Measurement of deformation heterogeneities in additive manufactured lattice materials by Digital Image Correlation: Strain maps analysis and reliability assessment.

The mechanical behaviour of porous lattice materials for potential orthopaedic applications was investigated at a fine scale by means of digital image correlation (DIC). Specimens with cubic, body cubic-centered reinforced (BCCZ), and diamond mesostructures were tested in quasi-static compression up to failure. Images were continuously recorded by an imaging setup and processed by a custom DIC program, OpenDIC. The resulting strain maps were analyzed in both spatial and temporal scales, displaying the onset and evolution of strain heterogeneities. The three geometries show different failure modes, i.e. collective buckling of an entire row for cubic, diagonal shearing band for BCCZ, and generalized crushing for diamond. The strain maps correlate well with these patterns. Most importantly, they show early strain localization below the macroscopic elastic limit. After failure, a phenomenon of strain release was witnessed and evaluated in the parts of the specimen that do not fracture. In the cubic geometry, the vertical struts sustain most of the deformation. Further analysis shows that the rows of vertical struts have similar, yet scattered, evolutions until failure. Interestingly, the row that leads to specimen failure is not necessarily the first one to deform. In addition to these experimental results, the uncertainties of the method were thoroughly assessed by means of calibration procedures.

[The first biologic for rheumatoid arthritis: factors influencing the therapeutic decision]. / Das erste Biologikum bei rheumatoider Arthritis: Einflussfaktoren auf die Therapieentscheidung.

BACKGROUND AND AIMS: Biologics (disease modifying antirheumatic drugs, bDMARD) have been in use in Germany for the treatment of rheumatoid arthritis (RA) since 2001, usually after failure of at least one conventional synthetic (cs)DMARD. We analyzed temporal changes in factors that influence the decision for either a first bDMARD or a further csDMARD. MATERIAL AND METHODS: We analyzed data from 9513 bDMARD-naive RA patients in the German biologics register RABBIT who switched to a new therapy. For three recruitment periods (2001-2003, 2004-2006 and 2009-2015) factors influencing the therapeutic decision were analyzed by means of machine learning methods and logistic regression analysis. RESULTS: In all recruitment periods the number of previous csDMARDs, high dosages of glucocorticoids (>7.5 mg/day) and a higher DAS28 (>5.1) were significantly associated with the decision for a first bDMARD. Over time, the chance of receiving a bDMARD increased in patients with moderate disease activity, moderate glucocorticoid dosages (5-7.5 mg/day) and those with comorbidities, such as congestive heart failure or prior malignancy. Men had a higher chance of receiving a bDMARD than women only in the first recruitment period. Private health insurance, high education and gainful employment were significantly associated with more frequent prescription of bDMARDs in all recruitment periods. DISCUSSION: The time-dependent changes in the impact of disease activity, concomitant drugs, gender and comorbidity on the prescription of bDMARDs mirror the increasing therapeutic options and the growing experience in the application of the new substances in patients at higher risk. The influence of demographic and social factors may reflect safety concerns in patients at increased risk of adverse events but also the need to economize drug costs..

Comprehensive assessment of food and nutrient intake of children and adolescents in Germany: EsKiMo II - the eating study as a KiGGS module.

BACKGROUND: As part of the second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2), food and nutrient intake of children and adolescents aged 6-17 years living in Germany is assessed in EsKiMo II - the Eating Study as a KiGGS Module. METHODS: EsKiMo II is a cross-sectional study, conducted from June 2015 until September 2017. The study population comprises 6 to 17-year-old study participants from the cross-sectional sample of KiGGS Wave 2 in 167 KiGGS sample points, which are revisited by trained nutritionists. Dietary intake is assessed by weighted food records during three consecutive days plus one randomly selected day within the following 3 months for children aged 6-11 years. Dietary intake for adolescents aged 12-17 years is assessed by computer-assisted dietary history interviews, reflecting the past four weeks, using the software DISHES. Further information, for example, about specific diets and dietary supplement intake, is reported during a standardised computer assisted interview for all participants. Food items are coded by the German Food Code and Nutrient Database (BLS 3.02). DISCUSSION: EsKiMo II provides actual data on the dietary behaviour of children and adolescents living in Germany and their determinants. Results of EsKiMo II will be relevant for decision-making, measures, and evaluations within nutrition, consumer and health policy.

Simulated air quality and pollutant budgets over Europe in 2008.

