Insect antimicrobial peptides: potential weapons to counteract the antibiotic resistance.

Misuse and overuse of antibiotics have contributed in the last decades to a phenomenon known as antibiotic resistance which is currently considered one of the principal threats to global public health by the World Health Organization. The aim to find alternative drugs has been demonstrated as a real challenge. Thanks to their biodiversity, insects represent the largest class of organisms in the animal kingdom. The humoral immune response includes the production of antimicrobial peptides (AMPs) that are released into the insect hemolymph after microbial infection. In this review, we have focused on insect immune responses, particularly on AMP characteristics, their mechanism of action and applications, especially in the biomedical field. Furthermore, we discuss the Toll, Imd, and JAK-STAT pathways that activate genes encoding for the expression of AMPs. Moreover, we focused on strategies to improve insect peptides stability against proteolytic susceptibility such as D-amino acid substitutions, N-terminus modification, cyclization and dimerization.

Silencing of the DNA methyltransferase 1 associated protein 1 (DMAP1) gene in the invasive ladybird Harmonia axyridis implies a role of the DNA methyltransferase 1-DMAP1 complex in female fecundity.

The invasive harlequin ladybird Harmonia axyridis is a textbook example of polymorphism and polyphenism as the temperature during egg development determines the frequency of melanic morphs and the number and size of black spots in nonmelanic morphs. Recent concepts in evolutionary biology suggest that epigenetic mechanisms can translate environmental stimuli into heritable phenotypic changes. To investigate whether epigenetic mechanisms influence the penetrance and expressivity of colour morphs in H. axyridis, we used RNA interference to silence key enzymes required for DNA methylation and histone modification. We found that neither of these epigenetic mechanisms affected the frequency of different morphs, but there was a significant impact on life-history traits such as longevity and fecundity. Strikingly, we found that silencing the gene encoding for DNA methyltransferase 1 associated protein 1 (DMAP1) severely reduced female fecundity, which correlated with an abundance of degenerated ovaries in DMAP1-knockdown female beetles. Finally, we observed significant differences in DMAP1 expression when we compared native and invasive H. axyridis populations with a biocontrol strain differing in egg-laying capacity, suggesting that the DNA methyltransferase 1-DMAP1 complex may influence the invasive performance of this ladybird.

Prospective study of device-related complications in intensive care unit detected by virtual autopsy.

BACKGROUND: There has been increasing use of invasive techniques, such as extracorporeal organ support, in intensive care units (ICU), and declining autopsy rates. Thus, new measures are needed to maintain high-quality standards. We investigated the potential of computed tomography (CT)-based virtual autopsy to substitute for medical autopsy in this setting. METHODS: We investigated the potential of virtual autopsy by post-mortem CT to identify complications associated with medical devices in a prospective study of patients who had died in the ICU. Clinical records were reviewed to determine the number and types of medical devices used, and findings from medical and virtual autopsies, related and unrelated to the medical devices, were compared. RESULTS: Medical and virtual autopsies could be performed in 61 patients (Group M/V), and virtual autopsy only in 101 patients (Group V). In Group M/V, 41 device-related complications and 30 device malpositions were identified, but only with a low inter-method agreement. Major findings unrelated to a device were identified in about 25% of patients with a high level of agreement between methods. In Group V, 8 device complications and 36 device malpositions were identified. CONCLUSIONS: Device-related complications are frequent in ICU patients. Virtual and medical autopsies showed clear differences in the detection of complications and device malpositions. Both methods should supplement each other rather than one alone for quality control of medical devices in the ICU. Further studies should focus on the identification of special patient populations in which virtual autopsy might be of particular benefit. CLINICAL TRIAL REGISTRATION: NCT01541982.

Genomic innovations, transcriptional plasticity and gene loss underlying the evolution and divergence of two highly polyphagous and invasive Helicoverpa pest species.

