[Intraoperative vascular air embolism : Evidence for risks, diagnostics and treatment]. / Intraoperative vaskuläre Luftembolie : Evidenz bei Risiko, Diagnostik und Therapie.

The entry of gases into the vascular system is called vascular air embolism (VAE). The blocking of the pulmonary circulation by VAE can lead to fulminant right-sided heart failure and cardiocirculatory arrest. A VAE can occur at any time if there is an open connection between the environment and a venous vessel with subatmospheric pressure. This situation occurs during ear nose throat surgery, hip surgery, surgery of the lesser pelvis or breast surgery, if the surgical field is above the level of the heart; however, a VAE can also occur during routine tasks, such as insertion or removal of a central venous catheter or during endoscopic procedures with the insufflation of gas.Because during these procedures VAE is not the main focus of the anesthesia or surgery personnel, in such situations its sudden unexpected occurrence can have severe consequences. In contrast, in cardiac surgery or neurosurgery the risk of intraoperative VAE is much better known. In procedures with a higher risk of a clinically relevant VAE, a patent foramen ovale should be ruled out by preoperative transesophageal echocardiography (TEE). Intraoperatively TEE is the most sensitive procedure not only to detect a VAE but also to visualize the clinical expression, e.g. acute right heart overload.The avoidance of an initial and repeated air embolism is the primary measure to minimize the incidence and severity of VAE.Intraoperatively the following measures should be undertaken: excellent communication between anesthesia and surgery personnel with predetermined actions, maintenance of normal volume, patient positioning with minimal difference in height between heart and head, state of the art surgical technique with closure of potential air entry sites, sufficient detection of air by TEE, repeated jugular vein compression during neurosurgery, intraoperative Trendelenburg positioning of the patient during persisting or clinically evident VAE, differentiated adjustment of ventilatory settings and catecholamine treatment, aspiration of the blood-air mixture (air lock) at the junction of the superior vena cava and right atrium through a large bore central venous line and keeping check of the coagulation status.

[Clinical anamnestic characteristics in neurological work-related medical rehabilitation : Necessity for a qualitative identification of severe restrictions of work ability]. / Klinisch-anamnestische Charakteristika in der neurologischen MBOR : Notwendigkeit einer qualitativen BBPL-Identifikation.

BACKGROUND: Severe restrictions of work ability (SRWA) as a condition for participation in neurological work-related medical rehabilitation (WMR) have not been adequately described up to now. Similarly, the applicability of the screening instrument SIMBO-C for evaluating SRWA in neurological rehabilitation has not yet been answered conclusively. OBJECTIVE: Determination of clinical and anamnestic characteristics of neurological SRWA and assessment of the applicability of the screening instrument SIMBO-C in neurological WMR. MATERIAL AND METHODS: For the identification of SRWA clinical and anamnestic characteristics of 344 rehabilitants were routinely collected. The clinically and anamnestically determined SRWA was described quantitatively and content-analytically and correlated with SIMBO-C. RESULTS: Of the rehabilitants 66% exhibited SRWA. Apart from the established characteristics of SRWA further person and disease-specific factors were found. The SIMBO-C score was significantly higher in the group with SRWA compared to the group without SRWA (45.6 ± 18.9 vs. 31.5 ± 12.5, p < 0.001); however, 31% of the group with SRWA and 50% of the group without SRWA demonstrated a SIMBO-C score ≤ 36 points and thereby a large overlap. The profile of the clinical and anamnestic characteristics in the group with SRWA was homogeneous, regardless of the SIMBO-C score. CONCLUSION: The characteristics of neurological SRWA are mainly qualitatively shaped and may only partly be identified by SIMBO-C. A combined quantitative and qualitative approach is necessary in neurological WMR.

End-tidal control vs. manually controlled minimal-flow anesthesia: a prospective comparative trial.

