[Procedures Performed in General Practice - a Cross-sectional Study]. / Prozeduren, die in der Allgemeinmedizin durchgeführt werden ­ eine Querschnittstudie.

OBJECTIVE: General practice offers basic medical care to patients. Therefore, general practitioners (GPs) perform a variety of medical procedures. In order to estimate GPs array of services from the perspective of health services research, it is indispensable to know the procedures that are carried out by GPs and identify relevant influencing factors. METHODS: Based on the results of a selective literature search, the Medical Association's regulations on specialty training and experiences gained so far in developing the competence-based curriculum for general practice, a questionnaire covering 89 procedures was developed and sent to 1 576 general practitioners all over Germany. RESULTS: The response rate was 42%; 42 of 89 procedures were carried out by at least 50% of the participants. These procedures include the anatomical areas skin, eyes, ears, nose, gastrointestinal tract, urological tract and musculoskeletal system. Significant differences were shown in 25 of the most frequent procedures regarding practices in urban and rural areas, in 9 procedures with regard to the participant's length of occupation in general practice and in 19 procedures regarding male and female participants. CONCLUSION: This is the first survey that shows which procedures are performed by German GPs and how often they are performed. Factors such as practice location in either rural or urban area, physician's gender and years practiced as GP have been identified as important influences on the spectrum of services provided.

[Patient Participation in Development of Quality Indicators using the Example of National Disease Management Guidelines for Chronic Heart Failure - A Qualitative Analysis of Collective Perspectives]. / Patientenbeteiligung bei der Entwicklung von Qualitätsindikatoren am Beispiel der Nationalen VersorgungsLeitlinie Chronische Herzinsuffizienz - Eine qualitative Analyse kollektiver Sichtweisen.

PURPOSE: In this qualitative study it was investigated by group discussions with patients suffering from chronic heart failure, how relevant the existing quality indicators of the National Disease Management Guidelines for Chronic Heart Failure are being estimated. METHODS: 6 group discussions were performed. The sample was formed from 4 mixed-gender groups, a male group and a female group. Participants were recruited from local heart sports groups. For the interpretation a method similar to the grounded theory was used. RESULTS: The main conclusion is that in principle quality indicators are accepted. However, many of these indicators neglect the everyday aspects of patients' life. Participants show a disposition of "yes - but" regarding the quality indicators. This phenomenon could be theoretically grasped using the concept of order of knowledge. While participants keep referring to an order of everyday knowledge, quality indicators make recourse to a medical order of knowledge. Both orders of knowledge may compete with each other. CONCLUSIONS: The professional knowledge order of medicine needs to open up to a patients' knowledge order. Patient representatives in health care bodies need to be trained to develop a reflexive point of view to different knowledge orders enabling them to represent patients' everyday knowledge more confidently. Otherwise there is danger of conformation to the professional knowledge order of medicine only for reasons of being recognised as equal partners.

[Oversupplied? Undersupplied? - The Perspective of Local Governments of the Federal State of Baden-Württemberg: A Contribution to the Discussion of Close-to-Home Health Care]. / Überversorgt? Unterversorgt? - die Sicht von Bürgermeistern in Baden-Württemberg: Ein Beitrag zur Diskussion um die wohnortnahe medizinische Versorgung.

BACKGROUND: The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning. METHODS: A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). RESULTS: The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher. CONCLUSION: Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a community's marketing strategy when competing for new physicians.

[Joint replacement quality index: the perspective of resident physicians]. / "Qualitätsindex Endoprothetik" aus Sicht von niedergelassenen Ärzten.

BACKGROUND AND AIM: Joint replacement is an established therapy for arthrosis. The quality index for joint replacement (knee and hip) should include screening for quality of patient-centred care in hospitals providing replacements, on the basis of administrative data. The quality index summarizes 16 inpatient and posthospital complications (indicators). The aim of the study was to evaluate this quality index from the medical practitioner's viewpoint. METHODS: Four semistructured focus groups with 11 family physicians and 8 orthopaedic/trauma surgeons were conducted. The discussions were recorded, transcribed and analysed qualitatively according to Mayring. RESULTS: Infections and the revision of a total joint arthroplasty have been weighted as the most important indicators from the existing quality indicators. Between the participants some differences regarding the relevance of the indicators thrombosis and pulmonary embolism occurred. These indicators were weighted as more important by family physicians than orthopedic/trauma surgeons. For eight of the indicators, imprecision in words/meaning was criticized. In an open-ended second section, 20 new indicators within the areas complications, management and overall sector communication were identified. CONCLUSION: Major amendments of the quality index for the joint replacement are necessary. The knowledge gained from this study may serve as a basis for this development.

