eCross-cultural adaptation of the spine oncology-specific SOSGOQ2.0 questionnaire to German language and the assessment of its validity and reliability in the clinical setting.

BACKGROUND: The recently developed Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) was proven a valid and reliable instrument measuring health-related quality of life (HRQOL) for patients with spinal malignancies. A German version was not available. OBJECTIVE: A cross-cultural adaptation of the SOSGOQ2.0 to the German language and its multicenter evaluation. METHODS: In a multistep process, a cross-cultural adaptation of the SOSGOQ2.0 was conducted. Subsequently, a multicenter, prospective observational cohort study was initiated to assess the reliability and validity of the German adaptation. To assess external construct validity of the cross-cultural adapted questionnaire, a comparison to the established questionnaire QLQ-C30 from the European Organisation for Research and Treatment of Cancer was conducted. Mean-difference plots were used to measure the agreement between the questionnaires in total score and by domain (deviation from mean up to 10% allowed). Further reliability and validity tests were carried out. Change to baseline was analysed 3-16 weeks later after different interventions occurred. Clinically relevant thresholds in comparison to the EORTC QLQ-C30 questionnaire were evaluated by ROC curve analysis. RESULTS: We could enroll 113 patients from four different university hospitals (58 females, 55 males). Mean age was 64.11 years (sd 11.9). 80 patients had an ECOG performance status of 2 or higher at baseline. External construct validity in comparison to the EORTC QLQ-C30 questionnaire in total score and by domain was confirmed (range of deviation 4.4 to 9.0%). Good responsiveness for the domains Physical Functioning (P < .001) and Pain (P < .001) could be shown. The group mean values also displayed a difference in the domains of Social Functioning (P = .331) and Mental Health (P = .130), but not significant. The minimum clinically relevant threshold values for the questionnaire ranged from 4.0 to 7.5 points. CONCLUSIONS: According to our results, the cross-cultural adapted questionnaire is a reliable and valid tool to measure HRQOL in German speaking patients with spinal malignancies. Especially the domains Physical Functioning and Pain showed overall good psychometric characteristics. In this way, a generic questionnaire, such as the EORTC QLQ-C30, can be usefully supplemented by spine-specific questions to increase the overall accuracy measuring HRQOL in patients with spinal malignancies.

Am I Ready to Be an Independent Neuroradiologist? Objective Trends in Neuroradiology Fellows' Performance during the Fellowship Year.

BACKGROUND AND PURPOSE: Aside from basic Accreditation Council for Graduate Medical Education guidelines, few metrics are in place to monitor fellows' progress. The purpose of this study was to determine objective trends in neuroradiology fellowship training on-call performance during an academic year. MATERIALS AND METHODS: We retrospectively reviewed the number of cross-sectional neuroimaging studies dictated with complete reports by neuroradiology fellows during independent call. Monthly trends in total call cases, report turnaround times, relationships between volume and report turnaround times, and words addended to preliminary reports by attending neuroradiologists were evaluated with regression models. Monthly variation in frequencies of call-discrepancy macros were assessed via χ2 tests. Changes in frequencies of specific macro use between fellowship semesters were assessed via serial 2-sample tests of proportions. RESULTS: From 2012 to 2017, for 29 fellows, monthly median report turnaround times significantly decreased during the academic year: July (first month) = 79 minutes (95% CI, 71-86 minutes) and June (12th month) = 55 minutes (95% CI, 52-60 minutes; P value = .023). Monthly report turnaround times were inversely correlated with total volumes for CT (r = -0.70, F = 9.639, P value = .011) but not MR imaging. Words addended to preliminary reports, a surrogate measurement of report clarity, slightly improved and discrepancy rates decreased during the last 6 months of fellowship. A nadir for report turnaround times, discrepancy errors, and words addended to reports was seen in December and January. CONCLUSIONS: Progress through fellowship correlates with a decline in report turnaround times and discrepancy rates for cross-sectional neuroimaging call studies and slight improvement in indirect quantitative measurement of report clarity. These metrics can be tracked throughout the academic year, and the midyear would be a logical time point for programs to assess objective progress of fellows and address any deficiencies.

