Southern ocean carbon and heat impact on climate.

The Southern Ocean greatly contributes to the regulation of the global climate by controlling important heat and carbon exchanges between the atmosphere and the ocean. Rates of climate change on decadal timescales are therefore impacted by oceanic processes taking place in the Southern Ocean, yet too little is known about these processes. Limitations come both from the lack of observations in this extreme environment and its inherent sensitivity to intermittent processes at scales that are not well captured in current Earth system models. The Southern Ocean Carbon and Heat Impact on Climate programme was launched to address this knowledge gap, with the overall objective to understand and quantify variability of heat and carbon budgets in the Southern Ocean through an investigation of the key physical processes controlling exchanges between the atmosphere, ocean and sea ice using a combination of observational and modelling approaches. Here, we provide a brief overview of the programme, as well as a summary of some of the scientific progress achieved during its first half. Advances range from new evidence of the importance of specific processes in Southern Ocean ventilation rate (e.g. storm-induced turbulence, sea-ice meltwater fronts, wind-induced gyre circulation, dense shelf water formation and abyssal mixing) to refined descriptions of the physical changes currently ongoing in the Southern Ocean and of their link with global climate. This article is part of a discussion meeting issue 'Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities'.

[Decision criteria for the appropriateness of inpatient treatment in patients with peripheral angiopathy]. / MDK - Prüfungen zur primären und sekundären Fehlbelegung am Beispiel der Angiologie.

In various medical subspecialties like angiology, invasive diagnostic procedures and elective therapy, which under certain conditions may be carried out on outpatients, represent a large proportion of all inpatient medical treatment. As regulations for the statutory health insurance in Germany demand that medical procedures should be preferentially carried out in outpatient facilities, there is a high potential for conflicting views with respect to the question whether hospitalisation of an individual patient is mandatory for medical reasons. Explicit criteria may be useful to prevent conflicting views and to increase truth and fairness in the proceedings of hospitals on one hand and the medical service of the statutory health insurance on the other hand. With respect to this problem we present decision criteria which were compiled by a hospital (Hochrhein-Eggberg-Klinik Bad Säckingen) and the medical service of the statutory health insurance in the state of Baden-Württemberg (MDK-Baden-Württemberg). Our model has proven to be of value in our practical experience. It seems to be transferable to medical subspecialties with similar problems.

[Perinatal centres in the state of Baden-Württemberg: effects of minimum volume standards and quality assessments by the Medical Service of Statutory Health Insurance (MDK)]. / Perinatalzentren in Baden-Württemberg: Auswirkungen von Mindestmengen und Qualitätsprüfungen durch den Medizinischen Dienst der Krankenversicherung (MDK).

BACKGROUND: In the year 2009 the Federal Joint Committee (G-BA) obliged neonatal units in Germany to publish yearly data on the number of preterm infants treated and their outcome in the internet. At the same time annual minimum volumes were introduced for each level of perinatal care. The exact numbers of compulsory minimum volumes are heavily discussed both scientifically and politically. METHODS: 28 perinatal centres (PNC) in the state of Baden-Württemberg published data on mortality and short-term morbidity of preterm infants with a birth weight (BW) <1,500 g admitted in the year 2008 (n=1,141). These data were analysed on the background of quality assessments of structures and processes in all hospitals performed by the Medical Service of Statutory Health Insurance (MDK). RESULTS: By the end of 2008, 8 PNC had fulfilled the quality criteria of the G-BA nearly completely and reached a numerical benchmarking value of more than 300 of 465 maximally achievable points. Introducing annual minimum volumes of 36 preterm infants with a BW <1,250 g would lead to a concentration of perinatal care in 7 PNC and minimum volumes of 50 preterm infants with a BW <1,500 g per year in 8 such centres. CONCLUSION: Further centralisation of clinical care for low birth-weight preterm infants in a limited number of PNC in the state of Baden-Württemberg would be economically reasonable and could be achieved either by the introduction of higher minimum volume standards or a stringent interpretation of quality criteria of the G-BA. Based on self-reported data of the PNC currently available in the Internet it is not possible to predict the effect of such a centralisation process on patient outcome.

[Guidance of medical experts]. / Führung ärztlicher Gutachter.

Guidance is an issue of growing importance for physicians responsible for medical experts working in public health services and on medical advisory boards. The challenge of ethics on the one hand and the constraints of economy on the other hand have considerable impact on the demands for quantity as well as quality of the expert opinions. Thus, executive staff in these organisations reflect as to whether and how they can influence performance through guidance. A short summary of the results of research on the subject of guidance - concerning the aspects (i) guidance as an interaction of people, (ii) guidance as a task in a concrete situation and (iii) guidance as a systemic process of development - shows and points out a wide range of possibilities for staff management and personnel development of medical consultants. Guidance of medical experts is possible and necessary in order to develop the professionalism of medical experts, in order to ensure quality, conformity to standards and efficiency of medical expertise, as well as for a future-oriented development of the medical advisory boards themselves.