[The image of general practitioners from the perspective of patients with and without a Turkish migration background - a qualitative study]. / Das Image von Hausärzten aus Perspektive von Patienten mit und ohne türkischem Migrationshintergrund - eine qualitative Studie.

OBJECTIVE: In order to improve the medical care of people with migration background, the existing specialties in medical understanding must be taken into account. The aim of this study was to explore the image of general practitioners from the viewpoint of patients and to evaluate possible differences in the perception of patients with and without a Turkish migration background. METHODS: 5 focus groups with participants with and without migration background were assessed in German language. In addition to a predefined interview guideline, the collage technique was used in order to explore the image of the practitioners through pictures. The content analysis was conducted according to Mayring using the software program ATLAS.ti. RESULTS: The patients revealed a highly positive image about the general practitioners. By means of the collage technique some negative aspects could be identified which were not discussed in the focus groups. Only minimal differences in the opinions of participants with and without Turkish migration background could be observed. These were a strongly negative attribution to the general practitioners with regard to financial aspects by the participants without migration background on the one hand and a rather paternalistic viewpoint by the participants with Turkish migration background on the other hand. Asked about an image change of general practitioners, the overall opinion has changed over the years from doctors being considered to be "powerful" and "unapproachable" to a "normal" level. Major reasons for this image change were attributed to the fact that patients are becoming increasingly informed about medical issues through the internet and the high work pressure of general practitioners. The image of general practitioners in Turkey was perceived more negative as compared to Germany. CONCLUSION: The image of general practitioners from the perspective of patients is predominantly positive. Altogether, only minor differences in the perception of German speaking patients with and without Turkish migration background could be identified. Therefore, specific ways of proceeding or qualification measures for general practitioners do not seem necessary in this context.

A randomized controlled trial of acupuncture and receptive music therapy for sleep disorders in the elderly-ELAMUS: study protocol.

BACKGROUND: Globally, the demographic shift towards an aging population leads to significant challenges in healthcare systems, specifically due to an increasing incidence of multimorbidity resulting in polypharmacy among the elderly. Simultaneously, sleep disorders are a common complaint for elderly people. A treatment with pharmacological therapies often leads to side effects causing a high potential for dependency. Within this context, there is a high need to explore non-pharmacological therapeutic approaches. The purpose of this study is to evaluate the effectiveness of acupuncture and music therapy, both individually and combined as a multimodal therapy, in the treatment of sleep disorders in individuals aged 70 years and older. METHODS: We conduct a confirmatory randomized controlled trial using a two-factorial study design. A total of n = 100 elderly people receive evidence-based standard care information for age-related sleep disorders. Beyond that, patients are randomly assigned into four groups of n = 25 each to receive acupuncture, receptive music therapy with a monochord, multimodal therapy with both acupuncture and music therapy, or no further therapy. The study's primary outcome measurement is the improvement in sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) (global score), at the end of intervention. Additionally, depression scores (Geriatric Depression Scale), health-related quality of life (Short-Form-Health Survey-12), neurovegetative activity measured via heart rate variability, and safety data are collected as secondary outcomes. Using a mixed-methods approach, a qualitative process evaluation will be conducted to complement the quantitative data. DISCUSSION: The study is ongoing and the last patient in is expected to be enrolled in April 2024. The results can provide valuable insights into the effectiveness of non-pharmacological interventions for sleep disorders among the elderly, contributing to a more personalized and holistic approach in geriatric healthcare. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00031886).

[Perceptions of the local government about the primary care physicians shortage - a survey among mayors in the Federal State of Baden-Wuerttemberg]. / Die Sichtweise der kommunalen Ebene über den Hausärztemangel - eine Befragung von Bürgermeistern in Baden-Württemberg.

BACKGROUND: Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue. METHODS: In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively. RESULTS: Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants. CONCLUSIONS: The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects.

[Development, factor-analytical control and psychometric evaluation of a questionnaire on specialty choices among medical students]. / Entwicklung, faktorenanalytische Überprüfung und psychometrische Evaluierung eines Fragebogens zur Gebietswahl von Medizinstudierenden.

