[Mortality after high-risk surgery in Jehovah's Witness patients]. / Letalität nach operativen Risikoeingriffen bei Zeugen Jehovas.

BACKGROUND: Jehovah's Witness (JW) patients strictly refuse allogeneic blood transfusion for religious reasons. Nevertheless, JW also wish to benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The Northwest Hospital in Frankfurt am Main Germany is a confidential clinic of JW and performs approximately 100 surgical interventions per year on this patient group. MATERIAL AND METHODS: A retrospective analysis of closed medical cases performed in the years 2008-2018 at the Northwest Hospital aimed to clarify (1) the frequency of surgical procedures in JW patients associated with a statistical allogeneic transfusion risk (presence of preoperative anemia and/or in-house transfusion probability >10%) during this time period, (2) the degree of acceptance of strategies avoiding blood transfusion by JW and (3) the anemia-related postoperative mortality rate in JW patients. RESULTS: In the 11- year observation period 123 surgical procedures with a relevant allogeneic transfusion risk were performed in 105 JW patients. Anemia according to World Health Organization (WHO) criteria was present in 44% of cases on the day of surgery. Synthetic and recombinant drugs (tranexamic acid, desmopressin, erythropoetin, rFVIIa) were generally accepted, acute normovolemic hemodilution (ANH) in 92% and cell salvage in 96%. Coagulation factor concentrates extracted from human plasma and therefore generally refused by JW so far, were accepted by 83% of patients following detailed elucidation. Out of 105 JW patients 7 (6.6%) died during the postoperative hospital stay. In 4 of the 7 fatal cases the cause of death could be traced back to severe postoperative anemia. CONCLUSION: Given optimal management JW patients can undergo major surgery without an excessive risk of death. The 6.6% in-hospital mortality observed in this institution was in the range of the 4% generally observed after surgery in Europe. The majority of JW patients accepted a variety of blood conservation strategies following appropriate elucidation. This also included coagulation factor concentrates extracted from human plasma enabling an effective treatment of even severe bleeding complications. In this analysis postoperative hemoglobin concentrations below 6 g/dl in older JW patients were associated with a high mortality risk due to anemia.

Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study.

PURPOSE: To evaluate the safety and efficacy of radiofrequency (RF) ablation of the basivertebral nerve (BVN) for the treatment of chronic low back pain (CLBP) in a Food and Drug Administration approved Investigational Device Exemption trial. The BVN has been shown to innervate endplate nociceptors which are thought to be a source of CLBP. METHODS: A total of 225 patients diagnosed with CLBP were randomized to either a sham (78 patients) or treatment (147 patients) intervention. The mean age within the study was 47 years (range 25-69) and the mean baseline ODI was 42. All patients had Type I or Type II Modic changes of the treated vertebral bodies. Patients were evaluated preoperatively, and at 2 weeks, 6 weeks and 3, 6 and 12 months postoperatively. The primary endpoint was the comparative change in ODI from baseline to 3 months. RESULTS: At 3 months, the average ODI in the treatment arm decreased 20.5 points, as compared to a 15.2 point decrease in the sham arm (p = 0.019, per-protocol population). A responder analysis based on ODI decrease ≥ 10 points showed that 75.6% of patients in the treatment arm as compared to 55.3% in the sham control arm exhibited a clinically meaningful improvement at 3 months. CONCLUSION: Patients treated with RF ablation of the BVN for CLBP exhibited significantly greater improvement in ODI at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain. These slides can be retrieved under Electronic Supplementary Material.

Behavioural and psychological symptoms in general hospital patients with dementia, distress for nursing staff and complications in care: results of the General Hospital Study.

