[Why Strive after Clinical Social Medicine? From Epidemiological Association to Personalized Social Medicine: a Case of Breast Cancer Care]. / Klinische Sozialmedizin - Warum? Von der epidemiologischen Assoziation zur personalisierten Sozialmedizin am Beispiel der Versorgung bei Mammakarzinom.

Advances in biomedicine, especially molecular biology and genetics, gave rise to the concept of personalized medicine targeting the patient's individual characteristics and needs to ensure the best possible therapy and healthcare. This concept, however, can be successfully implemented only if due consideration is given to (psycho-)social factors, as is shown for instance by considerably reduced post-therapy survival rates among cancer patients in regions with lower socioeconomic status, How breast cancer patients, for instance, find their way back to daily life and work after initial treatment at a breast center is substantially determined by multiple factors going beyond pure medical care. These factors critically affect health status and therapy outcomes, but are missing in current research agenda. A profound expertise in social medicine is required to respond in ways tailored to the individual's healthcare needs that go beyond just medical therapy. This expertise comprises, in particular, knowledge of inequality of access to healthcare due to varying health competence that in turn, results in inequality of health outcome and care. Competence in social medicine both in the clinic and outpatient care can help to individually target negative factors that originate from the social environment as well as from deficits in communication and coordination in the healthcare system and have an effect on the health status of patients..This, however, requires institutionalization of (clinical) social medicine and in particular, better opportunities for advanced training in social medicine in clinical departments and outpatient units.

[Plea for a strengthening of clinical social medicine]. / Plädoyer für eine Stärkung der klinischen Sozialmedizin.

Social medicine is concerned--in the midst of a constantly changing society--with the social and economic conditions that influence health, disease and medical care. A comprehensive medical care therefore requires medical doctors who, beyond the biomedical issues, realize diseases in the context of the social needs of the individual person and systematically include these in their prevention, treatment and rehabilitation concepts.The system of social security, particularly the health care system, depends on medical doctors' expertise in helping patients for the appropriate use of services from the system of social security. According to the German professional education regulations for doctors the additional specialization in "social medicine" also includes the competence for "assessment of the nature and extent of health disorders and their classification in the framework of social security systems". This judgment is one part of the tasks of the Medical Services belonging to the various branches of the social security system. It is also provided in practice by medical doctors with competence in social medicine working in acute care facilities.

[Country-specific differences in the utilisation profiles of cross-border health care point to differentiated degrees of interest and selective use. Results of a German-Swiss pilot project]. / Länderspezifische Unterschiede bei den Inanspruchnahmeprofilen grenzüberschreitender Gesundheitsversorgung weisen auf differenzierte Interessenlage und selektive Nutzung hin. Ergebnisse aus einem deutsch-schweizerischen Pilotprojekt.

AIM: The pilot project Lörrach-Basel was implemented in 2007 to reduce the border effect in respect to the health care services for the citizens of the region. The study deals with the questions as to which patient groups utilise cross-border health care, with special regard to the accompanying financial streams, and what implications these utilisation profiles will have for the development of a health region. METHODS: Applications for cost assumption and hospital routine data concerning cross-border care, data of legal health insurance schemes of both participating countries for the financing of border crossers' medical care, in addition, question-related contents from expert interviews with hospitals or rehabilitation facilities in both countries and a random sample from routine hospital data of treatments in Switzerland under complementary private insurance terms were analysed. RESULTS: Regarding the actual use of the pilot project by Swiss insured persons in the second project year, an exclusive utilisation appeared in the area of rehabilitation with a total of 125 cases. 73% of all treatments took place in two rehabilitation centres. Only 8 cases from the German side corresponded to the framework of the pilot project and concerned - according to contract - highly specialised in-patient care. The applications for cost assumption addressed to German legal health insurance schemes aimed at a wide spectrum which went beyond the offer within the pilot project's framework. Only one-half of the top 10 locations by number of applications are a partner in the pilot project. When looking at the whole transnational patient mobility in the border region of Basel-Lörrach, including the cases financed by complementary insurances and schemes for border crossers, but with the exception of private insured persons, a nearly well-balanced mutual use of the medical offers (scale: by 4 million Euros) is found concerning the costs. Persons insured in Basel consume more medical care within the scope of the compulsory health insurance in Lörrach than persons, insured in Lörrach, consumed in Basel; the reverse trend appears for treatment cases financed by complementary insurances. CONCLUSIONS: The differences concerning age groups, contents and kinds of treatment point in the direction of a search for complementary potentials with the aim of adapting the cross-border health care offers to the future needs of the region.

