[The MDK Reform Act and its effect on outpatient potential : Risk or opportunity for urology?] / Das MDK-Reformgesetz und seine Auswirkungen auf das ambulante Potenzial : Risiko oder Chance für die Urologie?

BACKGROUND: With the introduction of the MDK (Medizinischer Dienst der Krankenversicherung) Reform Act, there have been multiple new regulations for hospitals, some of which are confusing and interact with one another. A major focus of the legal changes is directly or indirectly on expanding the provision of outpatient services. OBJECTIVES: It can be assumed that-as a result of the new version of the framework conditions and the AOP catalog-the relevant OPS list will be expanded in the future. With the revision of the AOP catalog and the effects of the MDK Reform Act, the number of cases with outpatient potential will increase. Can the effects and challenges for hospitals and especially urology be identified? METHODS: Evaluation of official statistics of inpatient and outpatient treatments. Focusing on the problem based on a fictitious practical example from urology. RESULTS: A strategy is developed for dealing with cases with outpatient potential and identification of different solutions to compensate for this shift in services and enabling an increase in performance or a deliberate reduction in the provision of services. CONCLUSIONS: The choice of the type of service provision is increasingly no longer an issue, and the short-term inpatient treatment of many urological cases is coming under considerable pressure due to political measures such as the MDK Reform Act and the demands of health insurance companies. The reduction of different parts of the inpatient reimbursement for special patient groups must be anticipated. Individual strategies will range from simply not providing outpatient services to complex models of cooperation. This change also means opportunities for hospitals!

Use of antibiotic coated intramedullary nails in open tibia fractures: A European medical resource use and cost-effectiveness analysis.

PURPOSE: In patients with open tibial fractures, bone and wound infections are associated with an increased hospital length of stay and higher costs. The infection risk increases with the use of implants. Innovations to reduce this risk include antibiotic-coated implants. This study models whether the use of a gentamicin-coated intramedullary tibial nail is cost-effective for trauma centers managing patients with a high risk of infection. EFFICACY: Absolute infection risk and relative risk reduction, by fracture grade, for antibiotic-coated nails compared to standard nails for patients with open tibial fractures were estimated based on the results of a meta-analysis, which assessed the additional benefit of locally-administered prophylactic antibiotics in open tibia fractures treated with implants. The observed efficacy of antibiotic-coated nails in reducing infections was applied in an economic model. METHODS: The model compared infection rates, inpatient days, theatre usage and costs in high risk patients, with a Gustilo-Anderson (GA) grade III open fracture, for two patient cohorts from a trauma center perspective, with a 1-year time horizon. In one cohort all GAIII patients received a gentamicin-coated nail whilst GAI and GAII patients received a standard nail. All patients in the comparator cohort received a standard nail. Four European trauma centers provided patient-level data (n=193) on inpatient days, procedures and related costs for patients with and without infections. RESULTS: Using the gentamicin-coated nail in patients at high risk of infection (GAIII) was associated with 75% lower rate of infection and cost savings (€477 - €3.263) for all included centers; the higher cost of the implant was offset by savings from fewer infections, inpatient days (-26%) and re-operations (-10%). This result was confirmed by extensive sensitivity analyses. CONCLUSIONS: Analyses demonstrated that infection rates and total costs for in-hospital treatment could be potentially reduced by 75% and up to 15% respectively, by using a gentamicin-coated nail in patients at high risk of infection. Fewer infections, reduced inpatient days and re-operations may be potentially associated with use of antibiotic-coated implants. Results are sensitive to the underlying infection risk, with greatest efficacy and cost-savings when the coated implant is used in high risk patients.

A standardized protocol for measuring phenoloxidase in captive and wild Murray crayfish Euastacus armatus.

Innate immunity in arthropods is achieved largely through melanization which is in turn the result of the prophenoloxidase (ProPO) activation cascade; a series of biochemical reactions triggered by the immune identification of pathogen-recognition proteins (PRPs). Within this activation cascade, inactive proPO is cleaved to form the reactive enzyme phenoloxidase (PO). Methods of detecting PO are used to assess an arthropod's ability to respond to immune challenges. These detection assays have been described for some arthropods, especially those of commercial value, but none are available for Euastacus, a genus within the superfamily Parastacoidea. This study is the first step in developing a standardized protocol for the detection and quantification of PO activity in wild or captive Murray crayfish Euastacus armatus. Hemolymph extracts from 49 crayfish were assessed for PO activity using an assay measuring the conversion of l-dopa (3,4-dihydroxy-l-phenylalanine) into dopachrome. Short periods (up to 15 min) out of water did not cause any measurable change in PO activity. Phenoloxidase activity was detected in captive (n = 24, stressed) and wild (n = 25, healthy) crayfish with captive crayfish showing lower levels of PO possibly indicating immunosuppression. The proven protocol is the first of its kind to propose a standardized methodology for the detection and quantification of PO activity in Murray crayfish hemolymph as a means of determining stress.