AIMS: Little is known about how behavioural and psychological symptoms of dementia (BPSD) manifest in the general hospital. The aim was to examine the frequency of BPSD in general hospitals and their associations with nursing staff distress and complications in care. METHODS: Cross-sectional representative study with 1469 patients aged ≥65, including 270 patients with dementia, of 33 randomly selected general hospitals in Germany. BPSD and complications were reported by nurses. RESULTS: Overall frequency of BPSD was higher in patients with dementia (76%) than without (38%). The most frequent symptoms in patients with dementia were nighttime disturbances (38%), depression (29%) and aberrant motor behaviour (28%) and the most distressing symptoms for nursing staff were delusions, aggression and nighttime disturbances. The overall frequency of BPSD increased from 67% in mild dementia, to 76% in moderate dementia and to 88% in severe dementia. The most frequent symptoms in patients without dementia were depression (19%), nighttime disturbances (13%) and irritability (13%). The most distressing symptoms were aggression and delusions, while the same symptoms were consistently rated as less distressing than in patients with dementia. Factor analysis revealed three independent groups of BPSD that explained 45% of the total variance. First, expansive symptoms (aggression, irritability, nighttime disturbances, aberrant motor behaviour and disinhibition) were frequent, distressing for nursing staff and associated with many complications. Second, psychotic symptoms (delusions and hallucinations) were infrequent, distressing and associated with some complications. Third, affective symptoms (apathy, anxiety and depression) were frequent, non-distressing and associated with few complications. The results did not change when cases with delirium were excluded from both groups. CONCLUSIONS: BPSD are common in older hospital patients with dementia and associated with considerable distress in nursing staff, as well as a wide range of special treatments needs and additional behavioural and medical complications. Management strategies are needed to improve the situation for both patients and hospital staff.

[Primary Prevention of Impairments of Mobility Among Nursing Home Residents with Dementia]. / Primärprävention von Mobilitätseinschränkungen bei Menschen mit Demenz in Pflegeheimen.

The main aim of the study was to investigate the effectiveness of multidisciplinary guidelines in promoting the mobility of people with dementia in 20 German nursing homes. The study was based on a semi-experimental design [pre-post design with intervention (IG) and control group]. The statistical analyses revealed a significantly slower decline of the ability to walk among the residents of the IG than among the controls. With regard to other outcome measures the results were less clear.

[Scope and limitations of the median nerve mouse model in research on peripheral nerve regeneration]. / Möglichkeiten und Grenzen des N. medianus Maus Modells bei der Erforschung der peripheren Nervenregeneration.

INTRODUCTION: Peripheral nerve regeneration is usually studied in rat animal models (N. medianus or N. ischiadicus). In this article, we further evaluate the mouse median nerve model with its advantages and possible pitfalls. MATERIALS AND METHODS: 24 mice (C57BL/6) were operated. The median nerve was exposed in the left axilla. After transection, immediate microsurgical repair followed using 11/0 sutures. In the contralateral axilla, 1 cm of median nerve was resected. After the operation, functional regeneration of the median nerve was assessed using the grasping test. Histological analysis was performed after staining with toluidine blue. RESULTS: All animals survived the procedure. Grip strength increased starting at day 10 and reached its maximum at day 35. Myelinated fibres in the regenerated nerves showed a smaller diameter and a thinner myelin sheath and the typical microfasciculation of regenerated nerve fibres in comparison to the uninjured nerve. CONCLUSION: The mouse median nerve model is technically demanding but opens a wide field of possible research options using genetically modified mice.

[A comparison of special and traditional inpatient care of people with dementia]. / Besondere und traditionelle stationäre Betreuung demenzkranker Menschen im Vergleich.