Major gaseous and particulate pollutant levels over Europe in 2008 have been simulated using the offline-coupled WRFCMAQ chemistry and transport modeling system. The simulations are compared with surface observations from the EMEP stations, ozone (O3) soundings, ship-borne O3 and nitrogen dioxide (NO2) observations in the western Mediterranean, tropospheric NO2 vertical column densities from the SCIAMACHY instrument, and aerosol optical depths (AOD) from the AERONET. The results show that on average, surface O3 levels are underestimated by 4 to 7% over the northern European EMEP stations while they are overestimated by 7-10% over the southern European EMEP stations and underestimated in the tropospheric column (by 10-20%). Particulate matter (PM) mass concentrations are underestimated by up to 60%, particularly in southern and eastern Europe, suggesting underestimated PM sources. Larger differences are calculated for individual aerosol components, particularly for organic and elemental carbon than for the total PM mass, indicating uncertainty in the combustion sources. Better agreement has been obtained for aerosol species over urban areas of the eastern Mediterranean, particularly for nss-SO4(2), attributed to the implementation of higher quality emission inventories for that area. Simulated AOD levels are lower than the AERONET observations by 10% on average, with average underestimations of 3% north of 40°N, attributed to the low anthropogenic emissions in the model and 22% south of 40°N, suggesting underestimated natural and resuspended dust emissions. Overall, the results reveal differences in the model performance between northern and southern Europe, suggesting significant differences in the representation of both anthropogenic and natural emissions in these regions. Budget analyses indicate that O3 and peroxyacetyl nitrate (PAN) are transported from the free troposphere (FT) to the planetary boundary layer over Europe, while other species follow the reverse path and are then advected away from the source region.

[Preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The 2009 ESC guidelines]. / Präoperatives kardiales Risiko und perioperatives kardiales Management bei nichtkardialer Chirurgie. Die ESC-Leitlinie 2009.

In November 2009 the first European guidelines were presented regarding preoperative risk assessment and perioperative management in non-cardiac surgery. They were designed by the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology.In a standardized manner, patient-specific clinical variables, their exercise capacity and surgery-specific risk factors are summarized to a recommendation concerning medication and preoperative cardiac evaluation. These guidelines are straightforward and feasible for cardiologists as well as specialists in internal medicine and general practicioners. Nevertheless, some points still lack evidence.

[Requirements for leading surgeons from the viewpoint of hospital administration authorities]. / Anforderungen an den chirurgischen Chefarzt aus Sicht des Trägers.

A private hospital company has the same criteria for leading surgeons as all other healthcare providers. The main criteria are medical competency and good manners with patients and medical staff. Economical knowledge is also very important but does not necessarily include a special qualification in business administration, such as MBA. The head of a surgical department must be able to include current developments in health policy into the work. He should also be able to analyze his own situation and make corrections if possible and discuss the current economical situation in a constructive and trustworthy manner with the management. The head of a surgical department is responsible for the quality of medical and surgical education of his staff.

Quality of life in 1000 patients with early relapsing-remitting multiple sclerosis.

BACKGROUND AND PURPOSE: To examine the quality of life (QoL) in a large cohort of untreated patients with relapsing-remitting multiple sclerosis (RRMS) and to investigate the impact of intramuscular (IM) interferon beta-1a (IFNbeta-1a) treatment. METHODS: Prospective, observational, open-label, multicentre study conducted in Germany. Untreated patients with RRMS who initiated treatment with IM IFNbeta-1a were included and followed for 12 months. QoL was measured using the EQ-5D questionnaire. Clinical response was assessed by relapse rate and disability (Expanded Disability Status Scale; EDSS). RESULTS: A total of 1157 patients were included [mean age 37.6 years, median disease duration 13 months, mean relapse rate 1.7 (95%CI: 1.58-1.73), median EDSS score 2.0]. Relapse rate was reduced to 0.6 at 12 months (95%CI: 0.51-0.69, P < 0.0001). EDSS did not change significantly. At baseline, QoL was considerably lower in MS patients compared with the general German population, but was improved after treatment initiation [utilities of EQ-5D: 0.77 (95%CI: 0.75-0.78) vs. 0.75 (95%CI: 0.74-0.76) at baseline, 95%CI for difference: 0.01-0.03, P = 0.0046]. Higher disease activity and inability to work were negative predictors of QoL. 14.7% of patients were incapable of working for MS-related reasons. CONCLUSIONS: Quality of life is considerably impaired in early stages of MS. Treatment initiation with IM IFNbeta attenuates MS disease activity and improves QoL. Inability to work early during the disease is a major challenge for the social security systems.