Inefficiency of cynarin as therapeutic regimen in familial type II hyperlipoproteinaemia.

Seventeen ambulant outpatients with familial Type IIa or Type IIb hyperlipoproteinaemia were treated with Cynarin, the 1,5-dicaffeyl ester of quinic acid, the constituent of the artichoke (Cynara scolymus). The dose tested was 250 mg and 750 mg daily. The mean serum cholesterol and triglyceride concentrations were not significantly changed within 3 months. Cynarin, administered per os, has no hypolipidaemic effect in familial Type II hyperlipoproteinaemia.

Inhibition of the protective effect of estrogen by progesterone in experimental atherosclerosis.

The aim of the present study was to determine the effect of progesterone on the action of estrogen in the development of atherosclerosis. A total of 48 female New Zealand white (NZW) rabbits were ovariectomized. The animals were separated into 6 groups of 8 animals each and received subsequently a 0.5% cholesterol diet for 12 weeks. During this cholesterol feeding period, either estradiol (1 mg/kg body weight (BW)/week), progesterone (25 mg/kg BW/week), or combined estradiol/progesterone (in above dosages) was administered intramuscularly in each group (n = 8 each) of ovariectomized rabbits. One additional group of 8 animals received a combined estrogen/ progesterone regimen, but with progesterone at one third of the above mentioned dosage. In another 8 rabbits, progesterone was reduced to one ninth of the maximum dosage above, whereas estrogen was kept the same, at 1 mg/kg BW/week. Eight ovariectomized animals served as the control group and received no hormone treatment. After 12 weeks, the animals were sacrificed and the proximal aortic arch was removed for further histological examination. An inhibitory effect of estrogen of intimal thickening was found, in comparison to the control group (intimal area: 0.7 +/- 0.5 mm2 vs. 3.7 +/- 2.5 mm2, P < 0.01), whereas progesterone alone did not show a significant effect on intimal plaque size (intimal area: 4.0 +/- 2.3 mm2). In combination with progesterone (high dose), estrogen was not able to reduce intimal atherosclerosis (intimal area: 3.4 +/- 2.4 mm2). However, the beneficial effect of estrogen was not affected by progesterone, when this was reduced respectively to one third (intimal area: 0.8 +/- 0.7 mm2), or to one ninth of the highest dosage (intimal area: 0.6 +/- 0.4 mm2). Interestingly, these differences in atherosclerotic plaque development were observed without significant changes in plasma cholesterol concentrations by the administered hormones. In conclusion, progesterone was dose-dependently able to completely inhibit the beneficial effect of estrogen in experimental atherosclerosis, suggesting that progesterone exerts a direct inhibitory effect on the athero-protective action of estrogen. In the context of recently published data, the present work confirms the importance of the 'non-lipid-mediated', anti-atherosclerotic effect of estrogen, probably due to an interaction with six hormone receptors in vascular smooth muscle cells (VSMC).

Covered stents for prevention of restenosis. Experimental and clinical results with different stent designs.

RATIONALE AND OBJECTIVES: Metallic stents in small vessels go along with a significant risk of restenosis and reocclusion. Different models of stents and covering materials have been purported to prevent intraluminal neointimal proliferation by cover-based closure of the spaces in the wire mesh. METHODS: Tantalum stents covered with polyethylacrylate/polymethylmethacrylate (PEM) were implanted in the infrarenal aorta of six New Zealand white rabbits by aortotomy and compared with eight rabbits treated with uncovered tantalum stents. For deployment, covered and uncovered stents necessitated a 7-French (F) and 5-F sheath, respectively. In addition, nine human patients with arteriosclerotic lesions of the superficial femoral arteries (stenosis > 5 cm or total occlusion) were treated percutaneously with a Dacron-covered nitinol vascular stent via a 9-F sheath. Patients were followed for a mean of 13.5 months, and control angiography was performed after 6 months. RESULTS: Experimental placement of the tantalum Wiktor stent was feasible technically in all cases. Five of six stents covered with PEM were occluded 3 days after placement despite the intravenous use of heparin and aspirin. In the group with uncovered stents, no area of stenosis greater than 10% was observed. There was a neointimal layer of 89 +/- 68 microns around the stent wires. Stent placement was successful in all patients. In four patients, a hyperergic reaction occurred, resulting in noninfectious periarteriitis. This complication was treated successfully with nonsteroidal antiinflammatory drugs. The primary patency was 50%, and the secondary patency (after application of a second covered stent in two patients) was 63%. CONCLUSIONS: The uncovered stent induces little neointimal proliferation around the stent wires. The insertion of stents covered with PEM into the rabbit aorta was accompanied by a strong thrombotic reaction, despite sufficient anticoagulation. Dacron-covered nitinol stents showed a surprisingly high restenosis rate after 9 months of follow-up. Further research concerning the in vivo properties of new covering materials is mandatory before routine vascular clinical application.