BACKGROUND: To ensure safe general anesthesia, manually controlled anesthesia requires constant monitoring and numerous manual adjustments of the gas dosage, especially for low- and minimal-flow anesthesia. Oxygen flow-rate and administration of volatile anesthetics can also be controlled automatically by anesthesia machines using the end-tidal control technique, which ensures constant end-tidal concentrations of oxygen and anesthetic gas via feedback and continuous adjustment mechanisms. We investigated the hypothesis that end-tidal control is superior to manually controlled minimal-flow anesthesia (0.5 l/min). METHODS: In this prospective trial, we included 64 patients undergoing elective surgery under general anesthesia. We analyzed the precision of maintenance of the sevoflurane concentration (1.2-1.4%) and expiratory oxygen (35-40%) and the number of necessary adjustments. RESULTS: Target-concentrations of sevoflurane and oxygen were maintained at more stable levels with the use of end-tidal control (during the first 15 min 28% vs. 51% and from 15 to 60 min 1% vs. 19% deviation from sevoflurane target, P < 0.0001; 45% vs. 86% and 5% vs. 15% deviation from O2 target, P < 0.01, respectively), while manual controlled minimal-flow anesthesia required more interventions to maintain the defined target ranges of sevoflurane (8, IQR 6-12) and end-tidal oxygen (5, IQR 3-6). The target-concentrations were reached earlier with the use of end-tidal compared with manual controlled minimal-flow anesthesia but required slightly greater use of anesthetic agents (6.9 vs. 6.0 ml/h). CONCLUSIONS: End-tidal control is a superior technique for setting and maintaining oxygen and anesthetic gas concentrations in a stable and rapid manner compared with manual control. Consequently, end-tidal control can effectively support the anesthetist.

[Advantages and disadvantages of different methods for the implementation and the support of standard operating procedures: From PDF files to an app- and webbased SOP management system]. / Vor- und Nachteile verschiedener Techniken zur Bereitstellung und Pflege von Standard Operating Procedures: Von der PDF-Datei zum App- und webbasierten SOP-Management-System.

BACKGROUND: The quality assurance of care and patient safety, with increasing cost pressure and performance levels is of major importance in the high-risk and high cost area of the operating room (OR). Standard operating procedures (SOP) are an established tool for structuring and standardization of the clinical treatment pathways and show multiple benefits for quality assurance and process optimization. OBJECTIVES: An internal project was initiated in the department of anesthesiology and a continuous improvement process was carried out to build up a comprehensive SOP library. MATERIAL AND METHODS: In the first step the spectrum of procedures in anesthesiology was transferred to PDF-based SOPs. The further development to an app-based SOP library (Aesculapp) was due to the high resource expenditure for the administration and maintenance of the large PDF-based SOP collection and to deficits in the mobile availability. The next developmental stage, the SOP healthcare information assistant (SOPHIA) included a simplified and advanced update feature, an archive feature previously missing and notably the possibility to share the SOP library with other departments including the option to adapt each SOP to the individual situation. A survey of the personnel showed that the app-based allocation of SOPs (Aesculapp, SOPHIA) had a higher acceptance than the PDF-based developmental stage SOP form. CONCLUSION: The SOP management system SOPHIA combines the benefits of the forerunner version Aesculapp with improved options for intradepartmental maintenance and administration of the SOPs and the possibility of an export and editing function for interinstitutional exchange of SOPs.

[Interdisciplinary Cooperation as a Characteristic of Successful Rehabilitation Facilities--Results from the Project MeeR]. / Interdisziplinäre Zusammenarbeit als ein Merkmal erfolgreicher Rehabilitationseinrichtungen - Ergebnisse aus dem MeeR-Projekt.

OBJECTIVE: To determine if there is a difference between successful and less successful rehabilitation facilities concerning their extent and quality of interdisciplinary cooperation? METHODS: This analysis is part of the project MeeR, that aims to identify characteristics of rehabilitation facilities related to successful rehabilitation. 6 facilities were recruited based on a quantitative analysis; 3 facilities that ranked as above average and 3 as below average in terms of their success in rehabilitating patients. Comprehensive qualitative data were collected on these 6 facilities. RESULTS: In above average rehabilitation facilities, the extent of interdisciplinary cooperation was higher than in below average facilities; the position of the medical profession was less dominant and there was a wider access to team meetings. DISCUSSION: Promotion of interdisciplinary cooperation is an important component for the improvement of the success of rehabilitation facilities.