Recent studies reveal that approximately two thirds of the residents in German nursing homes suffer from some type of moderate to severe dementia. In addition to cognitive impairments, other psychiatric symptoms and behavior problems frequently impact the quality of life of the affected residents, their fellow residents and the nursing staff. Novel concepts of nursing care for dementia patients with behavior problems have been developed against this backdrop, e. g. within the framework of the program of special care for dementia patients in Hamburg. A comprehensive course study (follow-up period: approximately six months) of a sample population of nursing home residents and consecutive admissions focused upon:the degree to which the quality of life and care for dementia patients in Hamburg differs according to the type of care given, i. e. segregative (domus philosophy), or partially segregative (integration philosophy), and the differences between the special care of dementia patients as provided in Hamburg, as opposed to the traditionally integrative care of dementia patients as practiced in the city of Mannheim. In order to gain the most complete picture possible-also for persons with severe cognitive impairments-information was collected primarily on the basis of the assessments made by qualified nursing staff. In the city of Hamburg there were advantages and disadvantages, respectively, between segregative care (domus philosophy) and partially segregative care (integration philosophy): the activity rates were higher for care in integrative than in domus environments, and could be maintained better over time. Moreover, the number of visits from relatives and their involvement in the nursing and social care was also higher for the integrative, as opposed to the domus setting. Among the residents of domus-care homes, however, significantly more biographical information was collected, and the proportion of dementia patients receiving gerontopsychiatric care also was higher. Dementia patients in these homes also received more psychotropic medication, with antidementia drugs and antidepressants being prescribed significantly more frequently and antipsychotic drugs less frequently.The comparison of the special dementia care available in Hamburg with the traditional, integrative care available to dementia patients in Mannheim revealed a number of visible indicators for the quality of life that point in favor of the model program in Hamburg. This is apparent in the more frequent expression of positive feelings, the greater number of activities fostering competency, the significant involvement of relatives and volunteers, the greater number of social contacts with the staff, fewer use of physical restraint, and better gerontopsychiatric care. Contradictory to our expectation, however, dementia patients cared for in the traditional setting exhibited fewer behavior problems over time than did their counterparts cared for within the framework of the Hamburg model.

Tratamiento quirúrgico de las fracturas de columna cervical superior / Surgical treatment of the upper cervical spine factures

Objetivo: Descripción de las indicaciones y resultados del tratamiento quirúrgico de las fracturas de columna cervical superior, durante el periodo entre enero de 1989 y diciembre de 1998. Pacientes y métodos: Estudio retrospectivo de 17 casos, 15 hombres (88,2 por ciento) y 2 mujeres (11,8 por ciento), con una edad promedio de 32,7 años y un seguimiento promedio de 56.4 meses. Los casos correspondieron a 1 fractura del atlas (5,9 por ciento), 12 fracturas de apófisis odontoides (70,5 por ciento), 2 fracturas de los pedículos del axis (11,8 por ciento) y 2 fracturas del atlas y axis (11,8 por ciento). Dos casos presentaron compromiso radicular asociado (11,8 por ciento). Resultados: La consolidación se obtuvo en promedio a las 12 semanas en la fractura del atlas, a las 9.8 semanas en las fracturas del odontoides, a las 10 semanas en las fracturas de los pedículos del axis y a las 16 semanas en las fracturas de atlas y axis. Se presentó dehiscencia parcial de herida en 1 caso. Los casos con compromiso radicular se recuperaron completamente. Conclusión: El manejo de las fracturas de columna cervical superior es generalmente conservador y el tratamiento quirúrgico se encuentra reservado para las lesiones inestables y las complicaciones de la consolidación.

Resultados del tratamiento quirúrgico de las fracturas de acetábulo / Acetabulum fracture: results of surgical treatment

Objetivo: Evaluación de los resultados del tratamiento con reducción abierta y fijación interna de las fracturas desplazadas de acetábulo, intervenidas quirúrgicamente entre enero de 1989 y diciembre de 1998. Material y Método: Estudio retrospectivo de 57 pacientes con una edad promedio de 34, 6 años y un tiempo medio de seguimiento de 66,3 meses. El mecanismo lesional correspondió en 45 casos a accidentes de tráfico (78,9 por ciento) y en 12 casos a aplastamientos (21,1 por ciento). De acuerdo con la clasificación de Judet y Letournel hubo 24 fracturas simples (42,1 por ciento) y 33 fracturas complejas (57,9 por ciento). La fijación interna se realizó con placa y tornillo en 35 casos (61,4 por ciento) y con tornillos en 22 casos (38,6 por ciento). Resultados: La reducción postoperatoria fue anatómica en 27 casos (47,3 por ciento), satisfactoria en 16 casos (28,1 por ciento) y deficiente en 14 casos (24,6 por ciento). Los resultados funcionales fueron excelentes en 22 casos (38,6 por ciento), buenos en 18 casos (31,6 por ciento), regulares en 6 casos (10,5 por ciento) y malos en 11 casos (19,3 por ciento). Las complicaciones precoces fueron redesplazamiento de la fractura en 3 casos (5,3 por ciento), hematoma postoperatoria en 2 casos (3,5 por ciento), parálisis del nervio ciático en 2 casos (3,5 por ciento), trombosis venosa profunda en un caso (1,8 por ciento) infección profunda en un caso (1,8 por ciento) e infección superficial en un caso (1,8 por ciento). Las complicaciones tardías fueron osificación heterotópica en 7 casos (12,3 por ciento), artrosis postraumática en 6 casos (10,5 por ciento) y necrosis avascular de la cabeza femoral en 4 casos (7,0 por ciento). Conclusión: La reducción abierta y fijación interna es un método eficaz para el tratamiento de las fracturas desplazadas de acetábulo, pues permite reconstruir la articulación coxofemoral, consiguiendo buenos resultados clínicos en el largo plazo.