Identification of a Catalytically Highly Active Surface Phase for CO Oxidation over PtRh Nanoparticles under Operando Reaction Conditions.

Pt-Rh alloy nanoparticles on oxide supports are widely employed in heterogeneous catalysis with applications ranging from automotive exhaust control to energy conversion. To improve catalyst performance, an atomic-scale correlation of the nanoparticle surface structure with its catalytic activity under industrially relevant operando conditions is essential. Here, we present x-ray diffraction data sensitive to the nanoparticle surface structure combined with in situ mass spectrometry during near ambient pressure CO oxidation. We identify the formation of ultrathin surface oxides by detecting x-ray diffraction signals from particular nanoparticle facets and correlate their evolution with the sample's enhanced catalytic activity. Our approach opens the door for an in-depth characterization of well-defined, oxide-supported nanoparticle based catalysts under operando conditions with unprecedented atomic-scale resolution.

Effect of everolimus on skin lesions in patients treated for subependymal giant cell astrocytoma and renal angiomyolipoma: final 4-year results from the randomized EXIST-1 and EXIST-2 studies.

BACKGROUND: Tuberous sclerosis complex (TSC) is a genetic disorder associated with tumour growth in various organs, including the brain, kidneys, heart and skin. Cutaneous lesions are prevalent manifestations of TSC, occurring in up to 90% of patients. Oral mammalian target of rapamycin inhibitors, such as everolimus, is believed to be effective for treatment of TSC-associated lesions because they act on the underlying disease pathophysiology. OBJECTIVE: We evaluated the long-term effect of oral everolimus on TSC-associated skin lesions as a secondary objective in the phase III studies EXIST-1 (NCT00789828) and EXIST-2 (NCT00790400) after approximately 4 years of treatment. MATERIALS AND METHODS: Everolimus was dosed 4.5 mg/m2 /day (titrated to trough 5-15 ng/mL) in patients with TSC-associated subependymal giant cell astrocytoma in EXIST-1, and 10 mg/day initially in adult patients with TSC- or sporadic lymphangioleiomyomatosis-associated renal angiomyolipoma in EXIST-2. Following positive results from the core phase, remaining patients were offered open-label everolimus in an extension. Skin lesion response rate was the proportion of patients achieving complete or partial clinical response. RESULTS: A total of 105 patients in EXIST-1 and 107 in EXIST-2 received everolimus and had ≥1 skin lesion at baseline. Skin lesion response rate (95% confidence interval) was 58.1% (48.1-67.7%) in EXIST-1 and 68.2% (58.5-76.9%) in EXIST-2; most were partial responses. At week 192 (EXIST-1: n = 55; EXIST-2: n = 56), 69% and 66% had a response. Most common drug-related adverse event was stomatitis (41-45%). CONCLUSION: Oral everolimus improved TSC-related skin lesions, with responses sustained over 4 years of treatment in EXIST-1 and EXIST-2.

Association of proton density fat fraction in adipose tissue with imaging-based and anthropometric obesity markers in adults.

BACKGROUND/OBJECTIVES: The purpose of this study was to examine the relationship of the proton density fat fraction (PDFF), measured by magnetic resonance imaging (MRI), of supraclavicular and gluteal adipose tissue with subcutaneous and visceral adipose tissue (SAT and VAT) volumes, liver fat fraction and anthropometric obesity markers. The supraclavicular fossa was selected as a typical location where brown adipocytes may be present in humans and the gluteal region was selected as a typical location enclosing primarily white adipocytes. SUBJECTS/METHODS: In this cross-sectional study, 61 adults (44 women, median age 29.3 years, range 21-68 years) underwent an MRI examination of the neck and the abdomen/pelvis (3T, Ingenia, Philips Healthcare). PDFF maps of the supraclavicular and gluteal adipose tissue and the liver were generated. Volumes of SAT and VAT were calculated and supraclavicular and subcutaneous fat were segmented using custom-built post-processing algorithms. Body mass index (BMI), waist circumference and waist-to-height ratio were recorded. Statistical analysis was conducted using the Student's t-test and Pearson correlation analysis. RESULTS: Mean supraclavicular PDFF was 75.3±4.7% (range 65.4-83.8%) and mean gluteal PDFF was 89.7±2.9% (range 82.2-94%), resulting in a significant difference (P<0.0001). Supraclavicular PDFF was positively correlated with VAT (r=0.76, P<0.0001), SAT (r=0.73, P<0.0001), liver PDFF (r=0.42, P=0.0008) and all measured anthropometric obesity markers. Gluteal subcutaneous PDFF also correlated with VAT (r=0.59, P<0.0001), SAT (r=0.63, P<0.0001), liver PDFF (r=0.3, P=0.02) and anthropometric obesity markers. CONCLUSIONS: The positive correlations between adipose tissue PDFF and imaging, as well as anthropometric obesity markers suggest that adipose tissue PDFF may be useful as a biomarker for improving the characterization of the obese phenotype, for risk stratification and for selection of appropriate treatment strategies.

