[Quality Assurance in Sociomedical Evaluation by Peer Review: A Pilot Project of the German Statutory Pension Insurance]. / Qualitätssicherung in der Sozialmedizinischen Begutachtung durch Peer Review - ein Pilotprojekt der Deutschen Rentenversicherung.

BACKGROUND: The sociomedical evaluation by the German Pension Insurance serves the purpose of determining entitlement to disability pensions. A quality assurance concept for the sociomedical evaluation was developed, which is based on a peer Review process. Peer review is an established process of external quality assurance in health care. The review is based on a hierarchically constructed manual that was evaluated in this pilot project. METHODS: The database consists of 260 medical reports for disability pension of 12 pension insurance agencies. 771 reviews from 19 peers were included in the evaluation of the inter-rater reliability. Kendall's coefficient of concordance W for more than 2 raters is used as primary measure of inter-rater reliability. RESULTS: Reliability appeared to be heterogeneous. Kendalls W varies for the particular criteria from 0.09 to 0.88 and reached for primary criterion reproducibility a value of 0.37. CONCLUSION: The reliability of the manual seemed acceptable in the context of existing research data and is in line with existing peer review research outcomes. Nevertheless, the concordance is limited and requires optimisation. Starting points for improvement can be seen in a systematic training and regular user meetings of the peers involved.

Endogenous cortisol in keratinized matrices: Systematic determination of baseline cortisol levels in hair and the influence of sex, age and hair color.

The measurement of hair cortisol is increasingly used to measure long-term cumulative cortisol levels and investigate its role as an important stress mediator. In this study a comparative statistical analysis of five independent studies (all analyzed in our laboratory) was performed to investigate baseline ranges of cortisol values in hair and evaluate potential influences of sex, age and hair color. Cortisol concentrations in hair of 554 subjects were measured and a comparative statistical analysis was performed. The analysis showed that cortisol levels significantly differ depending on age. The toddler group (7 months (0.6 years) to 3 years) showed significantly higher values (median 10pg/mg, p-value<0.0001, d=0.78) than the adolescent group. The adolescent groups showed significantly lower (p-value<0.0001, d=0.58 and p<0.0001, d=0.13) values (median 2.4pg/mg and 2.8pg/mg) than the adult group (median 5.8pg/mg). Furthermore, in the adult group men showed significantly higher cortisol values than women (p-value<0.05, d=0.17). This effect could not be seen in the adolescent group. Black hair showed higher cortisol concentrations than blond hair (p-value<0.0001, d=1.3). In addition, two rounds of interlaboratory comparisons for hair cortisol samples between four laboratories revealed very consistent results. Our results demonstrate that baseline cortisol levels are generally low in hair thus making a standardized and well-elaborated analytical method indispensable for accurate determination. Age-dependent normative baseline cortisol levels (toddlers, adolescents and adults) are highly recommended based on the comparative analysis comprising five independent studies.

Advancements toward magneto immunoassays.

Recently, a magneto binding assay was conducted. The operational principle is based on a 'sandwich' mode of detection, where the target analyte (Concanavalin A) becomes bound nonselectively by protein adsorption between the solid support (silica carrier particles) and the ferromagnetic label (magneto markers). A magnetic transducer was employed for the detection. The binding assay gave a linear response in the dynamic range of 0-1.9 microM and proved to be sensitive by having a limit of detection at 250 nM. Furthermore, the relative standard deviation observed was 6.2% (n = 3). The demonstration of the 'sandwich' approach is a step toward achieving magneto immunoassays (MIA).

Multicentre evaluation of a new point-of-care test for the quantitative determination of D-dimer.

Imprecision studies, interference testing and multicentre method comparisons using patient samples were carried out with of a new point-of-care test for D-dimer (CARDIAC D-Dimer). The CV of the within-series and the day-to-day imprecision with blood samples and control materials were between 7% and 13%. Compared with Tina-quant D-Dimer, CARDIAC D-Dimer showed a good correlation and accuracy (n=353; r=0.91; y=1.06x-0.03), compared with STA LIATEST D-Dimer some poorer accuracy (n=304; r=0.91; y=1.12x-0.03). No interference was detected for different hematocrit values (16% to 51%) and in investigations with hemoglobin (up to 0.13 mmol/l), biotin (up to 30 microg/l), bilirubin (up to 340 micromol/l), intralipid (up to 31.1 mmol/l) and rheumatic factor (up to 79 IU/ml). Overdosing or underdosing by 10 microl did not affect the test result. The diagnostic sensitivity of CARDIAC D-Dimer for the detection of acute venous thromboembolic diseases was 100% in our study. With CARDIAC D-Dimer reliable quantitative D-dimer results can be easily obtained. Because of the good analytical and clinical agreement with Tina-quant D-Dimer, it should be suitable for ruling out venous thromboembolic diseases.