Comparative analysis of biofeedback and physical therapy for treatment of urinary stress incontinence in women.

OBJECTIVE: To compare the effectiveness of an intensive group physical therapy program with individual biofeedback training for female patients with urinary stress incontinence. DESIGN: Randomized study of two therapeutic interventions consisting of a specific physical therapy program (PT) or biofeedback training (BF) daily for 4 wk, followed by a 2-mo, unsupervised home exercise program in both groups in an outpatient clinic of a large university hospital. Forty women, referred by gynecologists for nonoperative treatment of genuine stress incontinence of mild-to-moderate severity, were included. Measurements of daytime/nocturnal urinary frequency and subjective improvement of incontinence were the main outcome measures at initial presentation, after completion of the therapy program, and at follow-up after 3 mo. Standardized examinations of digital contraction strength, speculum tests, and manometric measurements were documented as secondary outcome measures. RESULTS: In the PT group, the daytime urination frequency decreased 22% after 4 wk of therapy and 19% after 3 mo (P < 0.05) from baseline. The nocturnal urination frequency was reduced by 66% after 4 wk of therapy and 62% after 3 mo (P < 0.001). In the BF group, the daily urination frequency decreased 10% after 4 wk of therapy and 5% after 3 mo (P > 0.05). The nocturnal urination frequency declined 36% after 4 wk of therapy and 66% after 3 months (P < 0.05). Subjective assessment after 3 mo showed that in the PT group, 28% of patients were free of incontinence episodes, 68% reported improved symptoms (incontinence episodes improved by >50%), and 4% were unchanged. In the BF group, 62% were free of incontinence episodes, and 38% were improved. Results of the digital contraction strength assessments, speculum tests, and manometric measurements showed statistically significant improvement in all variables in both groups after 3 months. CONCLUSION: Four weeks of both intensive group physical therapy or individual biofeedback training followed by an unsupervised home exercise program for 2 mo are effective therapies for female urinary stress incontinence and result in a significantly reduced nocturnal urinary frequency and improved subjective outcome. Only group physical therapy resulted in reduced daytime urinary frequency. BF therapy resulted in a better subjective outcome and higher contraction pressures of the pelvic floor muscles.

Personal exercise habits and counseling practices of primary care physicians: a national survey.

OBJECTIVE: Regular physical activity can reduce the incidence and prevalence of many chronic diseases. A vast majority of Americans cite their physician as their primary source of information regarding healthy lifestyle decisions. This study was designed to obtain information about the personal exercise behavior and counseling practices of primary care physicians, to evaluate the relationship between their personal and professional exercise practices, and to determine whether physician specialty is associated with these practices. DESIGN: A cross-sectional survey was mailed to a randomly selected sample of primary care physicians in the United States. A questionnaire was used to obtain detailed information on the personal exercise habits, counseling practices, and barriers to counseling of these physicians, regarding both aerobic exercise and strength training. PARTICIPANTS: 298 primary care physicians, comprising 84 family practitioners, 79 pediatricians, 58 geriatricians, and 77 internists. MAIN OUTCOME MEASURES: Frequency of physician exercise, exercise counseling, and relationship between these practices. RESULTS: Physicians who perform aerobic exercise regularly are more likely to counsel their patients on the benefits of these exercises, as are physicians who perform strength training. Pediatricians and geriatricians counsel fewer patients about aerobic exercise than family practitioners and internists. Counseling regarding strength training is less common in all physician groups surveyed, and lowest among pediatricians, of whom 50% did not advise these exercises for any of their patients. Inadequate time was noted by 61% and inadequate knowledge and/or experience by 16% of respondents as the major barriers to counseling regarding aerobic exercise. CONCLUSION: Physicians who exercise are more likely to counsel their patients to exercise. Inadequate time and knowledge/experience regarding exercise are the most common barriers to counseling identified. These findings suggest strategies that might increase physician exercise counseling behavior.