Effects of dietary hop (Humulus lupulus L.) ß-acids on quality attributes, composition and oxidative stability of pork meat.

BACKGROUND: The effects of dietary levels of hop ß-acids on physical attributes, lipid oxidation and chemical composition of pork meat were evaluated. Thirty-two castrated male pigs obtained from a complete block design feeding experiment (6.23 ± 0.42 kg initial body weight (BW) to 20.45 ± 0.95 kg final BW) and fed diets supplemented with 0, 120, 240 or 360 mg kg-1 hop ß-acids during 35 days were slaughtered to sample longissimus dorsi muscle for meat analysis. RESULTS: No effects (P > 0.05) of dietary hop ß-acids were observed on meat physical attributes. Quadratic effects (P < 0.05) of hop ß-acids were observed on lipid and protein contents and on thiobarbituric acid-reactive substance (TBARS) values of meatballs, whose equations allowed the estimation of dietary hop ß-acid levels of 176, 169 and 181 mg kg-1 to provide up to 16.20% lipid reduction, 1.95% protein accretion and 23.31% TBARS reduction respectively. CONCLUSION: Dietary hop ß-acids fed to pigs might reduce lipid, increase protein and reduce lipid oxidation without affecting physical attributes of the pork meat. © 2017 Society of Chemical Industry.

[The cost estimator in the TraumaRegister DGU]. / Der Kostenschätzer im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVES: Estimated treatment costs of severely injured patients were often added to registry-based analyses. In the past, the TraumaRegister DGU® used a modular cost estimator for this purpose. A recent research project initiated by the German Trauma Society (DGU) evaluated the reimbursement of severely injured patients in the German DRG system. This project also allowed the generation of an improved update of the registry's cost estimator. METHODS: Detailed cost data for the acute therapy of severely injured patients were available from 10 hospitals that also participate in the TraumaRegister DGU®. Cost and registry data were matched using hospital code, date of admission, age, sex, and length of stay. A multivariate regression analysis with hospital costs as dependent variable included patients with an injury severity score (ISS) ≥ 9 points who stayed in hospital at least three days. All injuries were coded using the abbreviated injury scale (AIS). A total of 1002 patients treated in 2007 and 2008 were successfully matched. Cost data was collected for each case according to the method of calculation provided by the German DRG Institute (InEK). RESULTS: The mean age was 44 years and 73 % were males; the mean ISS was 27 points. The following aspects were significantly associated with the overall hospital costs: length of stay on the intensive care unit (ICU) (1152 € per day); length on intubation/ventilation (568 € per day); length of stay on normal ward (531 € per day); number of blood products (packed red blood cells; fresh frozen plasma) transfused until ICU admission (258 € per unit); a serious abdominal injury (AIS ≥3; 2849 €); an instable pelvic fracture with relevant blood loss (AIS 5; 7505 €); and a serious injury of the extremities (AIS 3-4; 2418 €). The estimated overall treatment costs calculated by the above mentioned formula averaged 22,138 € per case. The deviation from the measured real costs (21,546 € per case) was less than 3 %. CONCLUSION: Using only key data available for all patients in the registry, a valid cost estimator for acute care costs is now available in the TraumaRegister DGU®.

Meta-analysis of stomatitis in clinical studies of everolimus: incidence and relationship with efficacy.

