[What determines the participation in stepwise occupational reintegration on behalf of the German pension insurance? Results of the "SOR cohort study"]. / Wonach richtet sich die Inanspruchnahme von stufenweiser Wiedereingliederung zu Lasten der gesetzlichen Rentenversicherung? Erste Ergebnisse der STW-Kohortenstudie.

OBJECTIVE: Stepwise Occupational Reintegration (SOR) measures are of growing importance for the German statutory pension insurance. There is moderate evidence that patients with a poor prognosis in terms of a successful return to work, profit most from SOR measures. However, it is not clear to what extend these information are utilized when recommending SOR to a patient. METHODS: A questionnaire was sent to 40406 persons (up to 59 years old, excluding rehabilitation after hospital stay) before admission to a medical rehabilitation service. The survey data were matched with data from the discharge report and information on the participation in a SOR measure. Initially, a single criterion was defined which describes the need of SOR measures. This criterion is based on 3 different items: patients with at least 12 weeks sickness absence, (a) a SIBAR score>7 and/or (b) a perceived need of SOR.The main aspect of our analyses was to describe the association between the SOR need-criterion and the participation in SOR measures as well as between the predictors of SOR participation when fulfilling the SOR need-criterion. The analyses were based on a multiple logistic regression model. RESULTS: For 16408 patients full data were available. The formal prerequisites for SOR were given for 33% of the sample, out of which 32% received a SOR after rehabilitation and 43% fulfilled the SOR needs criterion. A negative relationship between these 2 categories was observed (phi=-0.08, p<0.01). For patients that fulfilled the need-criterion the probability for participating in SOR decreased by 22% (RR=0.78). The probability of SOR participation increased with a decreasing SIBAR score (OR=0.56) and in patients who showed more confidence in being able be return to work. DISCUSSION: Participation in SOR measures cannot be predicted by the empirically defined SOR need-criterion: the probability even decreased when fulfilling the criterion. Furthermore, the results of a multivariate analysis show a positive selection of the patients who participate in SOR measures. Our results point strongly to the need of an indication guideline for physicians in rehabilitation centres. Further research addressing the success of SOR measures have to show whether the information used in this case can serve as a base for such a guideline.

The relation between medical education and the medical profession's world view.

Thinking in medicine is still dominated by the cartesian view of science of the past centuries, dividing individuals into the reasoning mind (res cogitans) and an objective body as part of all non-subjective things of the world (res extensa). This classical scientific paradigm does not take into account the influence the observer exerts on the observed phenomena. Applying this paradigm to medical research and education has consequences regarding the relationship between physicians and patients as well as between medical teachers and their students. An improvement of medical education towards a broader understanding of complex illnesses with their psychosocial implications must be based on philosophical and epistemological issues. The requirements of modern medicine cannot just be met by adding more psycho-social content to somatic medical education or by changing the didactic approach without reflection on the underlying concepts and the relation of the human being to his world.

[Current trends in medical rehabilitation and their significance for the field of psychosomatic rehabilitation]. / Aktuelle Entwicklungstrends in der medizinischen Rehabilitation und ihre Bedeutung für den Bereich der Psychosomatischen Rehabilitation.

At present the process of serious restructuring can be observed in the system of medical rehabilitation in Germany. This paper focuses on recently initiated innovations and their consequences for psychosomatic rehabilitation. The patient's access to a psychosomatic rehabilitation system is analysed and examined to what extent innovations increase early detection of patients with psychosomatic disorders. Regarding the structure of psychosomatic rehabilitative offers, the initiated innovations such as an increase of flexibility, better transition and improvement of inpatient rehabilitative offers are described and discussed. Finally, the development of quality improvement programs and rehabilitation research in the field of psychosomatic rehabilitation is presented. Although many changes have taken place up to now, further relevant modifications in psychosomatic rehabilitation are predicted by the authors.

[Differential indications for ambulatory and inpatient medical rehabilitation--results of an expert survey]. / Differentielle Indikation für ambulante und stationäre medizinische Rehabilitation--Ergebnisse einer Expertenbefragung.