[Modern scoliosis surgery under the conditions of the German DRG-system]. / Finanzierbarkeit der modernen Skoliosechirurgie unter den Bedingungen des DRG-Systems.

In the German health system the payment of a hospital stay is standardised. The common basis is the G-DRG System (German diagnosis-related groups) in which every stay is paid by a lump sum. Scoliosis correction in our times means pedicle screw-based multilevel double rod instrumentation or anterior plate-rod instrumentation with primary stability. The outcome of those methods has improved the results of correction and decreased the complication rate but also means high costs due to the implants. Scoliosis correction is covered by DRG I06. Due to constant efforts a general improvement took place in the assessment of DRG I06. That is the reason why the losses incurred in DRG I06C could be lowered to 38% and in I06D to 22% in 2008. For an appropriate assessment further improvements are required.

[Can the frequency of color-coded duplex sonography in urgent examination of deep vein thrombosis be reduced by application of a clinical probability assessment?]. / Kann die Frequenz duplexsonografischer Notfalluntersuchungen der tiefen Beinvenenthrombose durch Anwendung einer klinischen Wahrscheinlichkeitsbewertung reduziert werden?

PURPOSE: Application and verification of the Wells score for pre-test probability of deep vein thrombosis in the lower limbs in clinical routine. The goal was to reduce the number of immediate diagnostic measures for excluding vein thrombosis during acute investigation. New parameters for upgrading or modification the existing score were checked. MATERIALS AND METHODS: In a period from March through November 2007, 333 patients were assigned to the department of radiology in order to exclude deep vein thrombosis. A standardized questionnaire was used to identify the probability of deep vein thrombosis. The patients were categorized as low, moderate, and high risk. The examination was conducted with colored-coded duplex sonography. RESULTS: In the patient population of 333, 41 (12 %) had deep vein thrombosis of the lower limb. The prevalence was approximately 3 % in the low risk group, 34 % in the moderate risk group, and 63 % in the high risk group. Categorization with the Wells score is an instrument with high sensitivity (99.6 %) and specificity (100 %). CONCLUSION: The pre-test probability with the Wells score represents a useful and established instrument in the clinical routine. Acute examinations, especially during stand-by, can be reduced without neglecting patient safety. Patients with a Wells score of 0 don't require an acute examination. An elective investigation should be targeted. Patients with a score between 1 and 8 needed to be treated (within the next 24 hours) with KS and FKDS. According to on our data records, therapy should be started immediately for patients with a high risk of deep vein thrombosis.

Patient characteristics and costs associated with dyslipidaemia and related conditions in HIV-infected patients: a retrospective cohort study.

BACKGROUND: Metabolic abnormalities are common in HIV-infected individuals and, although multifactorial in origin, have been strongly associated with antiretroviral therapy. METHODS: Using automated claims and clinical databases, combined with medical record data, we evaluated the burden of dyslipidaemia (DYS) and associated metabolic abnormalities among a cohort of 900 HIV-infected patients aged 18 years and older who received their care from a large multispecialty medical group between 1 January 1996 and 30 June 2002. A Cox proportional hazards model for DYS was developed. Resource use was compiled and subsequently costed with stratification to account for variable length of follow-up. RESULTS: Mean follow-up time was 3.3 years. DYS was present in 54% of the cohort and 3.4% experienced a cardiovascular (CV) event. Both unadjusted and adjusted results found patients with dyslipidaemia and cardiovascular events significantly more likely to have received protease inhibitor (PI) treatment for longer periods of time. In the Cox proportional hazards model the following factors were significantly associated with an increased risk for DYS: older age, white race, PI use and male sex. Diagnoses of hypertension, hepatitis C virus infection, depression or opportunistic infections were all negatively associated with a DYS diagnosis. When controlled for length of follow up, patients with DYS (and no CV-related events) incurred greater median and mean total average costs than patients without DYS or CV-related events. For patients with more than 2 years of follow up, these total cost differences were statistically significant (P<0.05). CONCLUSIONS: These findings indicate that DYS is common among patients with HIV infection and is associated with increased use of medical resources.

Mild-to-moderate uncomplicated hypertension: further analysis of a cost-effectiveness study of five drugs.

