[The delegation of medical services: is it a Trojan horse?]. / Delegation ärztlicher Leistungen : Ein trojanisches Pferd?

Delegation of medical treatment and responsibility from doctors to nonphysicians are being advocated more and more by public health politicians. The opinion of the German Union of Orthopaedic and Trauma Surgery is outlined. Definitions for treatment areas that cannot or may be delegated are presented. Physicians must be spared from overloading of administrative work. Delegating must not result in deterioration of patient care or destruction of the medical profession. Options and risks of delegation are discussed.

[Suggestions for implementation of DRG in the fields of Orthopaedics and Trauma Surgery for 2004]. / DRG-Anpassungsvorschläge der Fachgebiete Orthopädie und Unfallchirurgie für 2004.

OBJECTIVE: The Implementation of a DRG-Variant in Germany - voluntarily since January 1 st, 2003 and obligatory from January 1 st, 2004 - has been leading to uncertainty, particularly in the hospitals, due to fears that currently practised German diagnostic and therapeutic measures will not be financed properly by a DRG-Variant. The G-DRG-Version 1.0 that was drawn up in connection with an executive order law is to a large degree identical to the Australian AR-DRG-Version 4.1. Adjustments to German requirements were made only marginally. Therefore it is necessary for every medical field to investigate by stock-taking to what extent currently practised German diagnostic and therapeutic measures are considered in the G-DRG-Version 1.0 and whether and where modifications and adaptations need to be made. In order to make qualified statements scientific evaluations of possible problems have to be made based German data. Therefore an evaluation was made of the mapping of the medical fields of orthopaedics and trauma surgery. The German Society of Trauma Surgery (DGU), the German Society of Orthopaedy and Orthopaedic Surgery (DGOOC) in cooperation with the DRG-Research-Group of the University Hospital Muenster, the German Hospital Federation (DKG) and the German Medical Association carried out a DRG evaluation project in order to investigate the medical and economical homogeneity of the case groups. METHOD: 12,645 orthopaedic and trauma surgery cases from 23 hospitals - 11 university hospitals and 12 non-university hospitals - were collected within an period of three months and were scientifically evaluated with regard to their performance homogeneity and length of stay homogeneity. RESULTS: The data formed the basis for the proof of suspected deficiencies of mapping of orthopaedic and trauma surgery cases within the G-DRG-Variant. Based on the data and additionally on conclusions of medical experts when the number of cases were small, 14 suggestions for adaptation were proposed and submitted by the deadline of March 31 st, 2003 to the InEK. CONCLUSION: The results of the DRG-Evaluation Project demonstrate the problems of mapping the very heterogenous and complex medical performances of orthopaedy and trauma surgery to a flat rate financing system that is not adapted properly to German conditions. The G-DRG-Variant Version 1.0 does not offer the sufficient possibilities of differentiation that are needed to map the various orthopaedical and trauma surgical measures in Germany.

NMR investigations of protein-carbohydrate interactions: insights into the topology of the bound conformation of a lactose isomer and beta-galactosyl xyloses to mistletoe lectin and galectin-1.

A hallmark of oligosaccharides is their often limited spatial flexibility, allowing them to access a distinct set of conformers in solution. Viewing each individual or even the complete ensemble of conformations as potential binding partner(s) for lectins in protein-carbohydrate interactions, it is pertinent to address the question on the characteristics of bound state conformation(s) in solution. Also, it is possible that entering the lectin's binding site distorts the low-energy topology of a glycosidic linkage. As a step to delineate the strategy of ligand selection for galactosides, a common physiological docking point, we have performed a NMR study on two non-homologous lectins showing identical monosaccharide specificity. Thus, the conformation of lactose analogues bound to bovine heart galectin-1 and to mistletoe lectin in solution has been determined by transferred nuclear Overhauser effect measurements. It is demonstrated that the lectins select the syn conformation of lactose and various structural analogues (Galbeta(1-->4)Xyl, Galbeta(1-->3)Xyl, Galbeta(1-->2)Xyl, and Galbeta(1-->3)Glc) from the ensemble of presented conformations. No evidence for conformational distortion was obtained. Docking of the analogues to the modeled binding sites furnishes explanations, in structural terms, for exclusive recognition of the syn conformer despite the non-homologous design of the binding sites.

Extent and determinants of hospitalization in a cohort of older disabled people.

OBJECTIVES: The purpose of this prospective cohort study was to determine the extent and determinants of hospitalization in a population sample of older disabled people. DESIGN: A longitudinal cohort study. SETTING: Noninstitutionalized disabled people in the region of Augsburg, South Germany. PARTICIPANTS: The study population included 2427 persons, aged 60 years and older, who, between 1991 and 1993, applied for benefits from the statutory health insurance system provided to the most severely handicapped noninstitutionalized persons. MEASUREMENTS: Baseline variables were derived from a standardized medical examination. Information about hospitalization and mortality until June 30, 1996, was extracted from records of the pertinent health insurance plan. Rate ratios (RRs) of hospitalization were derived from a multivariable Poisson regression model corrected for the correlation of multiple hospitalizations for each person. RESULTS: The overall absolute hospitalization rate was 6.7 hospitalizations per 10 person-years at risk, with a mean length of stay per hospitalization of 19.2 days. Multivariable analysis showed an inverse association of age and hospitalization. Persons cared for primarily by their children had a lower rate of hospitalization (RR = 0.83) than persons relying mainly on professional home care. Medical causes of disability and dependency with respect to activities of daily living were unrelated to the hospitalization rate. A total of 1415 persons (58.3%) died during follow-up. The rate of hospitalization was twice as high among these subjects compared with others. The hospitalization rate increased rapidly during the last year of life, with a peak increase in the last 3 months. CONCLUSIONS: This study expands the current inadequate database on hospitalization in Europe. Further expansion is necessary for the efficient allocation of medical resources to older people, a group steadily increasing in numbers.