BACKGROUND: Everolimus, an oral mammalian target of rapamycin (mTOR) inhibitor, is used to treat solid tumors and tuberous sclerosis complex (TSC). Stomatitis, an inflammation of the mucous membranes of the mouth, is a common adverse event associated with mTOR inhibitors, including everolimus. We conducted a meta-analysis of data from seven randomized, double-blind phase 3 clinical trials of everolimus to determine the clinical impact of stomatitis on efficacy and safety. PATIENTS AND METHODS: Data were pooled from the safety sets of solid tumor [breast cancer (BOLERO-2 and BOLERO-3), renal cell carcinoma (RECORD-1), carcinoid tumors (RADIANT-2), and pancreatic neuroendocrine tumors (RADIANT-3)] and TSC studies (EXIST-1 and EXIST-2). Data from solid tumor trials and TSC trials were analyzed separately. RESULTS: The rate of stomatitis was 67% in the solid tumor trials (973/1455 patients) and 70% in the TSC trials (110/157 patients). Most stomatitis events were grade 1/2, with grade 3/4 events reported in only 9% (solid tumor trials) and 8% (TSC trials) of patients. Low TSC patient numbers prevented an in-depth evaluation of stomatitis and response. In the solid tumor trials, most first stomatitis episodes (89%; n = 870) were observed within 8 weeks of starting everolimus. Patients with stomatitis occurring within 8 weeks of everolimus initiation had longer progression-free survival (PFS) than everolimus-treated patients without stomatitis in BOLERO-2 {8.5 versus 6.9 months, respectively; hazard ratio (HR), 0.78 [95% confidence interval (CI), 0.62-1.00]} and RADIANT-3 [13.9 versus 8.3 months, respectively; HR, 0.70 (95% CI, 0.48-1.04)]. A similar trend was observed in RECORD-1 [HR, 0.90 (95% CI, 0.66-1.22)] and RADIANT-2 [HR, 0.87 (95% CI, 0.61-1.22)] but not in BOLERO-3 [HR, 1.01 (95% CI, 0.75-1.36)]. CONCLUSIONS: Stomatitis did not adversely affect PFS, supporting the administration of everolimus in accordance with standard management guidelines.

[Comparison of ICD 10 and AIS with the Development of a Method for Automated Conversion]. / Vergleich von ICD-10 und AIS mit der Entwicklung einer Methode zur automatisierten Umwandlung.

BACKGROUND: Most of the current scores and outcome prediction calculations in traumatology are based on the Abbreviated Injury Scale (AIS). However, this is not routinely used for documentation and coding of injuries in many countries, including Germany. Instead of the AIS, the International Classification of Diseases (ICD) is used. While the ICD functions as the basis for automated calculating of the diagnosis-related groups (DRG), no possibility of simple conversion of the 10th version of the ICD into AIS is available so far. OBJECTIVES: The aim of this work is to develop and apply a methodology for simple conversion from ICD 10 to current AIS. MATERIALS AND METHODS: The developed mapping procedure was based on a 1 : n relationship between trauma codes of ICD-10-GM and the codes of the AIS2005. Calculated ISS from the conversion codes were then compared with the actual ISS coding available from the clinical trauma documentation. RESULTS: It can be shown that, despite the considerable differences in the structure and systematic of both classification systems, an automated translation is technically possible. CONCLUSIONS: The preliminary result of the mapping suggests, however, that despite the technical feasibility of a reliable conversion and comparability of ICD 10 and AIS in the required quality is still questionable. An automated conversion is still possible and quality would possibly improve by inclusion of additional information.

The influence of a brittle Cr interlayer on the deformation behavior of thin Cu films on flexible substrates: Experiment and model.

Thin metal films deposited on polymer substrates are used in flexible electronic devices such as flexible displays or printed memories. They are often fabricated as complicated multilayer structures. Understanding the mechanical behavior of the interface between the metal film and the substrate as well as the process of crack formation under global tension is important for producing reliable devices. In the present work, the deformation behavior of copper films (50-200 nm thick), bonded to polyimide directly or via a 10 nm chromium interlayer, is investigated by experimental analysis and computational simulations. The influence of the various copper film thicknesses and the usage of a brittle interlayer on the crack density as well as on the stress magnitude in the copper after saturation of the cracking process are studied with in situ tensile tests in a synchrotron and under an atomic force microscope. From the computational point of view, the evolution of the crack pattern is modeled as a stochastic process via finite element based cohesive zone simulations. Both, experiments and simulations show that the chromium interlayer dominates the deformation behavior. The interlayer forms cracks that induce a stress concentration in the overlying copper film. This behavior is more pronounced in the 50 nm than in the 200 nm copper films.

Review of free software tools for image analysis of fluorescence cell micrographs.