AIM OF THE STUDY: A questionnaire was developed and validated which assesses factors influencing career choices of medical students and their perception of possibilities in general practice. METHODS: The first questionnaire version, which was developed based on a systematic literature review, was checked for comprehensibility and redundancy using concurrent think aloud. The revised version was filled out by a pilot sample of medical students and the factor structure was assessed using principal component analysis (PCA). The final version was filled out in an online survey by medical students of all 5 Medical Faculties in the federal state of Baden-Wuerttemberg. The factor structure was validated with a confirmatory factor analysis (CFA). Reliability was assessed as internal consistency using Cronbach's α. RESULTS: The questionnaire comprises 2 parts: ratings of (A) the individual importance and of (B) the possibilities in general practice on 5-point scales. The first version comprising 118 items was shortened to 63 items after conducting interviews using concurrent think aloud. A further 3 items giving no information were removed after piloting the questionnaire on 179 students. The 27 items of part A were structured in 7 factors (PCA): image, personal ambition, patient orientation, work-life balance, future perspectives, job-related ambition, and variety in job. This structure had a critical fit in the CFA applied to the final version filled out by 1 299 students. Internal consistency of the factors was satisfactory to very good (Cronbach's α=0.55-0.81). CONCLUSION: The questionnaire showed good psychometric properties. Further, not assessed factors influence career choice resulting in unexplained variance in our dataset and the critical fit of the model.

[Manual medicine in Germany. A descriptive analysis]. / Manuelle Medizin in Deutschland. Eine deskriptive Analyse.

BACKGROUND: In Germany manual medicine (MM) is widely used by physicians. The purpose of this study was to give a first description of relevant health service research aspects of MM. METHODS: A structured questionnaire was placed online between April 2009 and March 2010 after pilot testing. Cooperating MM schools invited their members to take part in the study through different media. RESULTS: A total of 60 female and 241 male physicians participated in this survey. The most common indication for MM is the ileosacral joint syndrome, 73% stated that from their experience a single therapy does change symptoms and 47% stated that there are average to severe unspecific effects involved in MM therapy. Factors most influencing current MM treatment are time pressure and own wellbeing. There were no differences between the schools or specialties with respect to experienced effects of MM and frequency of therapy. CONCLUSION: Future study research can be planned to cover all schools of MM.

[Challenges and potentials of primary care in a multicultural society]. / Herausforderungen und Potenziale hausärztlicher Versorgung in einer multikulturellen Gesellschaft.

The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.

[Validity of nonaffective functional psychosis of the DSM IV in a Congolese population. A transversal clinical trial]. / Validité des psychoses fonctionnelles non affectives du DSM IV dans une population congolaise. Une étude clinique transversale.

BACKGROUND: The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) distinguishes schizophrenia, schizophreniform disorder and brief psychotic disorder only according to the duration of the illness. Thus, the validity of these nosological concepts sounds uncertain. AIM: The aim of this study was to evaluate the validity of the DSM IV concepts schizophrenia, schizophreniform disorder and brief psychotic disorder. POPULATION AND METHODS: Seventy schizophrenics, 68 patients with brief psychotic disorder and 50 with schizophreniform disorder, all Congolese people, selected from the 'Telema' Mental Health Centre and the 'Neuropsychopathological centre of the University of Kinshasa, from 5(th) August 2003 to 14(th) March 2005 were compared with respect to the following clinical parameters: family schizophrenia and brief psychoses history, precipitating psychosocial factors, mode of onset of the disease, clinical syndromes linked to psychoses and general functioning. Statistical analyses included analysis of variances 'one way' (Anova), post hoc Tukey's test, discriminant analysis, and analysis of covariances. RESULTS: Brief psychotic disorder differed from schizophrenia and schizophreniform Disorder in respect with positive syndrome (F=8.76, df=2; 179, p=0.0002), cognitive syndrome (F=3.79, df=2; 179, P=0.024), syndrome of excitement (F=3.23, df=2; 179, P=0.042), general functioning (F=13.73, df=2; 179, P<0.0001), family history of schizophrenia (χ(2)=8.65; P=0.013), precipitating psychosocial factors (χ(2)=19.82; P<0.0001), and mode of onset of the disease (χ(2)=91.3; P<0.0001). Schizophreniform disorder differered from schizophrenia only by a more frequent acute onset and a better general functioning. Two nosological realities were thus distinguishable: brief psychotic disorder and schizophrenia-schizophreniform disorder complex. Surprisingly, negative syndrome could not distinguish brief psychotic disorder from schizophrenia and schizophreniform (F=2.80, df=2; 179, P=0.063). Data of the discriminant analysis based on scores on general functioning, positive, negative, depressive, cognitive and excitement syndromes was conclusive (F=6.41, df=2; 185, P<0.0001) and allowed correct classification rates of 75% for brief psychotic disorder, 48% for schizophreniform disorder, 54% for schizophrenia. Schizophreniform disorder was thus the less distinguishable group; this is in the line with longitudinal studies, which demonstrated the lowest diagnostic stability of this affection, compared with the two other diseases. Total error rate was 41%. CONCLUSIONS: Brief psychotic disorder could constitute a distinct affection from schizophrenia and schizophreniform disorder, whereas schizophreniform disorder and schizophrenia could be the same affection; the first being an acute and "good functioning" form of the second. However, these viewpoints need to be confirmed by data on long-term course. The data of this study validate ultimately a binary model of the major nonaffective functional psychoses, like that of the tenth edition of the International classification of mental and behavioural disorders (ICD-10).