[Rehabilitation goals in discharge reports and in patient questionnaires--on the example of endometriosis patients]. / Rehabilitationsziele in ärztlichen Entlassungsberichten und in Patientenfragebogen--am Beispiel von Endometriose-Patientinnen.

BACKGROUND: [corrected] The goal orientation of rehabilitation has increasingly found its way in research and practice. Though, shortcomings were ascertained for the implementation into the clinical routine furthermore. An empirical analysis of goal setting in clinical practice should complement the available evidence. METHODS: The study is based on a cross-sectional survey of all endometriosis patients, who had been treated at a rehabilitation center in 2008 or 2009. Data stemmed from the uniform medical rehabilitation discharge reports, and a patient questionnaire, which was sent to the registered women by the clinic routinely before the beginning of the rehabilitation. Data about rehabilita­tion goals were available as free text information for both the discharge reports as well as the pa­tient questionnaires. A category system oriented at the ICF system (International Classification of Functioning, Disability and Health), was developed to structure the goals. RESULTS: 293 patients had provided information concerning their rehabilitation goals, while 69 patients didn't reply to the question of their rehabilitation goals. The latter were excluded to the analysis. In the discharge reports, altogether, more goals were documented than in the patient questionnaires (5.98 compared to 4.97 goals per patient). In 35% of the numbers of rehabilitation goals clear congruence was found between the data in the discharge reports and the patient questionnaires. CONCLUSION: The results support the assump­tion that the included patients had difficulties in goal-setting. In addition it is obvious that the goals in the discharge reports had little relation to the goals framed by the patients, in language and content. A goal-setting process less oriented towards the medical and clinical needs but more towards the patients needs and expectation would be desirable particularly with regard to a more intensive patient orientation. The implementation of a prepared list of possible rehabilitation goals could serve for the shared goal-setting process in the context of anamnesis.

[Prewarming. Yesterday's luxury, today's minimum requirement]. / Vorwärmung. Von der Kür zur Pflicht.

Prewarming is a useful and effective measure to reduce perioperative hypothermia. Due to §23(3) of the German Infektionsschutzgesetz (Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen, Infection Act, act on protection and prevention of infectious diseases in man) and the recommendations of the Hospital Hygiene and Infection Prevention Committee of the Robert Koch Institute, implementation of prewarming is clearly recommended. There are several technically satisfactory and practicable devices available allowing prewarming on the normal hospital ward, in the preoperative holding area or in the induction room of the operating theater (OR) The implementation of prewarming requires additional equipment and training of staff. Using a locally adapted concept for the implementation of prewarming does not lead to inefficiency in the perioperative process. In contrast, the implementation can help to achieve stable arrival times for patients in the OR.

[Efficacy of a novel warming blanket: prospective randomized trial]. / Effektivität einer neuen Wärmedecke: Prospektive randomisierte Studie.

BACKGROUND: Perioperative hypothermia is a common complication of general anesthesia and occurs in up to 50 % of patients during ear, nose and throat (ENT) surgery. In this prospective, randomized controlled study the hypothesis that a new conductive warming blanket (Barrier® EasyWarm®, Mölnlycke Health Care Erkrath, Germany) is better in reducing the incidence of perioperative hypothermia in ENT surgery than insulation with a conventional hospital duvet alone was tested. MATERIALS AND METHODS: After approval of the local ethics committee and written informed consent 80 patients with a planned procedure time between 1 and 3 h were recruited. Anesthesia was induced and maintained using propofol, remifentanil and rocuronium and the core temperature was measured using an esophageal temperature probe. Patients in the study group were warmed at least 30 min prior to induction of anesthesia using the novel warming blanket (Barrier® EasyWarm®) and patients in the control group were insulated with a standard hospital duvet. Data were tested using Fisher's exact test, Student's t-test or the Mann-Whitney U-test as appropriate. Time-dependent changes in core temperature were evaluated using repeated measures analysis of variance (ANOVA) and post hoc Scheffé's test. Results are expressed as mean ± SD or as median and interquartile range (IQR) as appropriate. A p < 0.05 was considered to be statistically significant. RESULTS: The ANOVA did not identify a significantly higher core temperature in the study group at any time point. Furthermore, Fisher's exact test showed no differences in the incidence of intraoperative (12 out of 29 versus 10 out of 32 patients, p = 0.44) or postoperative hypothermia (12 out of 29 versus 9 out of 32 patients, p = 0.30) between the groups. No adverse effects were observed. CONCLUSIONS: In the studied patient group the new conductive warming blanket (Barrier® EasyWarm®) showed no superiority compared to conventional thermal insulation alone.