An increasing number of free software tools have been made available for the evaluation of fluorescence cell micrographs. The main users are biologists and related life scientists with no or little knowledge of image processing. In this review, we give an overview of available tools and guidelines about which tools the users should use to segment fluorescence micrographs. We selected 15 free tools and divided them into stand-alone, Matlab-based, ImageJ-based, free demo versions of commercial tools and data sharing tools. The review consists of two parts: First, we developed a criteria catalogue and rated the tools regarding structural requirements, functionality (flexibility, segmentation and image processing filters) and usability (documentation, data management, usability and visualization). Second, we performed an image processing case study with four representative fluorescence micrograph segmentation tasks with figure-ground and cell separation. The tools display a wide range of functionality and usability. In the image processing case study, we were able to perform figure-ground separation in all micrographs using mainly thresholding. Cell separation was not possible with most of the tools, because cell separation methods are provided only by a subset of the tools and are difficult to parametrize and to use. Most important is that the usability matches the functionality of a tool. To be usable, specialized tools with less functionality need to fulfill less usability criteria, whereas multipurpose tools need a well-structured menu and intuitive graphical user interface.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process]. / Abbildung orthopädisch-unfallchirurgischer Leistungen in den G-DRG-Systemversionen 2004 und 2014. Eine Zwischenbilanz des Weiterentwicklungsprozesses.

BACKGROUND: Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). CONCLUSION: Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

[Bone substitutes - basic principles and clinical applications]. / Knochenersatzmaterialien - Grundlagen und klinischer Nutzen.

Treatment of bone defects and non-unions frequently requires the transplantation of autologous bone. As an alternative, different kinds of bone substitutes have been used more often during the past years. These bone substitutes include synthetic materials, just as well as processed materials from human donors (allogen) or animals (xenogen). The relatively low hurdles in the approval process, compared to pharmaceutical drugs, have led to an almost unmanageable amount of different kinds of bone substitutes. Due to sparse clinical studies, evidence-based decisions for a specific product or a specific indication are hardly possible. Therefore, a deeper knowledge about basic properties of different bone substitutes is needed for a rational clinical decision. The present review aims to clarify the sometimes confusing nomenclature of bone substitutes and discuss their different biological properties. Generally, bone substitutes can be discriminated in osteogenic, osteoinductive and osteoconductive materials. The great majority of bone substitutes and especially synthetic materials serve as a matrix for bone growth and therefore possess mainly osteoconductive properties. The combination of these osteoconductive materials with osteogenic cells or osteoinductive growth factors, leads to composite materials with higher bone forming potential. Clinically, the quality and vitality of the recipient bone defect is of great importance. As a prerequisite for successful transplantation of bone substitutes or autologous bone, the recipient bone defect should be mechanically stable, free of infection with vital bone ends and intact soft tissue coverage. Bone defects in the spine, methaphyseal defects after trauma/tumour and diaphyseal segmental defects are typical indications for the application of bone substitutes. Unfortunately, the current literature does not allow concrete recommendations for specific bone substitutes or specific clinical indications. However, this review aims to discuss clinical benefits and limitations of bone substitutes for frequent indications to help clinicians in their decision making process.

Magnetic resonance imaging of less common pancreatic malignancies and pancreatic tumors with malignant potential.

Pancreatic tumors are an increasingly common finding in abdominal imaging. Various kinds of pathologies of the pancreas are well known, but it often remains difficult to classify the lesions radiologically in respect of type and grade of malignancy. Magnetic resonance imaging (MRI) is the method of choice for the evaluation of pancreatic pathologies due to its superior soft tissue contrast. In this article we present a selection of less common malignant and potentially malignant pancreatic neoplasms with their characteristic appearance on established MRI sequences with and without contrast enhancement.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. / Abbildung von Schwerverletzten im DRG-System : Wird die Schwerverletztenversorgung doch bezahlbar?

BACKGROUND: Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS: A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS: The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS: Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

Atomic structure and crystalline order of graphene-supported ir nanoparticle lattices.

We present the atomic structure of Ir nanoparticles with 1.5 nm diameter at half height and three layers average height grown on graphene/Ir(111). Using surface x-ray diffraction, we demonstrate that Ir nanoparticles on graphene/Ir(111) form a crystallographic superlattice with high perfection. The superlattice arrangement allows us to obtain detailed information on the atomic structure of the nanoparticles themselves, such as size, shape, internal layer stacking and strain. Our experiments disclose that the nanoparticles reside epitaxially on top of the graphene moiré structure on Ir(111), resulting in significant lateral compressive intraparticle strain. Normal incidence x-ray standing wave experiments deliver additional information on the particle formation induced restructuring of the graphene layer.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system]. / Die Herausforderung der sachgerechten Vergütung von Schwerverletzten im deutschen DRG-System.

BACKGROUND: Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. METHODS: A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. RESULTS: The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. CONCLUSION: The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.