[Plaque morphology after arterial interventions in the New Zealand white rabbit--which model of restenosis is most suitable?]. / Plaquemorphologie nach arteriellen Interventionen am Weissen Neuseelandkaninchen--Wann ist welches Restenosemodell geeignet?

PURPOSE: For evaluation of therapy for possible reduction of restenosis after PTA a suitable animal model is needed. The influence of different interventions on arterial plaque composition was analysed in New Zealand White Rabbits. MATERIAL AND METHODS: The following interventions were performed in the infrarenal aorta of New Zealand White Rabbits (n = 42): a) Balloon denudation (BD) with and b) without 0.5% cholesterol diet (CD), c) application of a Wiktor stent, d) CF without BD, and e) control group, 6 weeks after intervention morphometry and histology were performed. RESULTS: After BD the stenosis rate measured 26 +/- 18%, additional CD after prior BD increased the stenoses rate by 2.5 times up to 61.1%. After stent implantation there was only a thin neointimal layer (89 +/- 68 microns) around the stent wires. CONCLUSIONS: Neither implantation of stents nor single CD are suitable as restenosis models. BD with and without CD was followed by a distinct neointima formation with different cellular composition. The New Zealand White Rabbit constitutes an acceptable model for contemporary research in arteriosclerosis.

Nephrotoxic effects of di-(2-ethylhexyl)-phthalate (DEHP) hydrolysis products on cultured kidney epithelial cells.

1. Di-(2-ethylhexyl)-phthalate (DEHP) possesses a great industrial value as a plasticizing agent and has become an ubiquitous environmental contaminant. In most species it is rapidly metabolized to mono-(2-ethylhexyl)-phthalate (MEHP) and 2-ethylhexanoic acid (2-EHA). Evaluation of toxicity of DEHP and its primary metabolites has been focussed on reproductive toxicity and hepatocarcinogenic properties. The aim of this study was to determine the nephrotoxic potential of both DEHP metabolites by use of cultured kidney epithelial cells (Opossum kidney cells; OK cells). 2. For this purpose, OK cells were exposed for 3 days to MEHP and 2-EHA at concentrations ranging from 0.1 -500 micromol/L and the toxicity as well as the effects on migratory activity and intracellular cytoskeleton were studied by cell biological, morphological and morphometric methods. 3. When compared with corresponding controls, treatment of OK cells with MEHP and 2-EHA, respectively, showed marked differences in cell viability between both DEHP metabolites. MEHP caused a dose-dependent decrease in cell viability (ED50 = 25 micromol/L) accompanied by a moderate swelling of the cells at concentrations up to 25 micromol/L. MEHP concentrations higher than 25 micromol/L caused a dose-dependent shrinkage of the cells and the occurrence of a high amount of cell debris as a result of cell lysis. 2-EHA did not cause a reduced viability or an altered cell volume. The migratory activity of OK cells was not significantly influenced by both metabolites. Moreover, MEHP toxicity resulted in a largely reduced and altered organization of F-actin (stress fibers), but not of myosin, microtubules and vimentin. 4. The study indicates that cultured epithelial cells can be used as a prescreening system to assess the nephrotoxicity of hazardous substances such as DEHP. As demonstrated in this study, only MEHP, but not 2-EHA, has a marked nephrotoxic effect in vitro.

Sodium monochloroacetate causes cytotoxic effects, an increased lactate and pyruvate level and induces ultra structural and cytoskeletal alterations in cultured kidney and liver epithelial cells.