Outcome assessment in dermatology clinical trials and cochrane reviews: call for a dermatology-specific outcome taxonomy.

BACKGROUND: Standardized outcome reporting is crucial for trial evidence synthesis and translation of findings into clinical decision-making. The OMERACT 2.0 Filter and COMET outcome domain taxonomy propose frameworks for consistent reporting of outcomes. There is an absence of a uniform dermatology-specific reporting strategy that uses precise and consistent outcome definitions. OBJECTIVES: Our aim was to map efficacy/effectiveness outcomes assessed in dermatological trials to the OMERACT 2.0 Filter as a starting point for developing an outcome taxonomy in dermatology. METHODS: We critically appraised 10 Cochrane Skin Reviews randomly selected from all 69 Cochrane Skin Reviews published until 01/2015 and the 220 trials included covering a broad spectrum of dermatological conditions and interventions. Efficacy/effectiveness outcomes were mapped to core areas and domains according to the OMERACT 2.0 Filter. The extracted trial outcomes were used for critical appraisal of outcome reporting in dermatology trials and for the preliminary development of a dermatology-specific outcome taxonomy. RESULTS: The allocation of 1086 extracted efficacy/effectiveness outcomes to the OMERACT 2.0 Filter resulted in a hierarchically structured dermatology-specific outcome classification. In 506 outcomes (47%), the outcome concept to be measured was insufficiently described, hindering meaningful evidence synthesis. Although the core areas assessed in different dermatology trials of the same condition overlap considerably, quantitative evidence synthesis usually failed due to imprecise outcome definitions, non-comparable outcome measurement instruments, metrics and reporting. CONCLUSIONS: We present an efficacy/effectiveness outcome classification as a starting point for a dermatology-specific taxonomy to provide trialists and reviewers with the opportunity to better synthesize and compare evidence.

Old carbon reservoirs were not important in the deglacial methane budget.

Permafrost and methane hydrates are large, climate-sensitive old carbon reservoirs that have the potential to emit large quantities of methane, a potent greenhouse gas, as the Earth continues to warm. We present ice core isotopic measurements of methane (Δ14C, δ13C, and δD) from the last deglaciation, which is a partial analog for modern warming. Our results show that methane emissions from old carbon reservoirs in response to deglacial warming were small (<19 teragrams of methane per year, 95% confidence interval) and argue against similar methane emissions in response to future warming. Our results also indicate that methane emissions from biomass burning in the pre-Industrial Holocene were 22 to 56 teragrams of methane per year (95% confidence interval), which is comparable to today.

Healthcare costs associated with allergic rhinitis, asthma allergy immunotherapy.

Summary: Allergic rhinitis (AR) and asthma are chronic diseases in which the airways become inflamed in response to allergens. Allergy immunotherapy (AIT) is recommended for those unable to manage symptoms using pharmacotherapy. This study estimated healthcare costs and utilisation for patients with AR and asthma. Mean annual outpatient visits, pharmaceutical costs and inpatient hospitalisations were calculated for 2010 and 2014, with pharmaceutical and inpatient costs stratified by AIT use. AR and asthma patients had a 35% higher mean number of physician visits and up to 90% higher mean pharmaceutical costs compared to controls. The cost of pharmaceuticals and inpatient hospitalisations were 54% lower in those prescribed AIT. Further research is recommended to understand the reasons for these cost differences.

TREatment of ATopic eczema (TREAT) Registry Taskforce: an international Delphi exercise to identify a core set of domains and domain items for national atopic eczema photo- and systemic therapy registries.