BACKGROUND: Helicoverpa armigera and Helicoverpa zea are major caterpillar pests of Old and New World agriculture, respectively. Both, particularly H. armigera, are extremely polyphagous, and H. armigera has developed resistance to many insecticides. Here we use comparative genomics, transcriptomics and resequencing to elucidate the genetic basis for their properties as pests. RESULTS: We find that, prior to their divergence about 1.5 Mya, the H. armigera/H. zea lineage had accumulated up to more than 100 more members of specific detoxification and digestion gene families and more than 100 extra gustatory receptor genes, compared to other lepidopterans with narrower host ranges. The two genomes remain very similar in gene content and order, but H. armigera is more polymorphic overall, and H. zea has lost several detoxification genes, as well as about 50 gustatory receptor genes. It also lacks certain genes and alleles conferring insecticide resistance found in H. armigera. Non-synonymous sites in the expanded gene families above are rapidly diverging, both between paralogues and between orthologues in the two species. Whole genome transcriptomic analyses of H. armigera larvae show widely divergent responses to different host plants, including responses among many of the duplicated detoxification and digestion genes. CONCLUSIONS: The extreme polyphagy of the two heliothines is associated with extensive amplification and neofunctionalisation of genes involved in host finding and use, coupled with versatile transcriptional responses on different hosts. H. armigera's invasion of the Americas in recent years means that hybridisation could generate populations that are both locally adapted and insecticide resistant.

[Application for Inpatient Psychosomatic Rehabilitation: Frequency, Quality, and Approval Rates]. / Anträge auf psychosomatische Rehabilitation ­ Häufigkeit, Qualität und Befürwortungsrate.

BACKGROUND: There has been a steady increase in psychiatric primary diagnoses in medical rehabilitation services carried out by the statutory pension insurance (DRV). To date, no data are available regarding frequency, quality, and approval rates of applications for psychosomatic rehabilitation. Pension insurance physicians reviewing the application require sufficient information on rehabilitation-related needs, motivation, abilities, and prognosis of an insured person. Medical reports accompanying application for rehabilitation are often provided by a family physician. Psychiatric disorders are often misdiagnosed by general practitioners. METHOD: In a 2-week period, all decisions made by pension insurance physicians evaluating applications for rehabilitation were recorded. For each incoming application, the following data were documented: psychiatric and somatic primary diagnosis; availability of medical reports; information on prior treatment/therapy; request for further information; decision made by the physician. RESULTS: 1,366 applications (with 81% first-time applications) were included in the analysis. 16.2% of all applications were from insurants with psychiatric primary diagnoses. 44.0% of these applications included a medical report from the family physician only. The proportion of rejected applications (34.7%) and undecided applications (27.2%) was higher in the group of applicants with psychiatric primary diagnosis vs. somatic primary diagnosis (19.6% rejected; 12.7% undecided; χ2=79.8(4), p=0.001). Applications from patients with psychiatric primary diagnosis that lacked a medical report from a psychiatrist/psychotherapist were more likely to be rejected (45.3 vs. 32.3%) or to remain undecided (28.0 vs. 18.3%; χ2=10.2(2), p=0.006). In contrast, among applicants with a history of psychiatric/psychotherapeutic treatment, there was a higher proportion of undecided applications accompanied by a medical report from the family physician (35.7 vs. 18.2%). CONCLUSION: It might be useful to have medical reports generally provided by medical specialists. This may help both to increase the informative value of applications for psychosomatic rehabilitation and enable quicker decisions and better diagnosis.

[Video-assisted patient education in anesthesia : How do medical users assess the procedure?] / Videoassistierte anästhesiologische Patientenaufklärung : Wie bewerten ärztliche Anwender das Verfahren?

