Post-processing of DECT using a non-linear blending technique provides improved objective and subjective image quality of head and neck SCC compared to linearly blended images series.

[Cost of fractures in German hospitals--what role does osteoporosis play?]. / Frakturkosten im deutschen Krankenhaussektor--Welche Rolle spielt die Osteoporose?

OBJECTIVE: The objective of this study was to examine the total and osteoporosis-attributable inpatient costs of 16 fracture types accrued in the German hospital sector in the year 2009. METHODS: To calculate the inpatient fracture costs in the hospital sector we combined data from different official German statistics, i.e., fracture-specific diagnosis data from female and male inpatients in 2009, population data, fracture-specific diagnosis-related groups (DRGs), and per diem capital costs in hospitals. The share of fractures which were attributable to osteoporosis had been estimated by the epidemiological concept of "population attributable risk". Calculation of these risks was based on empirical data obtained from the national and international literature. RESULTS: For the year 2009 the total inpatient costs accrued by the 16 fracture types considered in our analyses amounted to 2.4 billion Euros. Of these, 860 million Euros (36%) were attributable to osteoporosis. The main cost drivers were hip fractures. CONCLUSION: Fractures accrue relevant hospital costs in Germany. In order to use the limited resources of the German health-care system in an efficient way, future measures to reduce the number of incident fractures should be designed and evaluated in terms of cost-effectiveness.

[Taxing unhealthy foods. A measure to promote public health in Germany?]. / Gesundheitssteuern auf Lebensmittel. Eine Maßnahme zur Förderung der Gesundheit in Deutschland?

Due to the substantial health burden and costs caused by malnutrition in Germany, for instance as a result of obesity, diabetes, and cardiovascular diseases, the taxation of unhealthy foods/nutrients has been proposed as a possible health promoting measure. In order to evaluate whether such a fiscal intervention constitutes an effective and suitable measure to promote population health in Germany, the article outlines central empirical findings regarding malnutrition in Germany. Subsequently, the economic background (price elasticity of demand) is explained, and empirical evidence on the influence of changes in price on changes in consumption and health is presented. As a result of findings from the international literature being heterogeneous, and because very little research has been conducted in Germany on this matter until now, the taxation/subsidization of foods in order to promote population health is difficult to justify at this point.

Role of uterine artery Doppler in the management of uterine leiomyoma by arterial embolization.

OBJECTIVES: To study Doppler changes in the uterine artery immediately following and 3 months after uterine artery embolization (UAE) and to test the feasibility of using uterine artery Doppler as a predictor of the predominant side of arterial supply to leiomyomas, amount of embolizing material needed and leiomyoma tumor volume at follow-up. METHODS: The study included 38 patients undergoing UAE for leiomyomas. Uterine artery Doppler was performed transabdominally before, within 6 hours after and 3 months after UAE to determine the peak systolic (PSV) and end-diastolic (EDV) velocities and resistance index (RI). Leiomyoma volume was measured using contrast-enhanced magnetic resonance imaging (MRI) before and 3 months after UAE. The predominant side of arterial supply to the leiomyoma was determined on digital subtraction angiography using the uterine artery diameter and tumor blush after contrast injection. For correlations with leiomyoma volume, the average PSV, EDV and RI of both sides was used, while for prediction of the predominant side of supply and for correlation with the amount of embolizing material needed, separate measurements from each side were used. RESULTS: Relative to the pre-embolization value, the uterine artery PSV and EDV were significantly reduced (P < 0.05) immediately following UAE, while the RI was significantly elevated (P < 0.05). For prediction of the predominant side of supply, the lowest RI showed the highest accuracy (81.6%). There was no significant correlation between the pre-embolization PSV, EDV or RI and the amount of embolizing material utilized. Immediately post-embolization EDV and RI values were statistically significantly correlated with the 3-month follow-up leiomyoma volume, with RI showing the strongest correlation (P = 0.0400 and 0.0002, rho = 0.34 and - 0.58, respectively). The leiomyoma volume was predicted to have reduced by 38-61% after 3 months if the immediate post-embolization average RI value was between 0.82 and 0.88. CONCLUSION: Pre-interventional Doppler assessment can be used to predict the predominant side of supply to leiomyomas but not the amount of embolizing material needed. Immediate post-interventional Doppler assessment can predict the leiomyoma volume after UAE.

[Effects of multimorbidity on health care utilization and costs]. / Auswirkungen von Multimorbidität auf die Inanspruchnahme medizinischer Versorgungsleistungen und die Versorgungskosten.