BACKGROUND: Evidence of immunomodulatory therapies to guide clinical management of atopic eczema (AE) is scarce, despite frequent and often off-label use. Patient registries provide valuable evidence for the effects of treatments under real-world conditions that can inform treatment guidelines, give the opportunity for health economic evaluation and the evaluation of quality of care, as well as pharmacogenetic and dynamic research, which cannot be adequately addressed in clinical trials. OBJECTIVES: The TREatment of ATopic eczema (TREAT) Registry Taskforce aims to seek international consensus on a core set of domains and items ('what to measure') for AE research registries, using a Delphi approach. METHODS: Participants from six stakeholder groups were included: doctors, nurses, nonclinical researchers, patients, industry and regulatory body representatives. The eDelphi comprised three sequential online rounds, requesting participants to rate the importance of each proposed domain item. Participants could add domain items to the proposed list in round 1. A final consensus meeting was held to ratify the core set. RESULTS: Participants (n = 479) from 36 countries accessed the eDelphi platform, of whom 86%, 79% and 74% completed rounds 1, 2 and 3, respectively. At the face-to-face consensus meeting attended by 42 participants the final core set was established containing 19 domains with 69 domain items (49 baseline and 20 follow-up items). CONCLUSIONS: This core set of domains and items to be captured by national AE systemic therapy registries will standardize data collection and thereby allow direct comparability across registries and facilitate data pooling between countries. Ultimately, it will provide greater insight into the effectiveness, safety and cost-effectiveness of photo- and systemic immunomodulatory therapies.

[Identification of Control Hospitals for the Implementation of the Nationwide and Standardized Evaluation of Model Projects According to § 64b SGB V: Analysis of Data from Structured Quality Reports]. / Auswahl geeigneter Kontrollkliniken für die Durchführung der bundesweiten und einheitlichen Evaluation von Modellvorhaben nach § 64b SGB V. Analyse von Daten der Strukturierten Qualitätsberichte.

BACKGROUND: Health care needs of mentally ill patients make special demands on cross-sectoral health care structures. § 64b SGB V enables care of mentally ill patients through model projects that are multi-professional, work across treatment periods and sectors and implement new forms of financing. These model projects in their hospitals (case hospitals) need to be evaluated and compared with standard treatment methods. OBJECTIVES: The aim of this analysis is to identify matching hospitals according to a priori defined criteria for the establishment of a control group (control hospitals) using secondary data. MATERIALS AND METHODS: A systematic analysis was conducted based on structured quality reports according to §+137 SGB V and matched data from the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). Based on a priori defined knock-out criteria, criteria based on patients (weighting 50%), structural features of hospitals (25%) and environmental factors (25%), a weighted similarity score was calculated for each of the 13 case hospitals, which could reach the maximum of 100 points (perfect match). RESULTS: 10 control hospitals per case hospital were identified according to the weighted similarity score. The median of the total deviation of potential control hospitals from the case hospitals was 34.3 (range: 17.6-66.7). The median of the 10 selected control hospitals per case hospital was 30.9 (range: 17.6-40.8). DISCUSSION: The defined algorithm could be used to identify similar control hospitals. The method using the mentioned databases and derivation of specific criteria of structural similarity are generally suitable in controlled designs for the evaluation of complex interventions based on routine data.

Quantitative assessment of structural image quality.

Data quality is increasingly recognized as one of the most important confounding factors in brain imaging research. It is particularly important for studies of brain development, where age is systematically related to in-scanner motion and data quality. Prior work has demonstrated that in-scanner head motion biases estimates of structural neuroimaging measures. However, objective measures of data quality are not available for most structural brain images. Here we sought to identify quantitative measures of data quality for T1-weighted volumes, describe how these measures relate to cortical thickness, and delineate how this in turn may bias inference regarding associations with age in youth. Three highly-trained raters provided manual ratings of 1840 raw T1-weighted volumes. These images included a training set of 1065 images from Philadelphia Neurodevelopmental Cohort (PNC), a test set of 533 images from the PNC, as well as an external test set of 242 adults acquired on a different scanner. Manual ratings were compared to automated quality measures provided by the Preprocessed Connectomes Project's Quality Assurance Protocol (QAP), as well as FreeSurfer's Euler number, which summarizes the topological complexity of the reconstructed cortical surface. Results revealed that the Euler number was consistently correlated with manual ratings across samples. Furthermore, the Euler number could be used to identify images scored "unusable" by human raters with a high degree of accuracy (AUC: 0.98-0.99), and out-performed proxy measures from functional timeseries acquired in the same scanning session. The Euler number also was significantly related to cortical thickness in a regionally heterogeneous pattern that was consistent across datasets and replicated prior results. Finally, data quality both inflated and obscured associations with age during adolescence. Taken together, these results indicate that reliable measures of data quality can be automatically derived from T1-weighted volumes, and that failing to control for data quality can systematically bias the results of studies of brain maturation.