BACKGROUND: Video-assisted patient education (VaPE) has in the past been a subject of many studies. Compared to conventional methods, most authors reported a better transfer of information, some found increased patient satisfaction and a time-sparing effect. There was no increase in anxiety caused by VaPE. Some authors even found a reduction of anxiety levels before anesthesia. All publications to date have focused on the patient's point of view. There have been no reports on how anesthetists as users assess VaPE. METHODS: In this study 22 anesthesia departments using VaPE were contacted. A total of 122 anesthetists were sent questionnaires of which 81 (66%) were completed and returned. The anesthetists were first questioned about the characteristics of the workplace, the frequency of preanesthesia patient contacts, the content of the videos, the technique of video presentation and their own professional experience. After this the anesthetists were asked to assess five statements concerning: usefulness of VaPE, economy of time, transfer of knowledge, induction of anxiety and influence on the quality of the consent interview. In each category there were 4 choices: fully agree, partly agree, partly disagree and fully disagree. The first two choices were evaluated as positive and the second two as negative answers. The anesthetists were also asked to state the most valued characteristics of VaPE. Out of eight given options they were to select the most favored three. A final question was whether in their opinion VaPE could be recommended to non-users. RESULTS: Of the anesthetists 97.5% stated that disclosure interviews predominantly took place in the preoperative anesthetic clinic and 73% performed 15 or more patient interviews per day. Videos about general anesthesia were applied by 70%, about non-obstetric regional anesthesia by 56% and about obstetric epidural anesthesia by 59%. The videos were presented to groups of patients via large screens by 27%, individually with CD players or tablet computers by 51% or with both methods (22%). Of the anesthetists 69% had 5 years or more professional experience, 97.5% found VaPE useful for patients education, 92.5% observed a time-saving effect for the following interview and 96% stated that after watching the video patients were better informed. An increase of anxiety caused by VaPE was noted by 46% whereas 54% found no such effect. As to the quality of interview 50% reported an advantage in focusing on the patient's individual risk profile and the other 50% reported no advantage. The ranking of the main advantages was 1) better patient information, 2) time-saving effect, 3) helpful for patient education, followed by 4) increased patient satisfaction, 5) better understanding of anesthesiology, 6) individualization of the interview and 7) helpful in questions of legal liability. The answer option "no advantage" was not chosen at all. Of the participants 82.5% would recommend VaPE unconditionally (fully agree), 17.5% would give a conditional recommendation to colleagues and no one would not recommend VaPE. CONCLUSION: This survey among anesthetists confirmed most results obtained from patient-based studies: medical users attributed to VaPE a better information transfer and a time-sparing effect. Furthermore, users regarded VaPE as helpful for the preanesthesia interview. As compared to the patient-based results, however, many anesthetists seem to overrate the anxiety, caused by disclosure videos. From the users' point of view, VaPE is a highly appreciated method for patient education which can be recommended to colleagues.

A DNA methylation site within the KLF13 gene is associated with orexigenic processes based on neural responses and ghrelin levels.

We investigated five methylation markers recently linked to body mass index, for their role in the neuropathology of obesity. In neuroimaging experiments, our analysis involving 23 participants showed that methylation levels for the cg07814318 site, which lies within the KLF13 gene, correlated with brain activity in the claustrum, putamen, cingulate gyrus and frontal gyri, some of which have been previously associated to food signaling, obesity or reward. Methylation levels at cg07814318 also positively correlated with ghrelin levels. Moreover, expression of KLF13 was augmented in the brains of obese and starved mice. Our results suggest the cg07814318 site could be involved in orexigenic processes, and also implicate KLF13 in obesity. Our findings are the first to associate methylation levels in blood with brain activity in obesity-related regions, and further support previous findings between ghrelin, brain activity and genetic differences.

Exploring complex pheromone biosynthetic processes in the bumblebee male labial gland by RNA sequencing.