Multiple chronic conditions (multimorbidity) are common among elderly patients; however, little is known about the specific effects of multimorbidity on health care utilization and health care costs. This article reviews empirical studies from the international literature that investigated the relationship between multiple chronic conditions and health care utilization (e.g. ambulatory care, stationary care, pharmacotherapy) and/or health care costs in elderly general populations. Although synthesis of studies was complicated, especially because of ambiguous definitions and measurements of multimorbidity, almost all studies observed a positive association of multimorbidity and utilization and costs. Many studies found that utilization and costs significantly increased with each additional chronic condition. In light of these findings coupled with the fear that current care arrangements may be inappropriate for many multimorbid patients, important implications for research and policy are presented and discussed.

Three-dimensional magnetic focusing of superparamagnetic beads for on-chip agglutination assays.

We present a new method for three-dimensional (3D) magneticfocusing of magnetic microparticles in a microfluidic system. On-chip magnetic particle manipulation in the microchannel is achieved by a high-gradient magnetic field generated by means of a micromachined field concentrator. The system allows retention of functionalized beads in a dense plug while flowing through buffer or analyte. Slowly reducing the magnetic retention force in the presence of a flow results in controlled release of the particles into a fine streamline with regular longitudinal interparticle spacing. Alignment at half-height of the channel is readily obtained through the symmetry of the magnetic field. A single lateral sheath flow is required to provide full 3D focusing of the microparticles in the middle of the microchannel with a maximum deviation of ±5 µm from the center position. With the use of this system, a new approach for performing an immunoagglutination assay on-chip has been implemented. Three-dimensional focusing allowed reliable counting of singlets and agglutinated doublets. We demonstrate the potential of the agglutination assay in a microfluidic format using a streptavidin/biotinylated bovine serum albumin (bBSA) model system. A detection limit of about 400 pg/mL (6 pM) is achieved.

[Health economic aspects of physical-mental comorbidity]. / Gesundheitsökonomische Aspekte psychischer Komorbidität bei somatischen Krankheiten.

Physical-mental comorbidity is often associated with worse clinical and psychosocial outcomes, reduced health-related quality of life, and increased healthcare utilization. The following article is dedicated to the health economic aspects of physical-mental comorbidity. It presents basic theoretical and methodological aspects of cost-of-illness studies and economic evaluations related to physical-mental comorbidity, which are explained and discussed for the practical example of comorbid depression in diabetes mellitus. The results show that mental comorbidity in diabetes is associated with increased healthcare costs, which can in part be attributed to an increased somatic health service use. Appropriate interventions can lower these excess costs. Economic evaluations assessing the effectiveness of interventions for depressive diabetics have shown that overall health can be improved and costs saved. However, especially in health economics, mental comorbidity in somatic diseases has not been comprehensively investigated and further research is warranted.

[Economic aspects of prevention and treatment of overweight and obesity in children and adolescents]. / Prävention und Therapie von Übergewicht und Adipositas im Kindes- und Jugendalter aus gesundheitsökonomischer Sicht.

This article provides an overview of the costs associated with overweight and obesity in children and adolescents, and of the cost effectiveness of preventive and therapeutic interventions. First, the results of cost-of-illness studies from the international literature are presented. These studies show ambiguous results, but indicate moderate excess costs due to obesity for this age group. Subsequently, this paper describes the methods that can be used to analyze the cost effectiveness of preventive and therapeutic interventions. Problems arise from the necessity to estimate long-term effects on costs and health consequences of multiple, associated diseases. A number of economic evaluations of preventive and therapeutic interventions published in the scientific literature have reported favorable cost effectiveness. In order to increase the efficiency of health care, more cost-effective services for overweight and obesity should be developed and used.

Emergency surgery for complications related to percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is used to restore enteral nutrition in patients with inadequate oral intake. Because of its minimally invasive nature complications are thought to be rare. We analyzed data on all patients treated for PEG-related complications at the Department of General, Visceral, and Oncologic Surgery at the Klinikum Bremen-Mitte, Germany, between 2005 and 2008. A total of 38 patients with complications required surgical evaluation. Emergency laparotomy was performed for leakage in 16 patients, for a misplaced or dislodged PEG tube in nine patients, for buried bumper with accompanying signs of peritonitis in four patients and for gastrocutaneous fistula in one patient. Eight complications were managed conservatively. Early complications within 10 days (60 %) were related to leakage or mispositioning of the PEG, while PEG device migration and fistula formation represented late complications. Hospital mortality was 17 % with the underlying disease contributing significantly to the fatal outcome. Most PEG-associated major complications were related to technical errors and carried a high mortality.

Percutaneous interventions below the knee in patients with critical limb ischemia using drug eluting stents.