Medical rehabilitation in the Federal Republic of Germany has been provided in an almost exclusively inpatient setting up to now. However, in view of an intensified development of outpatient rehabilitation programs there are new challenges to confront. As to indication criteria, new preconditions and handling directives have to be defined in order to refer patients to those rehabilitation programs from which they can profit the most. Up to now, there has been a considerable lack of knowledge as to what kind of criteria must be considered in the transfer process. The present study represents results of expert interviews (Delphi method) regarding this topic. 50 experts from inpatient and outpatient rehabilitation facilities, from the Medical Services of health insurance funds and the pension insurance system, from rehabilitation agencies as well as rehabilitation research, have been questioned since they take important stands on these questions and since their assessment has a guiding quality. An additional study had been directed at the factors which determine present decision-making in terms of inpatient vs. outpatient rehabilitation. The results show that the experts stress the importance of a multitude of different aspects; however, there still is but little consensus concerning the criteria that should invariably be considered in making these rehabilitation decisions.

A randomized study of radiotherapy alone versus radiotherapy plus 5-fluorouracil and platinum in patients with inoperable, locally advanced squamous cancer of the esophagus.

Squamous cell cancer of the esophagus is the most common cancer among black South African males, and 60% of patients present with localized inoperable disease. Combined chemoradiotherapy has been reported to be superior to radiotherapy alone for localized inoperable esophageal cancer in North American patients. A study was carried out to determine if this was also applicable to South African patients, who present with more advanced disease. From September 1991 through June 1995, 70 patients with locally advanced (T3N0-1M0) squamous cancer of the esophagus were prospectively randomized to receive radiotherapy alone or radiotherapy combined with cisplatin and 5-fluorouracil. There was no statistically significant survival difference between the two groups. The median survival was 144 days in the group receiving radiotherapy alone, and 170 days in the group receiving radiotherapy combined with chemotherapy (p = 0.42). The degree of weight loss before initiation of therapy had a significant effect on survival regardless of the treatment arm. Radiotherapy in combination with chemotherapy, as administered in this study for South African patients with locally advanced, inoperable squamous cancer of the esophagus, is no better than radiotherapy alone.

Ceramic coagulation tip for interstitial thermoablation of the prostate: first experiments.

A direct electrically heated ceramic coagulation tip for interstitial thermoablation has been developed. Both the coagulation tip and a laser system (Medilas 4060) were tested in vitro to compare their efficacies. We have obtained coagulation necroses of similar sizes. The electrical coagulation tip as opposed to laser coagulation is a new therapeutic option for the therapy of high risk patients with symptomatic benign prostatic hyperplasia. Because of the materials used and the principle of heating involved, certain economic and safety advantages over the laser system are offered.

Comparison of negative inotropic and vasodilator effects of isradipine and nifedipine after complete autonomic blockade in ischemic heart disease.

The cardiodepressant and vasodilator effects of an intravenous (i.v.) infusion of 0.5 mg isradipine or 2 mg nifedipine were interindividually (10 vs. 10 patients) compared in a double-blind study in patients with stable coronary heart disease. To minimize vasodilation-induced autonomic reflex mechanisms, which may counterbalance negative inotropic effects after acute administration of calcium antagonists, i.v. autonomic blockade was produced by 0.2 mg/kg propranolol and 0.04 mg/kg atropine. Systemic hemodynamics were measured before and 15 min after the end of the 15-min calcium antagonist infusion. After administration of both drugs, heart rate (HR) decreased similarly during the observation period (isradipine from 93 +/- 10 to 88 +/- 9 beats/min and nifedipine from 84 +/- 9 to 79 +/- 6 beats/min, both p less than or equal to 0.01). The reduction in total peripheral resistance (TPR) was significantly (p less than or equal to 0.01) greater after isradipine (from 1,376 +/- 285 to 1,002 +/- 224 dynes s cm-5) than after nifedipine (1,258 +/- 262 to 1,112 +/- 225 dynes s cm-5). Between the two drugs, the difference in the reduction of afterload independent dP/dt40, determined by tip-manometry, reached borderline significance (p = 0.08) (isradipine from 1,197 +/- 258 to 1,157 +/- 225 mm Hg/s, NS and nifedipine 1,228 +/- 226 to 1,109 +/- 227 mm Hg/s, p less than or equal to 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute and chronic effects of nitrendipine in patients with precapillary pulmonary hypertension due to pulmonary fibrosis.