[Health screening and vaccination status--results from a patient survey in German general practices]. / Gesundheitsuntersuchung und Impfstatus--Ergebnisse einer Patientenbefragung in deutschen Hausarztpraxen.

The vaccination status of German adults needs improvement. Low participation is also known in health screening programmes like the "Check up 35" which is offered every two years for adults aged 35 or above. However, the number of participants in health screening increases with age whereas vaccination status decreases. Within a study about patients' attitudes towards prevention in primary care, we investigated the knowledge about the vaccination status. Therefore, an anonymous survey was conducted among 333 patients from five general practices in 2007. 76% of the potential participants in health screening declared that they utilise it at least infrequently. In contrast to those who participate frequently in health screening (67%), those who participate infrequently (38%) or never (33%) but declare that their vaccination status is complete are significantly rare. Due to the results of our study it has to be discussed whether the health screening "Check up 35" should be regularly accompanied with vaccination counselling.

[Relevance and barriers of physician empathy in daily practice - current state of research and qualitative survey of physicians]. / Bedeutung und Barrieren ärztlicher Empathie im Praxisalltag - Stand der Forschung und qualitative Kurzumfrage mit Ärzten.

AIMS OF THE STUDY: The aim of this study was to investigate the relevance and the barriers of physician empathy in medical rehabilitation by conducting a narrative literature review and a qualitative survey in physicians. METHODS: First, we described the current state of research of physician empathy in medical rehabilitation based on a narrative (non-systematic) review of the literature. Additionally, the questions of relevance and barriers of physician empathy were examined in a qualitative short survey with physicians from Rehabilitation Medicine, Internal Medicine, Pediatric and Family Medicine. The qualitative data were analyzed according to the summarizing content analysis of Mayring. RESULTS: Only n=13 studies of physician empathy were conducted in Rehabilitation Medicine; of those, just a few were from Germany and a small number investigated the influence of empathy on patient health outcomes. The qualitative survey's results regarding the definition, patient outcomes and barriers of physician empathy are similar to other theoretical and empirical studies on those issues. Moreover, they show many new, practical aspects, particularly in the field of barriers of physician empathy. CONCLUSION: Although physician empathy has been shown to be an outcome-relevant factor in acute health care, less attention has been paid to it in Rehabilitation research. Physicians from Rehabilitation Medicine, Internal Medicine, Pediatric and Family Medicine perceive empathic behavior also as an outcome-relevant ability, which is particularly hindered by time pressure and stress but also by personal and patient-specific factors.

Increasing Warmth in Adolescents with Anorexia Nervosa: A Randomized Controlled Crossover Trial Examining the Efficacy of Mustard and Ginger Footbaths.

OBJECTIVE: To analyze the thermogenic effects of footbaths with medicinal powders in adolescents with anorexia nervosa (AN) in comparison to healthy controls (HCs). Intervention and Outcomes. Forty-one female participants (21 AN, 20 HCs; 14.22 ± 1.54 years) received three footbaths-warm water and mustard (MU, Sinapis nigra), warm water and ginger (GI, Zingiber officinale), or warm water only (WA), in random order within a crossover design. Data were collected before (t1), immediately after foot immersion (maximum 20 minutes) (t2), and after 10 minutes subsequently (t3). Actual skin temperature (high resolution thermography) and perceived warmth (HeWEF questionnaire) were assessed at each time point for various body parts. The primary outcome measure was self-perceived warmth at the feet at t3. Secondary outcome measures were objective skin temperature and subjective warmth at the face, hands, and feet. RESULTS: Perceived warmth at the feet at t3 was significantly higher after GI compared to WA (mean difference -1.02) and MU (-1.07), with no differences between those with AN and HC (-0.29). For the secondary outcome measures, a craniocaudal temperature gradient for the skin temperature (thermography) was noted at t1 for patients with AN and HC (AN with colder feet). The craniocaudal gradient for subjective warmth was only seen for patients with AN. CONCLUSION: Footbaths with ginger increased warmth perception at the feet longer than with mustard or warm water only for adolescents with AN as well as for HC. The impact of ginger footbaths on recovery of thermoregulatory disturbances in patients with AN repeated over extended periods merits further investigation.