Male marking pheromones (MPs) are used by the majority of bumblebee species (Hymenoptera: Apidae), including a commercially important greenhouse pollinator, the buff-tailed bumblebee (Bombus terrestris), to attract conspecific females. MP biosynthetic processes in the cephalic part of the bumblebee male labial gland (LG) are of extraordinary complexity, involving enzymes of fatty acid and isoprenoid biosynthesis, which jointly produce more than 50 compounds. We employed a differential transcriptomic approach to identify candidate genes involved in MP biosynthesis by sequencing Bombus terrestris LG and fat body (FB) transcriptomes. We identified 12 454 abundantly expressed gene products (reads per kilobase of exon model per million mapped reads value > 1) that had significant hits in the GenBank nonredundant database. Of these, 876 were upregulated in the LG (> 4-fold difference). We identified more than 140 candidate genes potentially involved in MP biosynthesis, including esterases, fatty acid reductases, lipases, enzymes involved in limited fatty acid chain shortening, neuropeptide receptors and enzymes involved in biosynthesis of triacylglycerols, isoprenoids and fatty acids. For selected candidates, we confirmed their abundant expression in LG using quantitative real-time reverse transcription-PCR (qRT-PCR). Our study shows that the Bombus terrestris LG transcriptome reflects both fatty acid and isoprenoid MP biosynthetic processes and identifies rational gene targets for future studies to disentangle the molecular basis of MP biosynthesis. Additionally, LG and FB transcriptomes enrich the available transcriptomic resources for Bombus terrestris.

Expression and characterization of a recombinant i-type lysozyme from the harlequin ladybird beetle Harmonia axyridis.

Lysozymes are enzymes that destroy bacterial cell walls by hydrolysing the polysaccharide component of peptidoglycan. In insects, there are two classes of lysozymes, the c-type with muramidase activity and the i-type whose prototypical members from annelids and molluscs possess both muramidase and isopeptidase activities. Many insect genes encoding c-type and i-type lysozymes have been identified during genome and transcriptome analyses, but only c-type lysozymes have been functionally characterized at the protein level. Here we produced one of five i-type lysozymes represented in the immunity-related transcriptome of the invasive harlequin ladybird beetle Harmonia axyridis as recombinant protein. This was the only one containing the serine and histidine residues that are thought to be required for isopeptidase activity. This i-type lysozyme was recombinantly expressed in the yeast Pichia pastoris, but the purified protein was inactive in both muramidase and isopeptidase assays. Transcription and immunofluorescence analysis revealed that this i-type lysozyme is produced in the fat body but is not inducible by immune challenge. These data suggest that i-type lysozymes in insects may have acquired novel and as yet undetermined functions in the course of evolution.

Failure of primary atovaquone prophylaxis for prevention of toxoplasmosis in hematopoietic cell transplant recipients.

The efficacy of primary prophylaxis with atovaquone in preventing Toxoplasma reactivation and disease in hematopoietic cell transplant (HCT) recipients is unknown. We describe 2 cases of atovaquone prophylaxis failure in pre-HCT Toxoplasma-seropositive (pre-HCTSP) recipients who underwent allogeneic HCT (allo-HCT) and review the literature on atovaquone prophylaxis in HCT recipients.

[Quality Assurance in Sociomedical Evaluation by Peer Review: A Pilot Project of the German Statutory Pension Insurance]. / Qualitätssicherung in der Sozialmedizinischen Begutachtung durch Peer Review - ein Pilotprojekt der Deutschen Rentenversicherung.

BACKGROUND: The sociomedical evaluation by the German Pension Insurance serves the purpose of determining entitlement to disability pensions. A quality assurance concept for the sociomedical evaluation was developed, which is based on a peer Review process. Peer review is an established process of external quality assurance in health care. The review is based on a hierarchically constructed manual that was evaluated in this pilot project. METHODS: The database consists of 260 medical reports for disability pension of 12 pension insurance agencies. 771 reviews from 19 peers were included in the evaluation of the inter-rater reliability. Kendall's coefficient of concordance W for more than 2 raters is used as primary measure of inter-rater reliability. RESULTS: Reliability appeared to be heterogeneous. Kendalls W varies for the particular criteria from 0.09 to 0.88 and reached for primary criterion reproducibility a value of 0.37. CONCLUSION: The reliability of the manual seemed acceptable in the context of existing research data and is in line with existing peer review research outcomes. Nevertheless, the concordance is limited and requires optimisation. Starting points for improvement can be seen in a systematic training and regular user meetings of the peers involved.