[Teaching health economics, health-care system and public health at German medical faculties]. / Die Lehre im Querschnittsbereich "Gesundheitsökonomie, Gesundheitssystem, Öffentliche Gesundheitspflege" an den medizinischen Fakultäten in Deutschland.

AIM: On 1 October 2003 the 9th Medical Practice Act came into effect and implemented the teaching subjects "health economics, health-care system, public health" in the medical curriculum. The purpose of the study was to define the content of teaching. METHODS: Interviews were conducted with professors in charge of "health economics, health-care system, public health-at 36 German medical faculties. On the basis of the guidelines produced by the German association for social medicine and prevention (DGSMP), the course contents of the education programmes were evaluated in terms of relevance and integration into the lessons. RESULTS: The response rate was 78% (28 questionnaires). Seminars and lectures are most commonly used. The subject is taught at the end of the study (8th-10th terms). The issue "public health" has the lowest time slice, "health-care system" and "health economics" dominate the education. "Financing the health-care system", "basic principles (health economics)" and "stakeholders in the health care system" were stated to be the most important and most frequently taught topics. DISCUSSION: With the teaching of the subject, medical students become sensitised to efficiency and other topics beyond the natural sciences. The collaboration between physicians and other professionals promotes the ability to be critical in an economic and public health context. Implementing the subject students expand their knowledge of the health-care system thereby contributing to professionalism of the medical profession.

[Situation and perspectives of public health in Germany--research and teaching. Position paper of the German Public Health Association]. / Situation und Perspektiven von Public Health in Deutschland--Forschung und Lehre. Positionspapier der Deutschen Gesellschaft für Public Health e. V.

This position paper of the German Public Health Association describes current situation and perspectives of public health in Germany with emphasis on research and teaching. It outlines those measures necessary for strengthening of public health research in Germany.

[General conditions concerning the implementation of an outpatient education programme--characteristics and distinctions from an inpatient training programme]. / Rahmenbedingungen für die Umsetzung eines ambulanten Schulungsprogramms--Besonderheiten und Abgrenzung zu einer stationären Schulung.

INTRODUCTION: The aim of the EVA study was to develop an outpatient education programme for women with endometriosis with a view to permanent transfer into routine care. Implementation of the programme generated several problems and obstacles that are not, or not to this extent, present in the inpatient setting of a rehabilitation clinic. METHODS: The patient education programme was developed in line with an existing inpatient programme, taking into account the criteria for evaluating such training programmes. Several adjustments to process, structure and content level had to be made to achieve the conditions of the outpatient setting. RESULTS: Since May 2008, 17 training courses took place in various outpatient and acute inpatient settings, and a total of 156 women with diagnosed endometriosis participated. The problems and obstacles that emerged affected similarly the process, structure and content of the training programme. DISCUSSION: On the structural level, especially problems with availability of rooms, technical equipment and trainers occurred, leading to significant time pressures. The main problem on the procedural level was the recruitment of participants, since--in contrast to the inpatient setting and to disease management programmes--no assignment by physicians or insurers takes place. Furthermore, gainful activity of the participants and the resulting shift of the training beyond the usual working and opening hours are important barriers for implementation. The unavailability of trainers in these settings requires creative solutions. Regarding the contents of the training it has to be taken into consideration that--unlike the inpatient setting--no aftercare intervention and no individual psychological consultation are possible. The training programme has to be designed in such a way that all problems that have occurred could be dealt with appropriately. CONCLUSION: In summary, the permanent implementation of an outpatient training programme is possible but is more time-consuming than inpatient trainings due to unfavourable conditions concerning recruitment, organization and procedure. It seems that "soft" factors such as motivation, integration into the clinic concept, well-defined acceptance of responsibility and experience in dealing with the disease and with patient groups are the critical success factors. Until now cost carriage by the health insurance funds has not been realized--except for disease management programmes; so there is still a need for action here.