A cost-effectiveness model was designed to explore the effect of adding a new angiotensin-II inhibitor, telmisartan, to the therapeutic options for treating mild-to-moderate uncomplicated hypertension. Incorporating the cost of drugs, physician visits, and adverse-event treatments, the model concluded that availability of telmisartan on formulary may shorten the mean time and costs to control. The stability of the initial findings over a range of sensitivity analyses lends credence to the model conclusions that availability of telmisartan on formulary improves the therapeutic options of care for hypertension.

Day clinics and hospitals--a cost comparison.

OBJECTIVE: To determine the types of surgical procedures currently undertaken in day clinics and to compare the number of procedures, the average in-facility cost, and the pre- and post-discharge costs for each procedure or group of procedures. DESIGN: A retrospective descriptive study of medical aid claims data. SETTING: Department of Family Medicine, University of the Witwatersrand, Johannesburg. SUBJECT: Three private sector medical aid schemes with in excess of 170,000 principal members (380,000 lives). OUTCOME MEASURES: For each surgical procedure the following were compared: (i) the total number of procedures done; (ii) the average total in-facility cost; and (iii) the cost of professional fees and medicines for 7 days before admission, during admission, and for 14 days after discharge. RESULTS: During 1997, 89,216 patients underwent surgery. Day clinics and hospitals accounted for 5,490 and 83,726 admissions respectively. Fifty-one different types of procedures were identified that met the inclusion criteria. On average the in-facility costs for 45 (88%) of the 51 compared procedures were lower in day clinics compared with hospitals. Average costs can be as much as 90% lower in day clinics. Some procedures, particularly certain dental operations, cost more in day clinics. The professional fees of attending doctors and the cost of medicines are generally higher when the procedure is undertaken in a hospital. CONCLUSION: In South Africa, as is the case in the USA, day clinics have the potential to reduce the cost of surgical procedures.

Delphi panel study of current hypertension treatment patterns.

OBJECTIVE: The purpose of this study was to assess whether, and to what extent, usual practice in the management of patients with mild to moderate hypertension differs from that recommended in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). The results were used as input for a clinical decision analytic model to assess the cost-effectiveness of a new treatment for hypertension. METHODS: A Delphi panel survey of general practitioners and cardiologists in the United States was conducted to determine current strategies for the treatment of mild to moderate uncomplicated hypertension. The purpose of the panel survey was to reach consensus on 3 key facets of the JNC-VI guidelines and how they relate to the respondents' clinical practices: (1) the definition of mild to moderate hypertension, (2) the treatment that adult patients with uncomplicated mild to moderate hypertension should receive, and (3) the management of patient follow-up. RESULTS: Of the 20 physicians contacted for the survey, 10 responded to both rounds of the questionnaire. There was considerable variation in the responses for defining the ranges of healthy, acceptable, unacceptable, and serious blood pressure. In general, the Delphi panel respondents cited higher limits than stated in the JNC-VI guidelines. Physicians followed the guidelines approximately 60% of the time. Primary determinants of initial drug choice among the panelists were comorbid conditions and the severity of hypertension; patients' age, race, and sex were secondary determinants. Follow-up typically occurred 1 month after therapy initiation. Panelists reported titrating the dose of new therapies upward once or twice before discontinuing the drug for lack of efficacy. Once adequate blood pressure control was achieved, patient follow-up was reported to occur every 3 to 4 months. CONCLUSIONS: This Delphi panel study highlights the differences between clinical practice and the JNC-VI guidelines in the treatment of hypertension. The results were used as a basis for defining a structure for a cost-effectiveness model and provided the management practice and prescribing practice patterns required by the model.

Doppler myocardial imaging in the assessment of regional myocardial function in longitudinal direction pre- and post-PTCA.

AIMS: Doppler myocardial imaging is potentially a sensitive tool to assess regional myocardial velocities pre- and post-percutaneous transluminal coronary angioplasty (PTCA) as a marker of contractility to evaluate short- to medium-term information on functional myocardial recovery following the release of ischaemia. METHODS: Thirty patients with single vessel disease were studied to assess regional myocardial peak systolic velocity, systolic velocity time integral and mitral valve plane excursion in longitudinal direction one day pre-, one day post- and 3 months post-PTCA. The patients were assigned to group A with coronary stenoses >70% and group B with stenoses < 70%. RESULTS: In group A pre-PTCA the ischaemic segments showed a significantly lower peak systolic velocity and velocity time integral compared with the values one day after PTCA (5.8 +/- 1.4 vs 7.7 +/- 1.4cm.s(-1); 1.06 +/- 0.22 vs 1.23 +/-0.28cm;P< 0.03). In contrast, mitral valve plane excursion in this group remained unchanged after PTCA for both the ischaemic and non-ischaemic left ventricular wall. In group B no changes of these parameters and no differences in mitral valve plane excursion of the ischaemic and the non-ischaemic left ventricular wall could be seen. CONCLUSION: With Doppler myocardial imaging it was possible to quantify a number of indices which changed due to the successful release of ischaemia.