1. Monochloroacetic acid (MCAA) and its sodium salt, sodium monochloroacetate (SMCA) are widely used in chemical industries as intermediates in the synthesis of carboxymethylcellulose, phenoxyacetic acid, thioglycolic acid, glycine, indigoid dyes and others. Moreover, MCAA has been found as a by-product of the chlorination disinfection of drinking water and as an environmental contaminant of the atmosphere from the photodechlorination reactions of chlorinated hydrocarbons. Little is known about the mode of action of both compounds on the cellular level. From cases of accidental poisoning of man it is known that MCAA accumulates in liver and kidney. 2. In this study, the cytotoxicity of SMCA on cultured liver (Chang liver cells) and kidney epithelial cells of the proximal tubule (Opossum kidney cells) was investigated and its effect on metabolism, ultrastructure and organization of cytoskeleton was examined. 3. Independent from the growth state of the cells (proliferating or quiescent), the results clearly show that SMCA causes a dose-dependent decrease in cell viability after an exposure period of 24 h. In all experiments, proliferating cells were more sensitive than quiescent and confluent cells. Liver cells were less sensitive against SMCA treatment than kidney epithelial cells. In contrast to liver cells, kidney cells exhibited a dose-dependent decrease in cell volume. The decrease in cell viability was accompanied by an increase of lactate and pyruvate concentrations released into the culture medium. In the case of Opossum kidney cells, lactate and pyruvate levels increased 5 - 6-fold, whereas in the case of Chang liver cells the increase was approximately twofold. While the ultrastructure of liver cells remained unaltered after drug treatment, kidney cells exhibited cytoplasmic vacuolization, membraneous disruption and especially mitochondrial alterations. In accordance with the changes in the ultrastructure of Opossum cells, was the reorganization of cytoskeletal elements with an increased stress fiber network at the basolateral surface as well as a partial depolymerization of microtubules and vimentin filaments. A cytoskeletal reorganization was not observed for Chang liver cells after SMCA treatment. 4. The results demonstrate that SMCA causes a dose-dependent cytotoxicity which is accompanied by metabolic, mitochondrial and cytoskeletal alterations in the cells.

Cytotoxic effects of 2-butoxyethanol in vitro are related to butoxyacetaldehyde, an intermediate oxidation product.

Ethylene glycol ethers belong to a group of solvents with a wide spectrum of applications, particularly because of their compatibility to both hydrophilic and lipophilic systems. Especially ethylene glycol monobutyl ether (2-butoxyethanol, BE) is widely used as a key ingredient in many industrial and consumer cleaning products. Therefore, the risk of human exposure and toxicity by BE as well as its potential for environmental contamination have to be carefully evaluated. By using an established kidney epithelial cell line from the proximal tubule (opossum kidney cells), we investigated the effects of BE on viability, proliferative activity, volume and the organization of the intracellular cytoskeleton of the cells. The experiments were performed with freshly used BE and BE that had been stored at room temperature in the original packing for 3 months after use. After this period of storage the latter BE contained-besides butyraldehyde and n-butanol-0.5 vol% butoxyacetaldehyde (BAL) as measured by capillary gas chromatography and mass spectrometry. Freshly used BE did not cause a toxic effect in the in vitro assays at all concentrations tested (up to 1 mg/ml). In contrast, stored BE which contained BAL reduced cell viability and mitotic activity in a dose-dependent manner. The effective concentration of stored BE causing a 50% loss in cell viability (EC(50/24h)) was calculated to be 1 mg/ml. The toxic effect of stored BE also resulted in alterations of cell morphology and a depolymerization of actin-containing stress fibers. Moreover, administration of stored BE also caused a dose-dependent cell volume increase by the uptake of water, pointing to a necrotic process. In addition, synthesized BAL with a purity of 73.5% (gas chromatography) was also tested and caused an EC(50/24h) of 15 µg/ml, which is a 70-fold lower concentration when compared with stored BE. The present study provides evidence that BE possesses only a low cytotoxic potential in vitro, whereas the corresponding BAL, an intermediate in the oxidation process of BE to butoxyacetic acid, has marked toxic effects. The occurrence of the aldehyde might explain the predominant hematological effects of BE observed in vivo.