Dosing practices of physicians for anticoagulation with warfarin during inpatient rehabilitation.

OBJECTIVE: To determine the percentage of international normalized ratios (INRs) maintained within the therapeutic range for patients receiving chronic anticoagulation treatment with warfarin during inpatient rehabilitation. DESIGN: A consecutive, 4-month, retrospective chart review of all patients receiving oral anticoagulation treatment was conducted in a large academic rehabilitation center. The percentage of INRs within and out of the therapeutic range, frequency of blood samples, length of therapy, and warfarin dose prescribed by physicians were calculated. A total of 181 patients receiving chronic anticoagulation treatment were identified. A total of 3,709 blood samples were analyzed. In 74 patients, the primary physician recommended a therapeutic range (Group 1). In the remaining 107 patients, no therapeutic range was specified, and a target INR range of 2.0-3.0 was assumed (Group 2). RESULTS: In Group 1, the INRs were in the recommended range in 38.2% of all blood samples. In Group 2, 37.6% of all blood drawn was within an INR range of 2.0-3.0. Statistical analysis showed that no better accuracy was obtained when the INR range was predefined by a physician (Group 1) or assumed to be in the 2.0-3.0 range (Group 2; P = 0.839). CONCLUSIONS: Despite frequent physician monitoring, this study demonstrates the difficulty in maintaining INRs within therapeutic ranges for patients receiving oral anticoagulation. An overall tendency for underdosing is observed. Improvement is necessary, given the high morbidity and mortality associated with insufficient anticoagulation in rehabilitation inpatients.

Predictors of mortality among demented elderly in primary care.

OBJECTIVES: To evaluate a wide range of sociodemographic, neurological and clinical variables as to whether they predict mortality in a representative sample of demented elderly. DESIGN: A three-stage community survey was conducted, based on a total of 3721 elderly patients whose cognitive status was assessed by their general practitioners (stage I). A stratified random sample of patients underwent a standardized research interview, including cognitive testing and the assessment of mental status, physical illness, sensory impairment and motor disability (stage II). After a mean interval of 28 months, all patients were recontacted. For deceased patients a close reference person was interviewed and the exact date of death was recorded (stage III). The influence of the predictor variables on mortality was determined by using the Cox proportional hazards model. SUBJECTS: A stratified random sample of 117 patients in primary care (mean age 82 years) suffering from mild, moderate or severe dementia (Alzheimer type, vascular or mixed dementia). MATERIALS: Hierarchical Dementia Scale (HDS), a modified version of the Hamilton Depression Scale, other clinical rating scales and CAMDEX criteria for clinical diagnosis and a degree of severity of dementia. RESULTS: Fifty-three of the 117 demented patients had died during the follow-up interval. The mortality risk increased steeply with the degree of severity of dementia. By controlling for this variable, only age and motor disability contributed significantly to the prediction of mortality, whereas gender, social class, type of dementia, extrapyramidal signs and other clinical features showed no or only a weak effect on the outcome. CONCLUSION: The remaining life expectancy of the demented elderly depends primarily on the severity of the dementia, the patients' age and their general physical health. The influence of other clinical features which often have been hypothesized as indicators of specific subgroups of dementia was mainly due to their relationship to the disease severity.

[Developing a rehabilitation databank for Germany--conceptional considerations exemplified by UDSMRSM (Uniform Datasystem of Medical Rehabilitation)]. / Entwicklung einer Rehabilitationsdatenbank für Deutschland--konzeptionelle Uberlegungen am Beispiel der UDSMRSM.