[Post-rehabilitation care in the context of cardiac rehabilitation--aspects of prevention and health promotion]. / Nachsorge im Rahmen der kardiologischen Rehabilitation--Ansätze von Prävention und Gesundheitsförderung.

PURPOSE: This article presents a literature review on post-rehabilitation care focussing on preventive and health promotion aspects set out on the example of coronary heart disease. Selected studies and programmes for intensified aftercare are analyzed as to whether and to what extent preventive and health promotion aspects are integrated in post-rehabilitation care. METHODS: The analysis includes a stock-taking of practice concepts and evaluation studies on aftercare programmes in cardiac rehabilitation in Germany. Presented is an overview of the aftercare programmes in place based on a comprehensive, systematic literature search. RESULTS: The review shows a great diversity of aftercare programmes available in cardiac rehabilitation. The findings support the assumption that aftercare offers a range of promising approaches for implementing preventive and health promotion activities due to its aim of achieving sustained rehabilitation success. So far, implementation of those activities has been insufficient. Cardiovascular risk factors such as lifestyle and psychosocial status are being considered to different degrees in those programmes in terms of intensity and frequency. Along with programmes showing a large proportion of preventive measures, only limited preventive structures are found for a majority of the aftercare concepts analyzed. Health promotion strategies are also identified in only few aftercare programmes. CONCLUSION: Effectiveness studies support good results for intensified aftercare, but they often refer to only part of the relevant cardiovascular risk factors and to only medium-term observation, while long-term proof of effectiveness is scarce. A small number of programmes with positive outcomes relative to the risk profile suggest that integration of preventive and health promotion activities can contribute strongly to improving and stabilizing the effects achieved in rehabilitation. The present analysis indicates further need for research in order to verify the effects of existing post-rehabilitation programmes concerning cardiovascular risk factors and determination of the relevant target groups.

[Patient education in pulmonary rehabilitation: results of an implementation study]. / Patientenschulungsprogramme in der pneumologischen Rehabilitation: Ergebnisse einer Implementationsstudie.

Patient education is considered to be a major feature of medical rehabilitation in chronic disorders. While the substantial advances in the proposition of patient education programmes in in-patient health-care remain unquestioned, there are some deficits in actually performing such programmes in clinical practice. Only few clinics adhere to the protocol and recommendations for patient education. Mostly there are deviations in the actual performance of asthma education, e. g., mixing of different education schemes or using self-developed material. The reasons why clinics hesitate to use evaluated patient education programmes is still unclear. One can assume that there are problems due to organisation, structure or staff. This project aimed at observing the process of implementation of a new asthma education programme in order to identify barriers and helpful factors for the implementation. We conducted the study in three rehabilitation centres that did not use evaluated asthma education programmes. In these clinics we implemented the new education programme. After identifying the structure of the clinic before and after the implementation, interviewing the trainers and other staff members, we could assess the specific resources and barriers. We then included these aspects into recommendations for implementation. The most important barriers we found were too few staff and problems in planning the time and rooms for the programme. There was a high level of acceptance among all staff members and patients. The entire programme causes costs of 97 euro per patient. The costs at the beginning of the implementation were higher than those for the routine use.

Supporting and Inhibiting Factors When Coping with Endometriosis From the Patients' Perspective.

Aim: Endometriosis is a chronic gynaecological disorder with manifold symptoms and psychosocial effects on the lives of affected women. The prevalence of endometriosis is estimated to be up to ten percent of women of reproductive age. As a result of its unclear aetiology, only limited treatment options are available. The treatment and care of affected women is therefore a challenge for their doctors. There is a need for healthcare services to provide affected women with support to cope with the disorder better. The aim of the study was to identify supporting and inhibiting factors on disease management to develop new support ideas. Materials and Methods: The results are based on a content analysis evaluation of text responses from 135 women with confirmed endometriosis. Open questions about disease management were posed in a patient questionnaire. A classification system was developed according to Mayrings Qualitative Content Analysis, which allowed the main topics to be identified and summarised qualitatively using a quantitative intermediate step. Results: Social support, treatment, as well as professional and healthcare system performance were found to be particularly supportive by patients. However, when questioned about inhibiting factors, healthcare system professionals and their performance were most commonly criticised. Just over 50 % of women expressed their criticism of doctors. Quality of care and empathy towards the patients were especially criticised. There is also a need for improvement with regard to communication and general support from doctors. The results illustrate the importance of doctors for women affected by endometriosis, but make it clear that there is a great need for improvement with regard to the profession. Conclusion: The results provide the first indication of problem areas in the management of endometriosis from which approaches could be developed to improve care. However, it must be pointed out that the perspective of affected women was solely investigated. For a comprehensive analysis, it would be necessary to include the perspective of care providers and the influence of society as well as the healthcare system.