Impulse control disorders in Parkinson's disease: don't set your mind at rest by self-assessments.

BACKGROUND AND PURPOSE: Impulse control disorders (ICDs) and related conditions in Parkinson's disease (PD) patients are frequent, disabling and sometimes devastating neuropsychiatric behaviors. Current knowledge on the prevalence of ICDs in PD is mainly based on assessments with questionnaires or patient interviews. This study was designed to evaluate the reliability of self-assessed ICDs and related conditions in PD by exploring the agreement between self-assessment of ICDs and related conditions in PD patients on the one hand and the estimation of their caregivers on the other hand. METHODS: After a short validation study of a novel ICD screening questionnaire, a cross-sectional study in 150 PD patients was performed. All patients filled out the self-assessment version of a screening questionnaire for ICDs, and caregivers completed an adapted version (n = 64). RESULTS: When comparing self-assessments of PD patients and ratings by their caregivers, significant differences with regard to the estimated prevalence of hypersexuality (55% vs. 17%), dopamine dysregulation syndrome (31% vs. 3%) and punding (22% vs. 9%) were found. CONCLUSIONS: Patients underestimate the presence and severity of some ICDs and related conditions, which shows how important assessments with caregivers are. After all, ICDs are probably much more frequent in PD than previously reported.

Psychological distress and need for psycho-oncological support in spouses of total laryngectomised cancer patients-results for the first 3 years after surgery.

PURPOSE: A total laryngectomy (TLE) leads to a variety of functional restrictions, which reduce the quality of life of cancer patients as well as their spouses. However, to date, there is little research focusing on the psychological distress of spouses of total laryngectomised cancer patients. The current study assesses psychological distress, need for psycho-oncological treatment and use of professional psychological care among spouses of total laryngectomised cancer patients. METHODS: A prospective multi-centre cohort study was conducted. Participants were interviewed in person 1, 2 and 3 years subsequent to their spouses' TLE with standardised questionnaires (HADS, Hornheide Screening) and self-designed items. RESULTS: One year after their partners' TLE, 154 spouses were interviewed. Over half of spouses (57 %) reported a high level of psychological distress and 33 % reported restlessness. Majority of spouses (21 %) reported wanting to learn relaxation methods and eight (5 %) had received psychological treatment in the past. Sixty-two spouses took part in the complete study. Over all three time points, psychological distress, the need for psycho-oncological support and the use of professional support among spouses remained stable. The need for additional professional counselling was low. CONCLUSIONS: In view of the stability of psychological distress among half of the spouses within 3 years after TLE and their refusal of professional support, there is a need for the development and evaluation of new treatment strategies to help spouses cope with psychological distress. Our results indicated the most common additional professional need was learning relaxation methods, which may be used as a starting point for the investigation of new coping strategies in future studies.

Molecular dynamics simulations reveal that apo-HisJ can sample a closed conformation.

The Escherichia coli histidine binding protein HisJ is a type II periplasmic binding protein (PBP) that preferentially binds histidine and interacts with its cytoplasmic membrane ABC transporter, HisQMP2 , to initiate histidine transport. HisJ is a bilobal protein where the larger Domain 1 is connected to the smaller Domain 2 via two linking strands. Type II PBPs are thought to undergo "Venus flytrap" movements where the protein is able to reversibly transition from an open to a closed conformation. To explore the accessibility of the closed conformation to the apo state of the protein, we performed a set of all-atom molecular dynamics simulations of HisJ starting from four different conformations: apo-open, apo-closed, apo-semiopen, and holo-closed. The simulations reveal that the closed conformation is less dynamic than the open one. HisJ experienced closing motions and explored semiopen conformations that reverted to closed forms resembling those found in the holo-closed state. Essential dynamics analysis of the simulations identified domain closing/opening and twisting as main motions. The formation of specific inter-hinge strand and interdomain polar interactions contributed to the adoption of the closed apo-conformations although they are up to 2.5-fold less prevalent compared with the holo-closed simulations. The overall sampling of the closed form by apo-HisJ provides a rationale for the binding of unliganded PBPs with their cytoplasmic membrane ABC transporters.