Current research in medical rehabilitation lacks well designed clinical studies to demonstrate the efficacy, effectiveness and efficiency of rehabilitation interventions. Randomized controlled studies (RCTs) are difficult to conduct in rehabilitation research because of multiple variables and difficulties to include appropriate control groups. Therefore, we propose the development of a rehabilitation database and network for Germany to allow data collection from daily rehabilitation practice in the three areas medical-objective, perceptive-subjective and economical-social, designed after the example of the Uniform Datasystem of Medical Rehabilitation (UDSMRSM). This American database uses the Functional Independence Measure (FIM) to monitor functional changes in medical rehabilitation patients. Quarterly reports are sent out to participating institutions and allow comparisons with other regional, national and international institutions. The database demonstrates an initial step towards the concept of "evidence-based rehabilitation" by defining a common rehabilitation outcome and it allows benchmarking with other rehabilitation facilities. This permits the development of quality standards, cost analyses, payment systems and a new research methodology that can identify the most effective rehabilitation method through statistical analysis for focused clinical trials.

Alcohol problems among residents in old age homes in the city of Mannheim, Germany.

OBJECTIVE: This study aims to determine the prevalence of alcohol problems among residents in old age homes, its demographic and clinical features, and its association with the risk of falling. METHOD: All residents (n = 1922) living in 20 randomly selected residential and nursing homes in the city of Mannheim, Germany, were included. Based on routine documentation, details of their sociodemographic features, medical diagnoses made upon admission, and current medication were compiled. The home staff filled out for each resident a standardised assessment sheet on activities of daily living-impairment (Barthel Index), behaviour problems, alcohol consumption, and frequency of falls. RESULTS: According to the diagnoses of the primary care physicians, 7.4% of the residents had mental and behavioural disorders due to alcohol (ICD-10: F10). Rates were particularly high among men, and younger and single or divorced residents. A high percentage of those with a diagnosis of alcohol abuse/dependence (41.1%) were transferred from mental hospitals. Home staff reported current alcohol abuse/dependence among 3.4% of all residents. The risk of falling was significantly elevated (Odds ratio: 2.65; p<0.01) among those with current alcohol problems. CONCLUSION: The results corroborate the findings from other studies wherein residents of old age homes constitute a group at risk of alcohol abuse and dependence. Alcohol problems were more the cause for, rather than the consequence of, home admission.

[Changes in homes for the aged and nursing homes: functional impairments and behavioral disorders of residents are increasing]. / Alten- und Pflegeheime im Wandel: Alltagseinschränkungen und Verhaltensauffälligkeiten der Bewohner nehmen zu.

Residents in homes for the elderly and in nursing homes suffer from physical and mental disorders that are prevalent far above average. In the course of the changes that are presently taking place in the German health care system there is now an increase in the number of mentally ill and severely impaired persons residing in old-age homes. Earlier epidemiological studies do not yield any conclusive predictions of changes in residential structures and hence in nursing care requirements. Two cross-sectional studies are presented on the prevalence of physical and mental diseases, daily and behaviour problems among residents of old-age and nursing homes in Mannheim. There was a distinct increase in average age, functional impairment, depression and disoriented behaviour among residents in 12 homes for the elderly in Mannheim conducted in 1988 (n = 542) and 1992 (n = 497). During the period it was noted that disoriented behaviour significantly increased the mortality risk. In another study the by far larger group of nursing home residents was investigated. So far we have data for 1995 and 1996 on results obtained from 1178 residents of Mannheim homes for the elderly and nursing homes. Among the residents of nursing homes there was a much higher prevalence of functional impairment and behaviour problems than among those of homes for the elderly. Despite a very high prevalence of depression or disorientation, only every third resident was diagnosed as suffering from organic brain disease and only every tenth resident had a depressive disorder. Since a growing proportion of residents will be mentally ill or severely impaired, these institutions will be facing increasing medical and nursing demands. Due to limited resources, the homes cannot meet these demands adequately. Hence, health policy changes are mandatory to improve nursing care and to avoid placing an increasing burden on the nursing staff.