[Utilization of Physical Therapy Services in Germany from 2004 until 2014: Analysis of Statutory Health Insurance Data]. / Physiotherapeutische Versorgungssituation in Deutschland von 2004 bis 2014. Analyse des Verordnungsverhaltens bei Versicherten der Gesetzlichen Krankenversicherung.

Background: Both at the national and international levels, direct access for patients to physical therapy services is currently under debate. Direct access for patients seeking physical therapy care might reduce waiting time and costs, and thus be of benefit for patients and health insurance companies. To critically evaluate this situation, reliable and valid data are needed, but currently lacking. The aim of this study is to evaluate the health care situation for physical therapy services included in the catalogue of remedies from 2004 up to 2014 in Germany. Methods: To obtain information regarding physical therapy services included in the catalogue of remedies, the freely available "Heilmittel-Informations-System (GKV-HIS)" was used. Data from the regional Associations of Statutory Health Insurance Physicians as well as data from federal reports were extracted for the years from 2004 up to 2014. Results: Prescription of physical therapy increased continuously from 2004 and 2014. In 2004, 155 677 860 and in 2014, 254 695 514 physical therapies were prescribed (increase of 61%). The highest number of physical therapies was prescribed in Saxony for all years, whereas in North Rhine-Westphalia and Hessen the lowest number per 1 000 GKV insured persons. Gross sales from physical therapy services differed between federal states and were the highest in Saxony (2004: 59.8; 2009: 54.6, 2014: 76.7) and Baden-Wuerttemberg (2004: 60.0; 2009: 57.6; 2014: 68.0). Discussion: The results of this study show utilization of physical therapy services as defined in the catalogue of remedies in Germany to be heterogeneous. However, causal relationship cannot be identified on the basis of the analyzed data highlighting the need for further research. Criteria for structural-, process- and outcome-quality are needed to be able to evaluate the quality of physical therapy services. To ensure the quality of physical therapy services, interprofessional and patient relevant research is needed.

[Orthopaedic and trauma surgical care until 2050. Analysis of the utilization behavior for relevant diseases and derivation of the number of medical service providers]. / Orthopädisch-unfallchirurgische Versorgung bis 2050. Analyse des Inanspruchnahmeverhaltens bei relevanten Erkrankungen und Ableitung der Häufigkeit ärztlicher Leistungserbringer.

BACKGROUND: Due to current and prospective demographic developments, the provision of high-quality medical care is not guaranteed in Germany. OBJECTIVES: The aim of this study is to analyze the utilization of medical service providers for diseases related to orthopedic/trauma surgery and deduce the corresponding number of medical service providers until 2050. MATERIALS AND METHODS: Data provided by the Statistical Offices of the Federal Republic and the Federal States and the Scientific Institute of the AOK (2008-2012) were used to analyze the utilization behavior of four pre-determined orthopedic/trauma surgery disease groups (osteoarthritis, back pain, osteoporosis, trauma). Routine data of the current (2012) health care provision delivered by the compulsory health insurances (GKV) are the basis of the prognosis. Using population projections from the Federal Statistical Office, the health care demand until 2050 was predicted and using statistics from the German Medical Association, the number of required health care providers was determined. RESULTS: An increase in physician consultations until 2040 is expected for osteoarthritis (+ 21 %), osteoporosis (26 %), and trauma (+ 13 %). From 2040-2050 the health care utilization behavior of all examined diseases is expected to decrease. The increasing health care usage behavior until 2040 is associated with an increase in health care providers. CONCLUSIONS: Until 2030 a significant increase in the burden of orthopedic/trauma surgery diseases is expected. In 2050 the level of health care needs will be equivalent to that in 2030. Comprehensive needs assessment and planning are needed in order to create health care provision structures and processes that address potential changes in utilization behavior.