AIM: Midterm technical and clinical evaluation of stent angioplasty with drug-eluting stents in infrapopliteal lesions in patients with critical limb ischemia (CLI). METHODS: Percutaneous stent angioplasty was performed in 128 limbs in 114 patients presenting with 320 vascular lesions. Lesions with up to 6 cm in length and at least one patent vessel below the obstruction were treated; 341 drug-eluting Cypher(R) stents (diameter of 2.5-3.5 mm; length of 18-33 mm) were implanted. Follow-up examinations were performed up to 18 months postinterventionally using clinical examination, ankle-brachial index (ABI) calculation, and color coded Duplex sonography. Patency rates were calculated on the basis of the Kaplan-Meier life-table analysis. RESULTS: Technical success was achieved in 99.06%. Minor complications (hematoma, distal emboli, and vessel dissection) were documented in 8.77% of the patients. The 6, 12, and 18 months primary patency rate as controlled by Duplex sonography was 89.8, 84.2 and 83.3%, respectively; 77.6% of the lesions healed postinterventionally. The cumulative limb salvage rate was 95.6%. CONCLUSION: Drug-eluting stent (DES) angioplasty in infrapopliteal arteries is a safe and effective technique for the treatment of patients with CLI. The use of a DES results in favorable technical and clinical outcome in the midterm follow-up.

On-chip immuno-agglutination assay with analyte capture by dynamic manipulation of superparamagnetic beads.

Magnetic bead-based lab-on-a-chip systems offer significant advantages compared to more conventional systems, mainly through the possibility of controlled manipulation of the magnetic carriers on-chip. In particular, microfluidic immunoassays using functionalized magnetic beads raise increasing interest. We present here a new approach for performing immuno-agglutination assays on-chip. Our system is based on a quadrupolar magnetic field set-up. Dynamic actuation of a confined plug of functionalized magnetic beads is used for analyte capture in a microchannel. A simple detection method based on the swelling of the released plug after agglutination is presented. We demonstrate the feasibility of on-chip agglutination tests by means of a streptavidin/biotinylated-bovine serum albumin (bBSA) model assay. A detection limit of about 200 pg/mL (approximately 3 pM) is achieved.

[C-arm computed tomography for transarterial chemoperfusion and chemo-embolization of thoracic lesions]. / Transarterielle Chemoperfusion und -embolisation thorakaler Neoplasmen mittels C-Arm CT.

PURPOSE: To evaluate the role of C-arm CT for on-line fluoroscopy in regional transarterial chemoperfusion (TACP) and chemo-embolization (TPCE) of primary and secondary malignant thoracic lesions. MATERIALS AND METHODS: From September 2008 to March 2009 a total of 31 patients (20 males and 11 females, average age: 61.7 years, range 22-84 years) with 53 thoracic malignant lesions from different origins (primary or secondary pulmonary carcinoma n=37, pleural mesothelioma n=16) were treated with TACP or TPCE using flat-detector CT (FD-CT). C-arm CT of the latest generation was used to localize the lesion before local chemotherapy (Artis Zeego, Siemens, Erlangen). For TACP a 220 degrees rotation and a volume of 150 ml (ratio of 1:2 contrast/normal saline), delay 2 s and flow 12 ml/s was used. For TPCE a volume of 75 ml (ratio of 1:2 contrast/normal saline), delay 2 s and flow 3 ml/s was used. RESULTS: TPCE C-arm CT allowed the evaluation of the degree of perfusion of the tumor and the geographic areas of enhancement correlated with the post-interventional lipiodol uptake in MSCT. In TACP the intercostal arteries involved could be visualized and in 30% of interventions the catheter had to be repositioned for the following intervention. CONCLUSION: C-arm CT provides additional information on the vascular characteristics and perfusion of pulmonary lesions resulting in a change of interventional strategy in a relevant number of patients.

Comparison of different imaging models handling partial coherence for aberration-corrected HRTEM at 40-80 kV.