Cross-national interrater reliability of dementia diagnosis in the elderly and factors associated with disagreement.

Thirteen researchers from five centers in Australia, Germany, the Netherlands, United Kingdom, and United States applied DSM-III-R and Clinical Dementia Rating (CDR) syndrome-level dementia criteria to written vignettes of 100 elderly people identified in clinics or community surveys. Subjects ranged in type from cognitively intact to severely demented and many were also frail, partially sighted, or deaf. This paper concerns reliability within and between centers, and the relationship between reliability and factors such as diagnostic criteria, dementia severity, and respondents' clinical characteristics. Within-center interrater reliability was high, more so for "yes-no" DSM-III-R diagnoses than the multi-level CDR. Between-center rates were lower but still moderate to good. Concordance was lower for intermediate dementia levels than for no dementia and severe dementia. Physical disability made an additional contribution to uncertainty but deafness, poor vision, anxiety, and depression had no discernible effects. Reliability levels are likely to be lower in representative aged populations than in carefully selected clinical groups.

Early development and progression of dementing illness in the elderly: a general-practice based study.

In a study carried out in 21 general practices in Mannheim, Germany, a stratified random sample (N = 507) of patients over the age of 65 years was drawn from the total of nearly 4000 who were medically documented. Eighty per cent of the sample were examined, using the Hierarchic Dementia Scale to test cognitive functioning and the CAMDEX criteria to assess global clinical severity. Repeat assessment after a mean interval of 27 months showed that all new cases of clinical dementia had arisen in persons with mild deficits initially and represented one-fifth of this group. The first-assessment ratings of cognitive function proved to be strongly predictive of risks for age-corrected mortality, admission to long-term care and dependency at follow-up, as well as of further progressive cognitive decline.

Growth factor mRNA levels in alopecia areata before and after treatment with the contact allergen diphenylcyclopropenone.

The early immune response in alopecia areata is characterized by a Th1 T helper cell cytokine pattern and an aberrant expression of ICAM-1 and HLA-DR molecules on lesional hair bulbs. A counteracting cytokine pattern induced by a therapeutic contact dermatitis is supposed to mediate the hair regrowth. In addition to cytokines, growth factors have been shown to influence immune responses, and we therefore investigated the expression levels for a panel of growth factors in untreated versus alopecia areata after treatment with the contact sensitizer diphenylcyclopropenone. Using semiquantitative reverse transcriptase polymerase chain reaction we detected a striking overexpression of transforming growth factor beta 1 mRNA in successfully treated patients. This cytokine has been shown to be a potent immune response modifier, which can suppress Th1 immune responses. The way in which topical immunotherapy induces hair regrowth in alopecia areata is unknown, but a lesional increased expression of transforming growth factor beta 1 may be a possible mechanism.

[Utilization of social departments before and after effectiveness of the 'need for disability care' health service reform in Mannheim]. / Die Inanspruchnahme von Sozialstationen vor und nach Inkrafttreten des Leistungstatbestandes 'Schwerpflegebedürftigkeit'--eine Studie in Mannheim.

Constituting a part of the new health reform in Germany ("Bundesgesundheitsreformgesetz"), a new arrangement to support home care for the very frail and severely disabled took effect in 1991. Since then the costs of basic nursing care and home-making services are partly covered by health insurance. To examine the impact of the new arrangement on the use of the community nursing services (the so-called "Sozialstationen") we compared two cross-sections of elderly patients under care in the city of Mannheim. The cross-sections encompassed all over 65-year old patients visited during January 1990 (first cross-section) and during May 1993 (second cross-section) by the "Sozialstationen" in Mannheim. The characteristics of the patients (degree of disability in everyday life, level of cognitive functioning etc.), together with the forms of care provided, were recorded by the nurses. The results show that the number of patients cared for by the "Sozialstationen" was smaller in May 1993 (n = 1649) than in January 1990 (n = 1842); especially the number of the severely disabled and demented patients was reduced. Although these findings can be viewed only as preliminary, one can conclude that--contrary to all expectations--there was no run on the "Sozialstationen" in the course of the implementation of the new social code.