Classification of mitral valve prolapse.

The scope of diagnosing mitral valve prolapse (MVP) has been enlarged by the earlier reported real-time B-scan criteria of small or "localised MVP". This form is believed to be the precursor of the overt MVP which is then readily diagnosed by angiocardiography and 1- and 2-dimensional echocardiography (1- and 2-dE). Rheumatic heart disease (RHD) is believed to be recognisable much earlier as well, by the previously reported 1- and 2-dE features of "early commissural fusion" (ECF). 30 patients in whom overt or localised MVP were diagnosed previously were reviewed for overt or early signs of ECF. In all patients early or overt echo features of RHD could be visualised. Thus RHD may be the most important cause of acquired MVP, even though it is rarely considered in recent classifications. It is proposed that RHD is perhaps the unifying link for all forms of MVP. GOTTLIEB and CHUNG were asking for such a unifying link "since the present classification is dubious at best. It offers nothing to use clinically and may actually be in error, since the primary form may be a less overt expression of the secondary form." It is proposed that mostly unrecognised rheumatic fever may be the underlying first lesion leading to the various different mechanisms described for MVP. If this can be confirmed, a new approach to primary prevention of rheumatic fever and its subclinical forms may be necessary. There is also some evidence to suggest that RHD may be the early and unrecognised microlesion in the coronary arteries as well and thus the important early factor in the development of macroscopic coronary artery disease.

Irreducible fracture of the calcaneus due to flexor hallucis longus tendon interposition.

An unusual fracture-dislocation of the calcaneus is presented in which tendinous interposition in the subtalar joint prevented the possibility of closed reduction. This situation has been reported in the literature in only five previous patients. The position of the flexor hallucis tendon in the joint could be visualized on the preoperative computed tomographic scan. The patient was treated operatively with reduction through a lateral approach without a supplemental medial incision.

Dermal nerve sheath myxoma of the hallux: a case report.

Dermal nerve sheath myxoma is a rare tumor with a predilection for the upper extremity, head, neck, and shoulder. It usually arises during childhood or early adult life. We present a case of a young woman who has this type of myxoid tumor of the hallux. To preserve viability of the hallux, debulking of the tumor was performed rather than complete marginal excision. This case and a literature review suggest that this tumor may be satisfactorily managed with debulking or marginal resection. Histology and pathology of dermal nerve sheath myxoma are reviewed.

Tibiotalocalcaneal arthrodesis with an intramedullary device.

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.

The significance of positive cultures from orthopedic fixation devices in the absence of clinical infection.

Microbiologic samples for culture were obtained from 21 patients during elective removal of fracture-fixation hardware. The hardware was being removed for pain, displacement, nonunion or malunion correction, or patient preference. None of the patients had evidence of infection as determined by medical history, physical examination, white blood count, and sedimentation rate performed on the day of hardware removal. Two sets of culture samples were obtained from each patient: swabs of the wound and of the hardware were obtained and processed by the hospital laboratory. Eleven hardware cultures and nine wound cultures were positive for microbiologic growth. None of the patients was treated with antibiotics, and none developed any problems with wound infection or healing nor any evidence of osteomyelitis. We concluded that positive cultures obtained during hardware removal in the absence of clinical signs of infection are not meaningful.

The clinical utility of duplicate readings for musculoskeletal radiographs.