[Case payments in hospital psychiatry in the USA. The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)]. / Fallpauschalen in der Krankenhaus-Psychiatrie der USA. Das Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).

OBJECTIVE: In Germany the introduction of a prospective payment system (PPS) is intended for inpatients hospitalised in psychiatric facilities. We investigate the various elements of the Prospective Payment System for Inpatient Psychiatric Facilities (IFP PPS) which was established in the USA in 2005 with respect to their potential to be incorporated into a german PPS. RESULTS: The most important elements of IFP PPS (impact of diagnosis, comorbidity, patient age, per diem adjustment for length of stay, various other adjustment factors like facility characteristics and geographical factors) are presented. The IFP PPS was especially designed for the requirements of psychiatric inpatient facilities in the USA. Complexity of the individual elements of the PPS appears to be manageable. However, various elements, e. g. the facility based adjustments including wage index or rural location and cost of living adjustments will not be applicable to countries other than the US. The 15 diagnosis related groups of the IFP PPS system refer to ICD-9 which is less differentiated than the ICD-10 which is in use in Germany, thus these psychiatric DRG will not be compatible under conditions of a german PPS. The per diem adjustment for length of stay is the predominating element of the IFP PPS, relation to effort/performance is insufficiently represented. CONCLUSION: Some elements of the IFP PPS may be applicable to a german prospective payment system for psychiatric inpatient facilities, especially with respect to the rules for per diem adjustment for length of stay and for handling of cases with frequent discharge and readmission of patients. Altogether a stronger representation of elements of performance of inpatient facilities seems to be desirable.

[How nationally concordated measures for quality assurance in clinical care of term and preterm infants are put into practice in Baden-Württemberg]. / Zur Umsetzung national vereinbarter Massnahmen zur Qualitätssicherung in der klinischen Versorgung Früh- und Neugeborener in Baden-Württemberg.

BACKGROUND: By the end of the year 2007, pediatric hospitals in Baden-Württemberg had assigned themselves to one of three levels of perinatal care according to a checklist of the German Federal Joint Committee (F-JC) effective since January 1st, 2006. The Medical Service of Statutory Health Insurance had been assigned to prove the plausibility of that self-assessment according to quality criteria for clinical care of term and preterm newborn infants concordated by the F-JC. METHODS: Between November 2007 and October 2008 31 providers were audited. Observations were documented in a checklist, reviewed and evaluated by expert auditors. For that purpose, quality criteria given by the F-JC were grouped into 7 quality categories which were weighted according to their practical relevance. In addition, a graded numeric system of evaluation was used for comparative analysis (absolute and relative benchmarking values). RESULTS: 3 of 23 providers fulfilled the quality criteria of the F-JC for PNC level 1 (highest level of care), 6 of 23 fulfilled them in part, and 14 of 23 did not fulfill them as judged by the auditors. Criteria for PNC level 2 were "fulfilled in part" by 2 of 6 providers and "not fulfilled" by 4. Both providers of perinatal special care ("level 3") fulfilled the quality criteria for "level 3" completely. There was no linear correlation between absolute or relative benchmarking values and assessment by expert auditors. CONCLUSION: If the criteria of the F-JC were interpreted very strictly, it would be difficult to guarantee comprehensive regional delivery of care in the state of Baden-Württemberg at the level formally requested by the F-JC for PNCs.

[DRG evaluation results--state comparisons: MDK Baden-Württemberg versus MDK Westfalen-Lippe]. / DRG-Prüfergebnisse im Ländervergleich: MDK Baden-Württemberg und MDK Westfalen-Lippe.

We report on the first detailed comparison of evaluation results regarding the correct billing in the G-DRG (German diagnosis-related group) system. For two Medical Review Boards of the Statutory Health Insurance Funds of comparable size (MDK Baden-Württemberg and MDK Westfalen-Lippe), we analysed consecutive expertises regarding correct billing according to section sign 275 SGB V, and the results were compared in terms of the frequency of DRG-relevant error codes, their relevance to revenue, and the question of error clustering (specific DRGs, primary diagnoses, etc.). The analysis comprised 51,010 individual expertises pertaining to billings of the year 2005 (admittance to hospital from January 1 to December 31, 2005). The proportion of disapproved cases was 38.5% in Baden-Württemberg and 44.6% in Westfalen-Lippe. Among these, errors to the disadvantage of the Health Insurance (incorrectly high) were 33.9% and 39.3%, respectively, and errors to the disadvantage of the hospitals (incorrectly low) were 4.6% and 5.3%, respectively. The resulting ratio (incorrectly high vs. low) was an identical 7.4 in both cases. Not only the most commonly rejected DRGs but also the primary and secondary diagnoses were similar in both cases, while the disapproved procedure codes showed a significant variability (analysis based on the respective 10 most common objections). We discuss the similarities and differences in these results and their possible causes, and demonstrate the cost relevance of this audit segment. Result comparisons of this type can yield insights into streamlining of the review practice of Medical Review Boards, as well as increase the efficiency and effectiveness of the selection of cases.