Volume-dependent compliance in ARDS: proposal of a new diagnostic concept.

OBJECTIVE: Adaptation of ventilator settings to the individual's respiratory system mechanics requires information about the pressure-volume relationship and the change of compliance which is dependent on inflated volume. Unfortunately, established methods of obtaining this information are invasive and time-consuming, and, therefore, not well suited for clinical routine. We propose a new standardized diagnostic concept based on the recently developed slice method. This multiple linear regression method (MLR) determines volume-dependent respiratory system compliance (C(SLICE)) within the tidal volume (V(T)) during ongoing mechanical ventilation. The impact of a ventilator strategy, recommended by a consensus conference, on the course of compliance within V(T) was investigated in patients with the acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). DESIGN: Prospective observational study. SETTING: Intensive care unit of a university hospital. PATIENTS: 14 ARDS patients, 2 patients with ALI. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: After measurement of flow and airway pressure and calculation of tracheal pressure, C(SLICE) was determined. The resulting course of C(SLICE) within V(T) was estimated using a mathematical algorithm. C(SLICE) data were compared to those obtained by standard MLR. We found decreasing C(SLICE) mainly in the upper part of V(T) in all patients. In 7 patients, we found an additional increasing C(SLICE) mainly in the lower part of V(T). CONCLUSIONS: C(SLICE) was not constant in patients with ARDS/ALI whose lungs were ventilated according to consensus conference recommendations. The proposed diagnostic concept may serve as a new tool to obtain a standardized estimation of respiratory system compliance within V(T) non-invasively without interfering with ongoing mechanical ventilation.

Short- and long-term effects of intensive training and motivational programme for continued physical activity in patients with inflammatory rheumatic diseases.

BACKGROUND: Despite the positive health effects of (intensive) exercise in patients with inflammatory rheumatic diseases, they are very often inactive. Motivational exercise interventions in other patient samples have shown good effects in promoting exercise behaviours. AIM: To evaluate the short- and long-term effects of an intensive exercise training programme in rheumatic patients with additional motivation for continued physical activity. DESIGN: Controlled prospective intervention study with repeated measures over 12 months. SETTING: Rheumatologic inpatient rehabilitation in two centres in Germany. POPULATION: Three-hundred-and-seven patients with chronic polyarthritis or spondyloarthritis. METHOD: The patients were assigned to a control group (CG, standard therapy, N.=156) or an intervention group (IG, motivation and intensive training, N.=151). Socio-demographic (age, gender, social background, employment) and health parameters (SF-36, HFAQ, HADS, pain, disease activity), exercise motivation, physical activity and costs of illness were assessed by questionnaires at baseline (t1), discharge (t2), and 12-months-follow-up (t5). Participants evaluated the rehabilitation programme at t2. RESULTS: At t2, IG-patients rated their rehabilitation better than CG-patients and reported higher exercise motivation. All patients had a better health status at t2 compared to t1. At t5, IG-patients reported more physical activity in everyday life. An unexpected lower physical component score (SF-36) of the IG compared to the CG lacked clinical relevance. No other variable showed significant group differences. Both CG- and IG-patients showed improvements in their health-related quality of life, pain, psychological well-being, sports activities, and exercise self-efficacy. CONCLUSION: The rehabilitation programme that included intensive training was perceived to be better than the conventional programme and the patients benefited more from the motivation intervention. Long-term improvements in all participants may be indicators of the positive effects of conventional rheumatic rehabilitation in Germany. Intensive training with motivation also improves physical activity and may have positive socio-economic effects. Future research needs to identify the most effective factors of the intervention and the patient groups that benefit most. CLINICAL REHABILITATION IMPACT: Intensive training with motivation is appropriate for patients with inflammatory rheumatic diseases aged up to at least 60 years and without severe health impairments. It enhances patients' exercise motivation and increases physical activity over at least 1 year.