It is a common practice in many hospitals to have all skeletal radiographs read by a second physician, usually a radiologist, as well as by the treating physician. A two-part study was performed in order to examine the cost and clinical benefit of this practice for plain films ordered by orthopedists. In the first part of this study, the attending orthopedic surgeons were surveyed about the clinical usefulness and effect on patient care of 1000 radiologic reports from plain films ordered on orthopedic patients. In the second part, the charts of 272 patients who had 704 radiographs were reviewed with the goal of identifying any discrepancies between the orthopedic interpretation and the radiologic reading. Thirty-eight reports were discarded because they were not reports of plain skeletal films. One hundred twenty-nine of the remaining 962 radiologic reports were never read by the attending orthopedist. The average time between the taking of the film and an orthopedic attending reading the printed report was 6.1 days. Three radiology reports contained findings that were incorrect. Only one report contained findings that the orthopedist was unaware, and one report may have led to an alteration in treatment. No reports resulted in an unplanned trip to the operating room or a patient being called back to the clinic. Of the 272 chart reviews (704 reports), 70 had no orthopedic interpretation recorded and 94 had no radiologic report in the chart. Twelve discrepancies were noted in the cases that had both reports. Four fracture displacements were identified by orthopedists, but not on the written radiology report; three of these required a return to the operating room. Four instances of hardware displacement or breakage were noted by orthopedists, but not commented on by the radiologists. Three incidental injuries (two fractures and an acromioclavicular injury) were noted on printed reports of films taken for other reasons, but not commented on by the orthopedist, and not treated. A dorsal bunion was noted on one film by the orthopedist, but not by the radiologist. From this study, one can conclude that the benefit of routine duplicate radiograph interpretation by a second physician does not justify its cost.

[M- and real-time b-scan diagnostic criteria and pit-falls in right ventricular volume overload (author's transl)]. / M- und Real-Time B-Scan-Kriterien und Irrtumsmöglichkeiten bei der Diagnose der rechtsventrikulären Volumenüberlastung.

The observation of a characteristic "see-saw" motion of the interventricular septum (IVS) in real-time B-scan (RTBS) in right ventricular volume overload (RVVO) reveals features which have not been taken into account in diagnostic M-scan echocardiography. From an investigation of 20 patients it became apparent that the criteria (1) increase in right ventricular internal diameter and (2) "paradoxical" septal motion, so far used for the M-scan diagnosis of RVVO, should be complemented by further criteria: (3) hypertrophy of the IVS in longstanding RVVO, (4) increase in septal amplitude of motion towards the cardiac apex, (5) selective increasing apical septal hypertrophy and (6) an apparent random septal motion without any resultant main direction as an indication of a displaced fulcrum of the septal "see-saw". All features may be visualised by carrying out a continuous sweep in M-scanning. The criteria 2-5 may be understood as a result of increased apical work load compensating for the haemodynamic loss of the reversed upper septal motion ("RUSM"). The diagnosis of RVVO can be made more readily and reliably with RTBS echocardiography, underlining the utility of a combined use of one- and two-dimensional ultrasonography in diagnostic cardiology.

[Interventricular septal motion in hypertrophic cardiomyopathy. Additonal knowledge from real-time b-scan echocardiography (author's transl)]. / Die Bewegung des interventrikulären Septums bei hypertrophea Kardiomyopathie. Erweiterte Erkenntnisse mittels Real-time-B-scan-Echokardiographie.

M-scan echocardiography had suggested that interventricular septal motion in patients with Hypertrophic Cardiomyopathy is immobile. In this study special attention was paid to this septal motion during Real-time B-scan (RTBS) investigations of 15 patients with proven Hypertrophic Cardiomyopathy. RTBS recordings have shown that the basal part of the interventricular septum (IVS), which bulges into the left ventricular outflow tract (LVOT), exhibits a forceful contraction towards the cardiac apex, while the more apical portion moves normally towards the left ventricular posterior wall. The direction of the basal septal motion is more or less at right angles to the single ultrasonic beam in M-scanning. The amplitude of this motion, therefore, can only be appreciated with M-mode according to that component of motion which moves parallel to the ultrasonic beam. According to the angle of incidence of the ultrasound waves, septal motion may be recorded as mobile or apparently immobile, and the transition zone from apical to posterior septal motion can be appreciated in a semiquantitative manner by using a Continuous Sweep Technique. From these observations and considerations it has emerged that the left ventricular internal diameter and the rate of change of this dimension in the region of the "immobile" basal septum does not allow conclusions to be drawn about the overall haemodynamic situation of the left ventricle in patients with Hypertrophic Cardiomyopathy. Furthermore, this study is another demonstration of the importance of the combined application of M-and RTBS echocardiography for optimal non-invasive clinical cardiac diagnosis.

Tapping with peripheral nerve block. a role for tactile feedback in the timing of movements.