Early detachment of colon carcinoma cells during CD95(APO-1/Fas)-mediated apoptosis. I. De-adhesion from hyaluronate by shedding of CD44.

Ligation of CD95 (APO-1/Fas) cell surface receptors induces death in apoptosis-sensitive cells. Induction of apoptosis in adherent gamma interferon-stimulated HT-29 and COLO 205 colon carcinoma cells by cross-linking CD95 with anti-APO-1 monoclonal antibody resulted in detachment of the cells from hyaluronate starting about 1 h after antibody exposure. Loss of adhesion was paralleled by a substantial reduction of the multifunctional cell surface adhesion molecule CD44. As evidenced by cycloheximide treatment, this effect was not caused by impaired protein synthesis. Depletion of surface CD44 was also not due to membrane blebbing, since cytochalasin B failed to inhibit ascension from hyaluronate. Instead, ELISA and time kinetics showed increasing amounts of soluble CD44 in the supernatant of CD95-triggered cells. SDS-PAGE revealed that soluble CD44 had an apparent molecular mass of about 20 kD less than CD44 immunoprecipitated from intact cells. Thus, CD95-triggering induced shedding of CD44. Shedding is a novel mechanism operative in early steps of CD95-mediated apoptosis. Shedding surface molecules like CD44 might contribute to the active disintegration of dying epithelial cells in vivo.

[GP (general practitioners)-centered care - international data and recent development in Germany with focus on Baden-Württember]. / Hausarztzentrierte Versorgung - internationale Daten und aktuelle Entwicklungen in Deutschland mit Fokus auf Baden-Württemberg.

BACKGROUND: Since the health-care reform in 1993, there are ambitious efforts of introducing gatekeeping in Germanys' primary health-care system. Gatekeeping is said to reduce costs and improve health-care quality. The aim of this article is to summarise the actual literature and the newest progression of gatekeeping for the example of Baden-Württemberg. METHODS: By means of a selective literature search, national and international data on gatekeeping are summarised. RESULTS: Most available data on gatekeeping are from US-American studies whereas data from Germany are rare so far. The effects of gatekeeping are defined by means of various outcome measures (e.g., physician-patient relationship, health-care quality, visits, referrals, costs, prescribing behaviour). The observed effects in terms of these outcome measures are not uniform and are contradictory to a great extent. Newest data from GP (general practitioners)-centred care model regions in Germany indicate a high satisfaction among these patients. Furthermore, an increase of consultations at specialists with referrals from the gatekeepers could be observed whilst the overall number of referrals to specialists remained equal so far. Baden-Württemberg's first generation contracts for GP-centred care were based on different legal paragraphs resulting in partially considerable differences in terms of the conditions for physicians and patients. DISCUSSION: On the basis of the available data, the effects of gatekeeping cannot conclusively be determined. In Germany, scientific evaluation of the different gatekeeping models and publication of their results are absolutely necessary to assess the expected cost saving and quality improving effects of gatekeeping.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers.

PURPOSE: Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD. PATIENTS AND METHODS: As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis. RESULTS: POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important. CONCLUSION: Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Montelukast as add-on therapy to inhaled corticosteroids in the treatment of mild to moderate asthma: a systematic review.