[Prioritization and Consentation of Criteria for the Appraisal, Funding and Evaluation of Projects from the German Innovationsfonds: A multi-perspective Delphi study]. / Priorisierung und Konsentierung von Begutachtungs-, Förder- und Evaluationskriterien für Projekte aus dem Innovationsfonds: Eine multiperspektivische Delphi-Studie.

BACKGROUND: The German Innovationsfonds provides the chance for evidence-based developments of the German healthcare system. OBJECTIVE: Prioritization of recommendations for an effective, efficient, fair, transparent, and sustainable granting of funds through a transparent, evidence-driven consensus-process involving all relevant stakeholder groups. METHODS: Representatives from health and research policy, payers, patient representatives, healthcare providers, and scientists were invited to nominate participants for an electronic 3 round iterative Delphi-study to prioritize the thematic focus, requirements concerning study methods, the team of applicants, evaluation, utilization of study results, and for the selection of reviewers. Criteria considered as relevant by at least 60% of the panel (consensus definition) in the first 2 Delphi rounds were rated as facultative, preferable, or obligatory criteria for project funding. Data were analyzed descriptively. ( REGISTRATION: Datenbank Versorgungsforschung Deutschland VfD_15_003561). RESULTS: All invited stakeholder groups except payers participated. 34 (85%) of 40 nominated representatives participated in the Delphi-study. A total of 64 criteria were consented as relevant for project review and funding concerning the thematic focus (n=28), methodological requirements (n=13), requirements for applicants (n=4), for the evaluation (n=4), utilization (n=6), and selection of peer reviewers (n=9). DISCUSSION: It is the collective responsibility of all stakeholders to spend the designated funds as efficient and sustainable as possible. The consented recommendations shall serve decision makers as a resource for the granting of funds and the evaluation of the Innovationsfonds.

Integrated Environmental Assessment of streams in the Sinos River basin in the state of Rio Grande do Sul, Brazil.

The deterioration of environmental quality in the Sinos River basin is directly associated with the impacts of intense industrialization and urbanization. An integrated environmental assessment (IEA) was conducted in July and September of 2012, in areas along the sources of the EstânciaVelha/Portão, Pampa and Schmidt streams using physical, chemical and biological methods. The water in the three sampling sites was not proper for human consumption, presented a low toxic contamination index (TCI) and mesotrophic characteristics. One site was included in Class 4, and two, in Class 3, according to current legislation. The rapid assessment protocol (RAP) indicated a natural environmental condition for habitat diversity and environmental impact in the three sites. The Tradescantia pallida (Rose) D.R. Hunt var. purpurea Boom biomarker showed water genotoxicity in two of the sites. The integrated diagnosis of water quality in these streams is fundamentally important to ensure the sustainable management of water resources and their multiple uses, as well to estimate their contribution to pollution in this river basin.

Milestones on a Shoestring: A Cost-Effective, Semi-automated Implementation of the New ACGME Requirements for Radiology.

RATIONALE AND OBJECTIVES: The advent of the ACGME's Next Accreditation System represents a significant new challenge for residencies and fellowships, owing to its requirements for more complex and detailed information. MATERIAL AND METHODS: We developed a system of online assessment tools to provide comprehensive coverage of the twelve ACGME Milestones and digitized them using freely available cloud-based productivity tools. These tools include a combination of point-of-care procedural assessments, electronic quizzes, online modules, and other data entry forms. Using free statistical analytic tools, we also developed an automated system for management, processing, and data reporting. RESULTS: After one year of use, our Milestones project has resulted in the submission of over 20,000 individual data points. The use of automated statistical methods to generate resident-specific profiles has allowed for dynamic reports of individual residents' progress. These profiles both summarize data and also allow program directors access to more granular information as needed. CONCLUSION: Informatics-driven strategies for data assessment and processing represent feasible solutions to Milestones assessment and analysis, reducing the potential administrative burden for program directors, residents, and staff.

Know your market: use of online query tools to quantify trends in patient information-seeking behavior for varicose vein treatment.