[Health in older age: cost of illness and cost-effectiveness of prevention]. / Gesundheit im Alter: Krankheitskosten und Kosteneffektivität von Prävention.

The objective of prevention is to avoid or to delay health impairments and diseases. For older people it is important to maintain their independence and to avoid and reduce the need for external help such as nursing care. Good starting points are the strategies for healthy life-style. Physical activity, smoking abstinence, and normal weight have proven to have their positive medical and economic effect on many chronic diseases such as type 2 diabetes mellitus, cardiovascular diseases, and certain types of dementia. The potential of prevention increases as those diseases affect one another. As for other health care, the cost-effectiveness of preventive measures must also be examined. There are few German studies addressing the cost-benefit of the non-medication prevention. Results from international studies can only partly be transferred to the German context. The cost-effectiveness for prevention for elderly people has been very rarely researched. Research in the field of prevention is so far not very well developed as for other health fields. There is a need for more specific research for methods, interventions and target groups. In health economics major challenges arise from different time schedules and various purchasers, as well as from the evaluation of human capital for elderly.

[Concepts for a demand-oriented structuring of palliative care in the German Health Care System: the example of Lower Saxony]. / Konzepte zur bedarfsgerechten Strukturierung der Palliativversorgung im deutschen Gesundheitswesen: Das Beispiel des Bundeslandes Niedersachsen.

Palliative care can be considered a holistic care approach for patients faced with incurable and progressive diseases in their last period of life. In this context, structural, cultural and content-related deficits are increasingly taken into account in the German health care system, however, there is a lack of scientific data. Therefore, it was the objective of an expert team at Hannover Medical School to analyse the current situation of palliative care in Lower Saxony from the perspective of health system research and to give recommendations for its further development, based on empirical studies in Lower Saxony and on a systematic national and international literature review. The study revealed that the main shortcomings were an unclear structuring and an inadequate definition with respect to other areas of care, a fundamental lack of integration in regard of routine processes of care and a lack of thorough tools for needs assessments. Therefore, a concept for the integration of palliative care in the care processes of cancer patients was developed and the specific need for hospice beds in regional districts was calculated by using parameters representing provision-related and epidemiological/demographic conditions. In comparison to current structures, an assessment of over- and undersupply as well as specific recommendations how to optimize palliative care were provided for politicians, payers and providers in Lower Saxony.

[Optimized hemodilution (OHD) with hydroxyethyl starch : A blood-sparing technique for surgical treatment of dysgnathia]. / Optimierte Hämodilution (OHD) mit Hydroxyethylstärke : Ein Blut sparendes Verfahren bei Dysgnathieoperationen.

Optimized hemodilution. To avoid blood transfusions, the method of optimized hemodilution (OHD) was developed. OHD consists of preoperative hypervolemic hemodilution with 500 ml hydroxyethyl starch (HES) and consecutive volume replacement with HES in the case of intraoperative intravasal fluid loss. This study verifies the efficacy of OHD. Results. Mono- and bimaxillary operations (n=213) performed between January 1995 and May 1999 were evaluated retrospectively with respect to reduction of blood transfusions due to application of OHD. The average blood loss in the OHD group (n=127) was 593 ml, and no blood transfusion was required. In contrast, the control group (n=86) showed an average blood loss of 738 ml, and 15% of these patients (n=13) required transfusion of a total of 18 blood units. Based on our results, provision of autologous blood is only necessary for patients who do not receive OHD. The costs of fluid replacement and transfusion are increased by a factor of 5.7 when OHD is not used. Discussion. OHD should be preferably used in cases of elective surgery on patients with good cardiopulmonary health. It is an easy to handle infusion regimen, which does not require additional monitoring, has no risk of infection, and results in a significant cost reduction.