[Reproducibility of a German scale for assessing the need for inpatient treatment in surgery]. / Reproduzierbarkeit eines deutschsprachigen Instruments zur Erfassung der Notwendigkeit von stationären Behandlungen in der Chirurgie.

During the past years, the assessment of the appropriateness of hospital utilization has become increasingly important in the German health care system. Previous evaluations by regional review organizations in several states demonstrated the need for a standardized, reliable, and valid instrument to evaluate the appropriateness of inpatient care. Objective of the study is to test the reliability of a German adaptation of the "Appropriateness Evaluation Protocol" (AEP). Among all 2672 admissions from the department of surgery of a regional medical center during one calendar year, 54 patients were randomly selected to evaluate the inter-rater reliability and 51 patients to test intra-rater reliability. Overall agreement, specific agreement and Kappa statistics were estimated for every hospital admissions and all consecutive hospital days. The German AEP showed an inter-rater agreement of 74% (62-86%) for hospital admissions (Kappa = 0.44) and 84% (79%-88%) for all hospital days (K = 0.55). Intra-rater reliability was 88% (79%-97%) for hospital admissions (K = 0.60) and 88% (85%-92%) for all hospital days (K = 0.70). The observed agreement is independent of length of hospital stay and proportion of appropriate days. A standardized instrument with known metric properties is essential for quality management in hospitals to prepare for an increasingly consolidating health care market in Germany. The German AEP is a reliable instrument, which will allow to identify inefficiencies in the management of surgical inpatients.

Conformer selection and differential restriction of ligand mobility by a plant lectin--conformational behaviour of Galbeta1-3GlcNAcbeta1-R, Galbeta1-3GalNAcbeta1-R and Galbeta1-2Galbeta1-R' in the free state and complexed with galactoside-specific mistletoe lectin as revealed by random-walk and conformational-clustering molecular-mechanics.

To study conformational parameters of ligands before and after complex formation with the galactoside-binding agglutinin of Viscum album L. (VAA) in solution, combined computer-assisted random walk molecular mechanics (RAMM) calculations extended by conformational clustering analysis (CCA), molecular dynamics (MD) simulations as well as two-dimensional rotating-frame nuclear Overhauser effect (ROE) and two-dimensional nuclear Overhauser effect (NOE) spectroscopy NMR experiments were employed. Derivatives of the naturally occurring disaccharides Galbeta1-3GlcNAcbeta1-R and Galbeta1-3GalNAcbeta1-R as well as of a synthetic high-affinity binding partner, i.e. the disaccharide Galbeta1-2Galbeta1-R', were chosen as ligands in this study. The disaccharides displayed inherent flexibility in the valley of the global minimum between phi/psi combinations of (40 degrees/60 degrees) and (40 degrees/-60 degrees). Calculations of the de-N-acetylated sugars revealed that presence of this group did not markedly influence the distribution of low-energy conformers in the phi, psi, epsilon plot. Occupation of side minima at phi/psi (180 degrees/0 degrees) or (0 degrees/180 degrees) is either unlikely or low according to the results of MD simulations and RAMM calculations extended by CCA. Notably, these side minima define conformations which are not stable during a MD simulation. Transitions to other minima occur already a few picoseconds after the start of the simulation. NMR experiments of the free-state ligand confirmed the validity of the data sets obtained by the calculations. Following the description of the conformational space in the free-state NMR experiments were performed for these disaccharides complexed with VAA. They yielded two interresidual contacts for Galbeta1-3GlcNAcbeta1-R and Galbeta1-2Galbeta1-R'. The ligand conformations in the complex did not deviate markedly from those of a minimum conformation in the free state. One- and two-dimensional transferred nuclear Overhauser enhancement (TRNOE) experiments at different mixing times excluded the influence of spin-diffusion effects. When the NOE build-up curves in the three studied cases were compared, the residual mobility of the penultimate carbohydrate unit of Galbeta1-3GalNAcbeta1-R was observed to be higher than that of the respective hexopyranose unit of the other two bound ligands. Due to the availability of the conformational parameters of Galbeta1-2Galbeta1-R' in association with a galectin, namely the beta-galactoside-binding protein from chicken liver, it is remarkable to note that this ligand displays different conformations in the binding sites of either the plant or the animal lectin. They correspond to local energy-minimum conformations in the phi,psi, epsilon plot and substantiate differential conformer selection by these two lectins with identical nominal monosaccharide specificity.

[The mistletoe myth--claims, reality and provable perspectives]. / Mythos Mistel--Anspruch, Wirklichkeit und prüfbare Perspektive.

Intuition guided R. Steiner to refer to mistletoe as the future remedy for cancer. He proposed that its spiritual qualities support re-establishment of the harmonious integration of the alleged four different entities of human existence in a patient. The assumption of potency without chemical basis is derived from the dogmatic system of anthroposophic reasoning. It explains the evidently similar claim of clinical efficiency for the proprietary mistletoe extracts despite the lack of information on the actual contents of the complex mixtures and despite the conspicuous diversity of methods of manufacture for these products. Thorough scientific analysis of the published clinical experience does not justify this claim. Due to the increasing reference to defined substances in advertisements for commercial extracts, they should no longer avoid rigorous testing according to common quality standards. Interdisciplinary research efforts on the immunomodulatory galactoside-binding lectin illustrate how to yield a clinically testable substance from an ill-defined extract, thereby providing a notable example for rational investigation of unconventional treatment modalities.