Eleven patients with histologically confirmed fibrosis of the lung were investigated for the effects of the dihydropyridine calcium antagonist nitrendipine on pulmonary hemodynamics. After 5 mg of acute sublingual nitrendipine, mean pulmonary artery pressure was significantly lowered (p less than or equal to 0.05) from 32 +/- 3 to 29 +/- 3 mmHg at rest, and significantly lowered (p less than or equal to 0.05) during exercise from 55 +/- 4 to 49 +/- 4 mmHg. Short-term oxygen application at rest significantly reduced this parameter to 28 +/- 3 mmHg (p less than or equal to 0.001). Nitrendipine lowered total pulmonary vascular resistance during both rest (from 412 +/- 50 to 351 +/- 49 dyn.s.cm-5; p less than or equal to 0.05), although it did not affect pulmonary arteriolar resistance. Also, oxygen treatment at rest influenced only total pulmonary vascular resistance (reduction from 412 +/- 50 to 373 +/- 48 dyn.s.cm-5; p less than or equal to 0.01), but not pulmonary arteriolar resistance. Pressure-flow curves, which were derived from cardiac output at rest and during exercise and from the corresponding gradient between mean pulmonary artery pressure and pulmonary capillary wedge pressure, remained unchanged by acute medication. Since a change in arterial oxygen partial pressure was not noticed after nitrendipine, arteriovenous shunting or a worsening of ventilation perfusion relationships can be excluded. Long-term (3 weeks) treatment (double-blind parallel design) with 10 mg of nitrendipine (4 patients) once daily showed no advantage in comparison to placebo (6 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of 5 mg sublingual nitrendipine in patients with precapillary pulmonary hypertension due to pulmonary fibrosis.

In 10 patients with precapillary pulmonary hypertension due to pulmonary fibrosis, the arterial blood pressure, right heart hemodynamics, cardiac output, and arterial oxygen partial pressure were measured to evaluate the benefits of acute sublingual (5 mg) nitrendipine. Additionally, the effect of oxygen enriched air was compared to control. At rest, nitrendipine significantly diminished arterial blood pressure [102 +/- 3 to 93 +/- 3 mm Hg (mean +/- SEM)], right atrial pressure (5.7 +/- 0.9 to 3.4 +/- 0.8 mm Hg), mean pulmonary artery pressure (33.4 +/- 3.5 to 29.8 +/- 3.3 mm Hg), and pulmonary artery wedge pressure (13.0 +/- 2.0 to 6.8 +/- 0.8 mm Hg). During exercise, nitrendipine reduced mean pulmonary artery pressure (54.5 +/- 4.8 to 49.3 +/- 4.7 mm Hg) and right atrial pressure (9.3 +/- 1.3 to 6.8 +/- 1.4 mm Hg). A diminuation of arterial partial oxygen pressure did not occur at rest (63.2 +/- 3.8 mm Hg) or during exercise (50.9 +/- 5.1 mm Hg). Thus, nitrendipine causes a slight but significant improvement of right heart hemodynamics. The occurrence of arteriovenous intrapulmonary shunting due to vasodilatating effects of nitrendipine can be excluded. Also, nitrendipine can safely be used in combined arterial hypertension and pulmonary fibrosis.

Suppression of avian hepatic lipid metabolism by solvent extracts of garlic: impact on serum lipids.