PURPOSE: To analyze Internet search data to characterize the temporal and geographic interest of Internet users in the United States in varicose vein treatment. MATERIALS AND METHODS: From January 1, 2004, to September 1, 2012, the Google Trends tool was used to analyze query data for "varicose vein treatment" to identify individuals seeking treatment information for varicose veins. The term "varicose vein treatment" returned a search volume index (SVI), representing the search frequency relative to the total search volume during a specific time interval and region. Linear regression analysis and Kruskal-Wallis one-way analysis of variance were employed to characterize search results. RESULTS: Search traffic for varicose vein treatment increased by 520% over the 104-month study period. There was an annual mean increase of 28% (range, -18%-100%; standard deviation [SD], 35%), with a statistically significant linear increase in average yearly SVI over time (R(2) = 0.94, P < .0001). All years showed positive growth in mean SVI except for 2008 (18% decrease). There were statistically significant differences in SVI by month (Kruskal-Wallis, P < .0001) with significantly higher mean SVI compared with other months in May (190% increase; range, 26%-670%; SD, 15%) and June (209% increase; range, 35%-700%; SD, 20%). The southern United States showed significantly higher search traffic than all other regions (Tukey-Kramer, P < .00001). CONCLUSIONS: There have been significant increases in Internet search traffic related to varicose vein treatment in the past 8 years. Reflected in this trend is an annual peak in search traffic in the late spring months with an overall geographic bias toward southern states. Rigorous analysis of Internet search queries for medical procedures may prove useful to guide the efficient use of limited resources and marketing dollars.

Barriers to the prescription of systemic therapies for moderate-to-severe psoriasis--a multinational cross-sectional study.

Despite the availability of a plethora of approved systemic treatments, high proportions of patients with moderate-to-severe psoriasis do not receive systemic treatment. This study aims at identifying barriers that hinder dermatologists from prescribing systemic treatments for psoriasis. A cross-sectional online survey in six countries (Canada, Germany, Spain, France, Italy, UK) was performed among 300 dermatologists, assessing the relevance of 15 potential barriers towards prescribing acitretin, cyclosporine, methotrexate, adalimumab, etanercept, infliximab and ustekinumab. Multivariate regression analyses were used to explore provider characteristics related to these barriers. Treatment barriers are perceived differently in the countries investigated, with Spanish, Italian and Canadian dermatologists being particularly concerned about the safety of methotrexate and Canadian dermatologists about the safety of cyclosporine. In general, safety concerns were the most important barrier to the use of cyclosporine, (18 % of participants' moderate/9 % strong or very strong barrier). Costs were being perceived as a strong or very strong barrier to the use of the different biologics by 19-24 % of the participants. Overall, country and work place were the most important determinants of treatment barriers. Sex, age, training, position and experience were minor determinants of treatment barriers. Medical reasons such as safety concerns or an inappropriate risk-benefit profile are particularly relevant barriers to the prescription of conventional treatments; whereas for biological treatments, economic reasons such as costs are more prevalent. Country specific analysis showed national differences in the perception of safety. The treatment barriers identified in this exploratory study should be confirmed in further health services research.

Assessment of health state utilities of controlled and uncontrolled psoriasis and atopic eczema: a population-based study.

BACKGROUND: Health utilities are used to express relevant trade-offs for resource allocation. The absence of valid and generalizable utilities for atopic eczema (AE) and psoriasis limits the validity of previous cost-utility analyses. OBJECTIVES: (i) To assess health utilities of standardized scenarios of controlled and uncontrolled AE and psoriasis in participants from the general population and in patients using the time trade-off (TTO) method; (ii) to test the association of the utilities obtained with demographic and patient characteristics; and (iii) to compare these utilities with other health economic outcomes [utilities assessed on visual analogue scale (VAS), willingness to pay (WTP)]. METHODS: A single-centre study conducted in 2006 at the Department of Dermatology, Dresden, Germany. Standardized interactive computer-assisted interviews in a random sample from the general population (n=139), and patients with AE (n=58) and psoriasis (n=62). Information on health states included characteristic clinical pictures and a short text explaining aetiology, signs, symptoms and quality of life impact. RESULTS: In participants from the general population median utilities (TTO) of controlled and uncontrolled AE were 0.97 and 0.64, respectively. For psoriasis the corresponding utilities were 0.93 and 0.56. Utilities were independent of sex and socioeconomic position, and tended to be lower in patients with psoriasis. Correlations between TTO, VAS and WTP responses were weak. CONCLUSIONS: To avoid uncontrolled psoriasis or eczema participants chose an approximately 40% shorter life expectancy. This indicates that severe chronic inflammatory skin diseases may be considered as severe as angina pectoris, chronic anxiety, rheumatoid arthritis, multiple sclerosis or regional oesophageal cancer. The different economic outcomes assessed are not interchangeable.