This study examines the impact of peripheral nerve block, that is, the elimination of tactile feedback on synchronization performance. In a tapping experiment in which subjects were instructed to tap in synchrony with an auditory pacing signal, three different tasks were studied under conditions with and without peripheral nerve block: standard tapping with tactile contact, isometric tapping, and contact-free tapping. In addition, the maximum tapping rate was registered both with and without peripheral nerve block. It was found that the anticipatory error, usually observed in synchronization tasks, was affected by the peripheral nerve block in the standard tapping and the isometric tapping task. In both tasks, local anesthesia led to an increase in asynchrony between the pacing signal and the tap. Performance remained unimpaired in those tasks in which tactile information was assumed to play a minor role (maximum tapping rate and contact-free tapping). The results clearly demonstrate the importance of tactile feedback for the timing of movements. The predictions of a model assuming a strong correlation between the amount of sensory feedback and the size of the negative asynchrony in synchronization tasks were examined and discussed.

Hierarchical coding in the perception and memory of spatial layouts.

Two experiments were performed to investigate the organization of spatial information in perception and memory. Participants were confronted with map-like configurations of objects which were grouped by color (Experiment 1) or shape (Experiment 2) so as to induce cognitive clustering. Two tasks were administered: speeded verification of spatial relations between objects and unspeeded estimation of the Euclidean distance between object pairs. In both experiments, verification times, but not distance estimations, were affected by group membership. Spatial relations of objects belonging to the same color or shape group were verified faster than those of objects from different groups, even if the spatial distance was identical. These results did not depend on whether judgments were based on perceptually available or memorized information, suggesting that perceptual, not memory processes were responsible for the formation of cognitive clusters.

[What kind of information is expected to be provided by medical information services?]. / Welche Informationen erwarten Patienten und Versicherte von medizinischen Informationsdiensten?

OBJECTIVE: The improvement of health-related information services is one major issue in reforming the German health care system to provide more transparency in health care services for patients and persons covered by the German statutory health insurance system. To meet the general need for specific medical information a telephone-based health information service may give individual advice and provide a helpful selection of information. The study aims at users expectations and preferences with regard to health information services. More particularly, users perception concerning the type of health information and the ways of choosing the information were to be explored. METHOD: The study included 160 participants of different ages. Prototypical medical advice conversations were presented to the participants consisting of/identifying the consumer's inquiry, followed by the expert's answering sequence. The answers were based on typical inquiries from medical information providers focussing on treatment methods and illnesses. Health information from these conversations with its special contents were ranked by preference judgements resulting in Thurstone scalings. RESULTS: In terms of different health questions, the participants' judgements showed general preference structures for special health information, independent from any personal attitude towards medical information services. Great emphasis was placed on the medical conversation competence of the service provider, which is evident from recognising the specific needs and selection of information of a caller. Overall such health information was preferred that strengthened the patient's and user's autonomy and ability for decision making. CONCLUSION: Patients and persons covered by German statutory health insurance are characterised as users of information by special preferences. Identifying these preferences permits a reasonable selection of information and individual advice. Therefore, these services provide a major advantage over non-interactive health information services (print media, internet sites).

Non-invasive left ventricular volume determination by two-dimensional echocardiography.

Twenty patients undergoing routine left ventricular single-plane angiography have been investigated by an ultrasonic triggered B-scan technique to provide a two-dimensional cross-sectional image of the left ventricle in end-systole end-diastole. An area-length method has been used to establish the correlation between the angiographic and the echocardiographic assessments of left ventricular chamber volume (r equals 0.88) and ejection fraction (r equals 0.81). Differences between the two techniques are discussed, and it is concluded that in approximately 80 per cent of patients triggered B-scanning may provide a safe, non-invasive, and convenient technique for the determination of volumes and certain functional parameters, especially in patients with dilated hearts and irregular left ventricular shape, where M-scanning is known to be less reliable.

[Use of a computer in a clinical-toxicological laboratory with a fuzzy search]. / Ein Computereinsatz im klinisch-toxikologischen Laboratorium mit Verwendung von unscharfen Suchkriterien.

If a clinician is faced with acute intoxications a rapid toxicological test is essential. The toxic substances are identified by a combined use of various systems of analysis such as gas chromatography, thin-layer chromatography or UV-spectroscopy. As the result of the analysis a data pattern is obtained which can be interpreted by comparing it with substance-related reference patterns. This paper describes a computer-program which allows more efficient reference comparisons and which gives a support of the decisions. The algorithms of the comparisions are based on fuzzy-theory.