RNA-sequencing analysis reveals abundant developmental stage-specific and immunity-related genes in the pollen beetle Meligethes aeneus.

The pollen beetle (Meligethes aeneus) is a major pest of oilseed rape (Brassica napus) and other cruciferous crops in Europe. Pesticide-resistant pollen beetle populations are emerging, increasing the economic impact of this species. We isolated total RNA from the larval and adult stages, the latter either naïve or immunized by injection with bacteria and yeast. High-throughput RNA sequencing (RNA-Seq) was carried out to establish a comprehensive transcriptome catalogue and to screen for developmental stage-specific and immunity-related transcripts. We assembled the transcriptome de novo by combining sequence tags from all developmental stages and treatments. Gene expression data based on normalized read counts revealed several functional gene categories that were differentially expressed between larvae and adults, particularly genes associated with digestion and detoxification that were induced in larvae, and genes associated with reproduction and environmental signalling that were induced in adults. We also identified many genes associated with microbe recognition, immunity-related signalling and defence effectors, such as antimicrobial peptides (AMPs) and lysozymes. Digital gene expression analysis revealed significant differences in the profile of AMPs expressed in larvae, naïve adults and immune-challenged adults, providing insight into the steady-state differences between developmental stages and the complex transcriptional remodelling that occurs following the induction of immunity. Our data provide insight into the adaptive mechanisms used by phytophagous insects and could lead to the development of more effective control strategies for insect pests.

[Optimising the rehabilitation discharge report of the German statutory pension insurance: the recipients' and users' perspectives]. / Optimierung des Reha-Entlassungsberichts der Deutschen Rentenversicherung - die Sichtweisen der Adressaten bzw. Nutzer.

BACKGROUND: Given the significance of documentation and information transfer in the health-care system as well as new technological options, there is a need for continuously modifying and enhancing the pension insurance's rehabilitation discharge report while taking into account the benefits and expenses associated with it. Among the regular discharge report recipients/users are general practitioners, medical specialists, socio-medical consultants of the German pension insurance and other health-care providers and funding agencies (e. g., statutory health insurance, federal labour agency), external socio-medical consultants, judges in charge of social legislation issues, pension insurance administrators, and rehabilitation quality assurance officials. In the context of a broader project on the optimisation of the pension insurance's rehabilitation discharge report, the specific needs and interests of its recipients/users as well as suggestions concerning the improvement of structure and content of the discharge report were assessed. METHOD: Discharge report recipients/users were asked via questionnaire to indicate how frequently they use certain information from the report for their work. They were also asked to state objections/areas of concern and sugges­tions for improvement. RESULTS: 400 recipients/users filled in the questionnaire. More than half of the respondents considered the discharge report too long. Sugges­tions for shortening the report centred on avoiding redundancies and including standardised response items instead of free text passages. User groups differed with regard to the content that should be subject to reductions. CONCLUSIONS: The non-representative sample notwithstanding, the survey's results have rendered important starting points for optimising the statutory pension insurance's discharge report.

[External quality assurance in inpatient medical rehabilitation and prevention centers for mothers, fathers and children: comparative outcome quality analyses across rehabilitation/prevention centers]. / Externe Qualitätssicherung in Einrichtungen der stationären Vorsorge und Rehabilitation für Mütter und Väter einschließlich Mutter-/Vater-Kind-Einrichtungen: Einrichtungsvergleichende Analysen im Bereich Ergebnisqualität.