The effects of garlic on lipid metabolism were examined in White Leghorn pullets that had been fed for 4 weeks either a control diet based on corn and soybean meal or an experimental diet containing either 3.8% garlic paste, a solvent extract (petroleum ether, methanol and water in sequence) of garlic paste, the residue or commercial garlic oil. Significant decreases in hepatic 3-hydroxy-3-methylglutaryl-CoA reductase (79-83%), cholesterol 7 alpha-hydroxylase (43-51%), fatty acid synthetase (17-29%) and in representative pentose-phosphate pathway (23-39%) activities accompanied the feeding of the petroleum ether-, methanol- and water-soluble fractions of garlic. Garlic paste and oil also suppressed these activities. Significant decreases in serum lipids occurred in response to the feeding of these garlic fractions: serum total cholesterol by 20-25%, low density lipoprotein cholesterol by 28-41% and triglycerides by 10-26%; but high density lipoprotein cholesterol failed to respond to these treatments. The residue remaining after solvent fractionation had little influence on these parameters. These findings were substantiated by a second study in which pullets of a commercial broiler line were fed the garlic fractions. The results confirm that garlic oil and odorous components of garlic lower cholesterol levels. An odorless water-soluble component of garlic also has this effect. The mechanism of the hypocholesterolemic action is at the level of the suppression of cholesterol biosynthesis.

Suppression of cholesterogenesis and reduction of LDL cholesterol by dietary ginseng and its fractions in chicken liver.

The effects of ginseng root powder and of serially extracted solvent fractions of ginseng on avian hepatic cholesterol metabolism and lipogenesis and on avian serum lipoprotein cholesterol levels were examined. In one study, White Leghorn females were fed for 4 weeks a corn-based diet (control) or an experimental diet in which was incorporated 0.25% Wisconsin ginseng or an equivalent quantity of a serial solvent fraction [petroleum ether (PESF), methyl alcohol (MESF), water (WASF)] or of the residue. beta-hydroxy-beta-methylglutaryl-CoA (HMG-CoA) reductase activity was significantly lower (P less than 0.01) in each of the treatment groups (31-37% of control activity) except that fed the extracted residue (90% of control, N.S.). Cholesterol 7 alpha-hydroxylase activity was lowered in parallel (45-64% of control, P less than 0.01) by all treatments except the residue (100% of control). Also with the exception of the residue treatment, each ginseng treatment effected a lowering of the serum total cholesterol level (67-83% of control, P less than 0.01) and of serum low density lipoprotein cholesterol level (53-81% of control, P less than 0.01). Lipogenic activities and serum triglycerides levels were lowered (P less than 0.01) by two of the ginseng treatments. The PESF treatment was the most effective suppressor of each parameter, 74% and 68% respectively, of the control values. The WASF also had significant impact. Not one of the experimental diets influenced the serum high density lipoprotein level. The PESF, the potent source of suppressors, effected a change in the ratio of low to high density lipoprotein cholesterol from 1.46 (control) to 0.88. The levels of cholesterol and triglycerides in liver under these conditions showed a similar pattern as that of serum. In companion studies, broiler females were fed 0.28% Chinese red ginseng root powder or its various fractions. The results confirmed those recorded above. The factor(s) responsible for lowering the serum total and low density lipoprotein cholesterol levels were generally more concentrated in the PESF and WASF of ginseng and each was significantly more effective than was ginseng root powder. Ginsenosides (saponins) are considered to be the active agents for the suppression of cholesterogenesis and lipogenesis.

Inhibition of cholesterol and fatty acid biosynthesis in liver enzymes and chicken hepatocytes by polar fractions of garlic.

Different concentrations of polar fractions, methanol-soluble (MESF), or water-soluble (WASF), of 1-8% equivalent to fresh garlic paste were added to yellow corn-soybean based diets and fed to 5-week-old male broiler chickens for 3 weeks to measure the inhibition of hepatic beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase, cholesterol 7 alpha-hydroxylase (7 alpha-hydroxy) and fatty acid synthetase (FAS). Dose-related decreases in the activities of these enzymes were obtained. Decreases in serum total cholesterol and in low density lipoprotein (LDL) levels were also observed. There was no effect on the level of cholesterol in high density lipoprotein (HDL). The most effective dose for these decreases was found 0.54% (MESF) and 1.2% (WASF) equivalent to 6% of the fresh garlic. The inhibition of HMG-CoA reductase and FAS by 25-300 micrograms of MESF or WASF for 15 min was tested in vitro, in male and female chicken hepatocytes. Inhibitions of activity were dose-dependent and the degree of inhibition increased with duration of incubation (150 micrograms of MESF or WASF 5 to 60 min). Dietary supplementation of odorless WASF of garlic was found to be very effective in lowering the total and LDL cholesterol levels compared to control chickens.