[Assessment of drain insertion in thyroid surgery?]. / Prophylaktische Drainage in der Schilddrüsenchirurgie? Eine Effizienzüberprüfung anhand klinischer und sonographischer Parameter.

INTRODUCTION: Although generally recommended the benefit of suction drains in thyroid surgery is not proven. METHODS: Therefore, we started a prospective randomized trial including all patients who were referred to our institution for resection of an euthyroid goiter (n = 52 with drains and 48 without). On the third postoperative day as well as four weeks later the patients were questioned and physically examined, including an ultrasound of the neck and, if present, the measurement of a hematoma. RESULTS: Two patients had to be reoperated due to a hemorrhage detected by the drains. Further the study revealed that patients without drains left the hospital significantly earlier (3.9 vs 4.6 days, p = 0.006). On the other hand the hematoma size in this group was larger than in the group with drains (1.9 ml vs. 0.9 ml, p = 0.016). The other clinical parameters were comparable in both groups. Four weeks postoperatively no differences were detected. DISCUSSION: So far neither our results nor those in the literature could prove that severe postoperative hemorrhage can be recognized or treated faster with the use of drains. Although drains reduce the size of hematomas significantly, the quantity is too small for any clinical relevance. Based on these results a general insertion of drains after resection of an euthyroid goiter is not recommended.

Potential savings in the cost of caring for Alzheimer's disease. Treatment with rivastigmine.

OBJECTIVE: To estimate savings in the cost of caring for patients with Alzheimer's disease (AD) during 6 months, 1 year and 2 years of treatment with rivastigmine. An intermediate objective was to estimate the relationship between disease progression and institutionalisation. DESIGN AND SETTING: We assessed the relationship between Mini-Mental State Examination (MMSE) score and institutionalisation using a piecewise Cox proportional hazard model. To estimate cost savings from treatments lasting 6 months, 1 year and 2 years, estimates of the probability of institutionalisation were integrated with data from two 6-month phase III clinical trials of rivastigmine and a hazard model of disease progression. MAIN OUTCOME MEASURES AND RESULTS: Our data suggest that savings in the overall cost of caring for patients with mild and moderate AD can be as high as $US4839 per patient after 2 years of treatment. Furthermore, the probability of institutionalisation increases steadily as MMSE score falls. Among our study individuals, age, race, level of education and marital status were significant predictors of institutionalisation, whereas gender had little effect. CONCLUSIONS: Using rivastigmine to treat AD results in a delay in disease progression for patients who begin treatment during the mild or moderate stages of the disease. By delaying the probability that a patient will be institutionalised, the cost of caring for AD patients can be significantly reduced.

Roundtable discussion: Part I--Epidemiologic, demographic, and treatment challenges in hypertension.

Hypertension is one of the most pervasive medical disorders in this country. As the nation's population ages, the number of patients with hypertension can be expected to rise substantially. On December 9, 1999, a panel of managed care medical directors, pharmacy directors, clinicians, and health economists convened in Irvine, Texas to discuss aspects of hypertension management and economic analysis. This roundtable is presented in three parts, including (1) a summary of the challenges of hypertension management from the point of view of the clinician, (2) the introduction of a pharmacoeconomic model of hypertension management, and (3) a discussion of how health plans approach this insidious disorder.

Roundtable discussion: Part II--Development of a pharmacoeconomic model in hypertension.

Antihypertensive medications are targeted by most health plans as a major cost center. However, the efficacy of these medications, their side effects, and their resulting ability to prevent serious long-term complications must be factored into the value equation. To illustrate the possible economic effects of a single antihypertensive agent's inclusion on a health plan's drug formulary, an innovative pharmacoeconomic model was developed. In this portion of the roundtable, the design, results, and caveats of this model are discussed.

Roundtable discussion: Part III--Hypertension management in health plans.

In the final section of the roundtable discussion, participants describe how their individual managed care plans approach hypertension from the standpoints of disease management targeting, strategies to combat noncompliance, and how these plans utilize pharmacoeconomic information in drug formulary decision making.