Partial coherence of the electron waves leaving the specimen is taken into account in the high-resolution transmission electron microscopy (HRTEM) image simulation by mainly three methods - the incoherent summation approach, the transmission cross-coefficient (TCC) model, and the quasi-coherent model. In the incoherent summation approach, coherent images are calculated for each point in the effective source and summed up incoherently. The TCC is the transfer function of the microscope obtained based on the incoherent summation approach. An analytical form of the TCC can be derived by assuming a Gaussian distribution for the source radiation and for the variation of the focal length caused by the energy spread of the effective source. In the quasi-coherent model, the partial coherence effect is simplified by multiplying the wave function at the diffraction plane with the envelope functions. Envelope functions suppress the contributions to the image contrast from waves which do not propagate along the optical axis. The quasi-coherent model is usually sufficient for the image simulation of weak phase objects. This model is more computationally efficient than both the incoherent summation approach and the TCC model. For the Cs-corrected and Cc/Cs-corrected microscopes operating at 80 kV, we have compared images simulated by using the three models with the experimental images. The comparison shows that the quasi-coherent model also provides a sufficient approximation for the image simulation of high-Z materials if chromatic aberration is corrected and the samples comprise only several atomic layers. In the case of only Cs-correction, the incoherent summation approach or the TCC model needs to be employed for modelling the imaging of high-Z samples even though it is more computationally consuming.

Rapid fluidic exchange microsystem for recording of fast ion channel kinetics in Xenopus oocytes.

We present a new lab-on-a-chip system for electrophysiological measurements on Xenopus oocytes. Xenopus oocytes are widely used host cells in the field of pharmacological studies and drug development. We developed a novel non-invasive technique using immobilized non-devitellinized cells that replaces the traditional "two-electrode voltage-clamp" (TEVC) method. In particular, rapid fluidic exchange was implemented on-chip to allow recording of fast kinetic events of exogenous ion channels expressed in the cell membrane. Reducing fluidic exchange times of extracellular reagent solutions is a great challenge with these large millimetre-sized cells. Fluidic switching is obtained by shifting the laminar flow interface in a perfusion channel under the cell by means of integrated poly-dimethylsiloxane (PDMS) microvalves. Reagent solution exchange times down to 20 ms have been achieved. An on-chip purging system allows to perform complex pharmacological protocols, making the system suitable for screening of ion channel ligand libraries. The performance of the integrated rapid fluidic exchange system was demonstrated by investigating the self-inhibition of human epithelial sodium channels (ENaC). Our results show that the response time of this ion channel to a specific reactant is about an order of magnitude faster than could be estimated with the traditional TEVC technique.

Preferences for home- and community-based long-term care services in Germany: a discrete choice experiment.

BACKGROUND: Most people prefer to "age in place" and to remain in their homes for as long as possible even in case they require long-term care. While informal care is projected to decrease in Germany, the use of home- and community-based services (HCBS) can be expected to increase in the future. Preference-based data on aspects of HCBS is needed to optimize person-centered care. OBJECTIVE: To investigate preferences for home- and community-based long-term care services packages. DESIGN: Discrete choice experiment conducted in mailed survey. SETTING AND PARTICIPANTS: Randomly selected sample of the general population aged 45-64 years in Germany (n = 1.209). MAIN VARIABLES STUDIED: Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes (with 2-4 levels): care time per day, service level of the HCBS provider, quality of care, number of different caregivers per month, co-payment. RESULTS: Quality of care was the most important attribute to respondents and small teams of regular caregivers (1-2) were preferred over larger teams. Yet, an extended range of services of the HCBS provider was not preferred over a more narrow range. WTP per hour of HCBS was €8.98. CONCLUSIONS: Our findings on preferences for HCBS in the general population in Germany add to the growing international evidence of preferences for LTC. In light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

Integrated microsystem for non-invasive electrophysiological measurements on Xenopus oocytes.

We propose a new non-invasive integrated microsystem for electrophysiological measurements on Xenopus laevis oocytes. Xenopus oocyte is a well-known expression system for various kinds of ion channels, that are potential tools in drug screening. In the traditional "Two Electrode Voltage Clamp" (TEVC) method, delicate micromanipulation is required to impale an oocyte with two microelectrodes. In our system, a non-invasive electrical access to the cytoplasm is provided by permeabilizing the cell membrane with an ionophore (e.g. nystatin). Unlike the classical patch-clamp or "macropatch" techniques, this method does not require removal of the vitelline membrane. Cell handling is significantly simplified, resulting in more robust recordings with increased throughput. Moreover, because only part of the oocyte surface is exposed to reagents, the required volume of reagent solutions could be reduced by an order of magnitude compared to the TEVC method. The fabrication process for this disposable microchip, based on poly-dimethylsiloxane (PDMS) molding and glass/PDMS bonding, is cost-efficient and simple. We tested this new microdevice by recording currents in oocytes expressing the human Epithelial Sodium Channel (hENaC) for membrane potentials between -100 and +50 mV. We recorded benzamil-sensitive currents with a large signal-to-noise ratio and we also obtained a benzamil concentration-inhibition curve displaying an inhibition constant IC(50) of about 50 nM, comparable to previously published values obtained with the TEVC technique.