OBJECTIVE: To systematically review the evidence for the medium to long term benefits and risks of montelukast as add-on therapy to inhaled corticosteroids (ICS) in comparison with placebo and active controls in mild to moderate asthma. DATA SOURCES: Medline, Embase, Cochrane Register of Controlled Trials, reference lists of retrieved articles, clinical trial registries and study results databases. REVIEW METHODS: Systematic review of randomised controlled trials (duration > or = 12 weeks) in adolescents and adults comparing montelukast/ICS versus ICS monotherapy or montelukast/ICS versus active control/ICS. Meta-analyses were conducted where feasible. The main focus was on clinical outcomes (eg, exacerbations). Adverse events were also assessed. RESULTS: 13 studies meeting all of the inclusion criteria were identified: 7 studies, including constant or tapered doses of ICS, compared montelukast/ICS with ICS monotherapy. Six studies compared add-on montelukast with an add-on active control (salmeterol). Overall, the data indicated that montelukast/ICS was clinically more effective than ICS monotherapy. The ICS sparing potential of montelukast was clearly demonstrated in one study. Montelukast/ICS and ICS monotherapy showed similar safety profiles. In the active controlled studies, montelukast/ICS was clinically less effective than salmeterol/ICS in the 12 week trials (pooled proportion of patients with > or = 1 exacerbation: p = 0.006). However, separate analysis of active controlled 48 week trials showed comparable proportions for patients with > or = 1 exacerbation in both groups. CONCLUSIONS: Montelukast as add-on therapy to ICS improves control of mild to moderate asthma compared with ICS monotherapy. Although the addition of salmeterol to ICS is clinically as effective as or even more effective than the addition of montelukast, montelukast may have a better long term safety profile and offer a treatment alternative for asthma patients.

Effects of Footbaths with Mustard, Ginger, or Warm Water Only on Objective and Subjective Warmth Distribution in Healthy Subjects: A Randomized Controlled Trial.

OBJECTIVE: To analyze the short-term thermogenic effects of footbaths with warm water alone (WA) versus when combined with medicinal powders. DESIGN: Randomized controlled trial with cross-over. INTERVENTIONS AND OUTCOMES: Seventeen healthy volunteers (mean age 22.1 years, SD = 2.4; 11 female) received three footbaths with WA or WA combined with mustard (MU) or ginger (GI) in a randomized order. Self-perceived warmth (Herdecke warmth perception questionnaire) and actual skin temperatures (thermography) were assessed before (t0), immediately after footbaths (t1), and 10 minutes later (t2). The primary outcome was perceived warmth in the feet. Secondary outcomes were warmth perception in the face, hands and overall, as well as actual skin temperature in the feet, face, and hands. RESULTS: Perceived warmth at the feet (primary outcome) increased significantly (all p's < .001) for MU and GI at t1 as well as for GI at t2 when compared to t0 with high effect sizes. At t2, GI differed significantly from WA (p < .001) and MU (p = .048). With regards to the secondary measures of outcome, no significant effects were seen for perceived warmth at the face or hands. Overall warmth was significantly higher at t1 compared to t0 (p = .01). Thermography assessments of skin temperature at the feet at t1 increased after all conditions (p < .001). No effects were seen in the face. At the hands, temperature decreased at t1 (p = .02) and t2 compared to t0 (p < .001). CONCLUSION: The present study provides preliminary evidence that mustard and ginger increase warmth perception at the feet more than warm water alone, with only the effects for GI enduring at the brief follow-up.

Neuroendocrinological effects of acupuncture treatment in patients with irritable bowel syndrome.

OBJECTIVES: Quality of life (QoL) improvement in patients with irritable bowel syndrome (IBS) during acupuncture (AC) treatment seems to be due to a placebo effect. The aim was to explore if acupuncture has some specific influence on the neuroendocrinic and autonomic nervous system (ANS). DESIGN/SETTING: Patients with IBS were randomly assigned to receive either acupuncture (AC) or sham acupuncture (SAC) using the so-called "Streitberger needle". QoL was measured with the functional quality of life diseases quality of life questionnaire (FDDQL) and SF-36. The effect on ANS was evaluated by measuring salivary cortisol and by cardiovascular responses on a tilt table before and after 10 AC treatments. Complete data sets of tilt table and salivary morning cortisol were available for 9 patients in the AC and 12 in SAC group. RESULTS: QoL increased in both groups (p=0.001) with no group differences. Salivary cortisol decreased in all groups (F=10.55; p=0.006). However, the decrease was more pronounced in the AC group (F=4.07; p=0.033) (ANOVA repeated measures model). Heart rate response decreased during orthostatic stress in the AC group while it increased in the SAC group (F=9.234; p=0.005), indicating an increased parasympathetic tone in the AC group. Improvement of pain was positively associated with increased parasympathetic tone in the AC group (F=10.1; p=0.006), but not in the SAC group. CONCLUSIONS: The acupuncture specific physiological effects are in contrast to the unspecific improvement of QoL in both AC and SAC groups. Thus, different mechanisms seem to be involved in placebo and real-acupuncture driven improvements. The specific mechanism of action of acupuncture on the ANS remains unclear and deserves further evaluation.