[The Impact of Diseases (ICD-10) and Impairments of Activity and Participation (ICF) on the Long-Term Care Insurance in Germany (SGB XI)]. / Der Einfluss von Organschädigungen (ICD-10) und Aktivitäts- und Teilhabeeinschränkungen (ICF) bezüglich der Feststellung von Pflegebedürftigkeit (SGB XI).

On the basis of a representative sample of expert records from the Medical Review Board of the statutory care insurance funds (MDK) it could be shown that in the year 2003 more diseases of dementia had been examined for the long-term care insurance. The diagnois of dementia is statistically significant as a determinat of exposition related to get benefit from the care insuance. Help assistance which is needed after suffering form fraturs of bones are significant too, but related to get no benefits. In Germany the expert records of the long-term care insurance investigate the help assistance defined by the Social Code (SGB XI) which is needed in the daily live of the disabled and handicaped people. The classification of the SGB XI for daily performances offers the required transparency by using the mulitvariate logistic regression analysis with the predictor to get benefits from the care insurance. The help assistance estimated in the sample was recoded with the International Classification of Functioning, Disability and Health (ICF). Within this classification activity and participation in daily life of disabled and handicapped people are investigated. It was found that there could be more subdivions for these performances. A new analysis of the body function recorded in the ICF could be of interest to explain significant variables relating to the amount of help assistance.

Methodological issues in the assessment of substance use phenotypes.

The measurement of behavior is inherently problematic, and this is especially true of substance use and abuse phenotypes. The contingent nature of many assessments, such that symptoms of abuse and dependence cannot be obtained from those who have not initiated substance use, presents special difficulties. Furthermore, it is not clear whether individual differences in liability to use, abuse and dependence are best characterized as dimensions or classes or a combination of both. This article outlines research designs and methods suitable for quantifying liability to substance use. The value of data collected from relatives is emphasized in this context, as they permit identification of models normally compromised because data on, e.g., substance dependence symptoms, are systematically missing in those who have not initiated use of the substance in question.

Routes to the future German health economy.

A fundamental reorganisation of the health-care system to introduce a market orientation, more transparency and patient autonomy is proposed as the way to deliver the required high-quality care of the future.

Costs and benefits of cold tolerance in transgenic Arabidopsis thaliana.

Cold tolerance in plants is an ecologically important trait that has been under intensive study for basic and applied reasons. Determining the fitness benefits and costs of cold tolerance has previously been difficult because cold tolerance is normally an induced trait that is not expressed in warm environments. The recent creation of transgenic plants constitutively expressing cold tolerance genes enables the investigation of the fitness consequences of cold tolerance in multiple temperature environments. We studied three genes from the CBF (C-repeat/dehydration responsive element binding factor) cold tolerance pathway, CBF1, 2 and 3, in Arabidopsis thaliana to test for benefits and costs of constitutive cold tolerance. We used multiple insertion lines for each transgene and grew the lines in cold and control conditions. Costs of cold tolerance, as determined by fruit number, varied by individual transgene. CBF2 and 3 overexpressers showed costs of cold tolerance, and no fitness benefits, in both environments. CBF1 overexpressing plants showed no fitness cost of cold tolerance in the control environment and showed a marginal fitness benefit in the cold environment. These results suggest that constitutive expression of traits that are normally induced in response to environmental stress will not always lead to costs in the absence of that stress, and that the ecological risks of CBF transgene escape should be assessed prior to their use in commercial agriculture.