To date, there are no programs for external quality assurance for inpatient prevention and rehabilitation programs for mothers, fathers and children. Instruments for outcome quality assessment were evaluated with the goal of determining their ability to document differences between prevention/rehabilitation centers in quality-relevant outcome parameters. Referring to the ICF, relevant outcome variables were specified and operationalized using established questionnaires. Data from 45 inpatient prevention and rehabilitation centers for mothers, fathers and children were analyzed using multilevel modeling with risk adjustment. Intra-class correlations were computed to determine in which parameters differences between institutions could be found. The percentage of variability accounted for by patient vs. institution characteristics was computed while statistically controlling for relevant confounders. For prevention centers, substantial variation on the institutional level was found in 9 out of 15 parameters. Almost all institutions did not deviate significantly from the grand mean of the respective parameter. For rehabilitation centers, significant variability was found in 2 out of 10 parameters. The differences between most institutions remained within a range of expectable variability. The results imply that comparative analyses across hospitals are better suited to identify institutions with low quality rather than establish quality-based rankings of institutions.

[The 'ideal therapy process': testing a new approach for assessing process quality in inpatient parent-child facilities]. / Der "ideale Behandlungsprozess": Erprobung eines neuen Ansatzes zur Prüfung der Prozessqualität in Mutter-/Vater-Kind-Einrichtungen.

Instruments for external quality assurance in inpatient parent-child rehabilitation and prevention facilities were developed in 2 projects. For the assessment of process quality, we sought an alternative test to the peer review procedure which also places a stronger emphasis on patient perspectives. The aim was to define an "ideal process" as a standard, to develop quantifiable criteria, and to test a multimethod approach which involves different data levels. On the basis of different sources, the "ideal process" for parent-child rehabilitation and prevention and associated criteria were defined by involving an accompanying expert group during a consensus process. Criteria were assessed on different levels: on the rehabilitation/prevention centre level, a questionnaire of process-relevant structural features was used; on the patient level, a case-related routine documentation filled in by clinic staff and an incident-related patient questionnaire were applied. Data were collected in 37 centres (prevention: 19; rehabilitation: 11; 7 offering both types of programmes). Analysis of patient-related data is based on a sample of 1 513 prevention patients and 286 rehabilitation patients. The resulting "ideal process" consists of the stages "preparation", "arrival", "treatment planning", "treatment", "completion of treatment", and "organisation", each containing specific criteria. Exemplarily, the outcomes for the stages "treatment planning" and "treatment" are presented. There is variability both between features and between clinics. The majority of the patients report that the criteria are fulfilled while there are medium to high levels of fulfillment regarding the routine documentation. The criteria of the questionnaire of process-relevant structural features are mostly fulfilled according to the clinics. Agreement between the 3 data levels can be observed. On the basis of the defined "ideal process", the methods that were tested seem to be appropriate to illustrate process-relevant features from different perspectives. The exemplary measured process quality of the pilot clinics can be judged as predominantly good. Individual deficits of process quality and limitations of the chosen methods are discussed.

[Specific work-related problems: do they matter in access to work-related medical rehabilitation?]. / Besondere berufliche Problemlagen: Spielen sie eine Rolle beim Zugang in die medizinisch-beruflich orientierte Rehabilitation?

BACKGROUND: The study determined if need for rehabilitation in work-related medical rehabilitation (WMR) is more frequently characterised by specific work-related problems than in conventional medical rehabilitation (MR). METHODS: In 6 rehabilitation centres, persons with back pain (M50, M51, M53, M54) were surveyed about work-related restrictions of work ability at begin of their rehabilitation. RESULTS: Differences in work ability of WMR and MR patients confirmed need-related access. However, these differences were exclusively explained by screening-based access decisions. If access was not supported by a screening, WMR and MR patients did not differ. Decisions by rehabilitation centres compared with decisions by insurance agencies resulted in similar differences between WMR and MR patients. CONCLUSION: Screening-based decisions about access enable a more need-related access to WMR. As there were no differences between access decisions by rehabilitation centres and insurance agencies, access decisions can be realised already by the insurance agency.