Quantitative trait loci associated with AutoFOM grading characteristics, carcass cuts and chemical body composition during growth of Sus scrofa.

A three-generation full-sib resource family was constructed by crossing two commercial pig lines. Genotypes for 37 molecular markers covering chromosomes SSC1, SSC6, SSC7 and SSC13 were obtained for 315 F2 animals of 49 families and their parents and grandparents. Phenotypic records of traits including carcass characteristics measured by the AutoFOM grading system, dissected carcass cuts and meat quality characteristics were recorded at 140 kg slaughter weight. Furthermore, phenotypic records on live animals were obtained for chemical composition of the empty body, protein and lipid accretion (determined by the deuterium dilution technique), daily gain and feed intake during the course of growth from 30 to 140 kg body weight. Quantitative trait loci (QTL) detection was conducted using least-squares regression interval mapping. Highest significance at the 0.1% chromosome-wise level was obtained for five QTL: AutoFOM belly weight on SSC1; ham lean-meat weight, percentage of fat of primal cuts and daily feed intake between 60 and 90 kg live weight on SSC6; and loin lean-meat weight on SSC13. QTL affecting daily gain and protein accretion were found on SSC1 in the same region. QTL for protein and lipid content of empty body at 60 kg liveweight were located close to the ryanodine receptor 1 (RYR1) locus on SSC6. On SSC13, significant QTL for protein accretion and feed conversion ratio were detected during growth from 60 to 90 kg. In general, additive genetic effects of alleles originating from the Piétrain line were associated with lower fatness and larger muscularity as well as lower daily gain and lower protein accretion rates. Most of the QTL for carcass characteristics were found on SSC6 and were estimated after adjustment for the RYR1 gene. QTL for carcass traits, fatness and growth on SSC7 reported in the literature, mainly detected in crosses of commercial lines x obese breeds, were not obtained in the present study using crosses of only commercial lines, suggesting that these QTL are not segregating in the analysed commercial lines.

[Neonatal septicemia in the G-DRG system]. / Die Neugeborenensepsis in DRG-System.

INTRODUCTION: The introduction of Diagnosis Related Groups in Germany (G-DRG) has brought forward the obligation for physicians to take into account an intricate system of medical, economical and legal implementations. Mistakes in the process of encoding the principal diagnosis or procedures may have financial consequences. Problems to determine the correct ICD-code will be most prominent for diseases with poorly defined or even inconsistent diagnostic criteria as is the case for neonatal septicemia. We decided to evaluate whether the introduction of G-DRG resulted in a change of frequency of the diagnosis "neonatal septicemia". METHODS: We analysed data derived from the quality assurance program "Neonatalerhebung" in the state of Baden-Württemberg during the years of 2001 through 2004, i. e., 2 years before and 2 years during the introduction of G-DRG. During this period an annual number of 12,316 up to 13,172 newborns were admitted to the participating hospitals. RESULTS: The mean number of diagnoses per patient increased from 2.2 to 3.8. The frequency of the diagnosis of septicemia remained constant. The percentage of newborns receiving antibiotic therapy did not change. The ratio of cases with "septicemia yes" over "antibiotics yes" did not change. Although it is difficult to determine the diagnosis of neonatal septicemia and in spite of the economic implications of this diagnosis, no change in the frequency of this diagnosis occurred during the introduction of DRG. CONCLUSIONS: Assuming that the participating hospitals used an identical database for the quality assurance program "Neonatalerhebung" and for accounting, we conclude that the DRG system is stable with respect to neonatal septicemia.

Association between body composition of growing pigs determined by magnetic resonance imaging, deuterium dilution technique, and chemical analysis.

Development of body composition of 440 growing pigs from a three generation full-sib design to identify quantitative trait loci (QTL) was determined by three different methods. Firstly, the non-invasive method deuterium dilution technique (DT), was applied to all pigs in the experiment at six weights 20, 30, 60, 90, 120 and 140kg. Secondly, at each weight class, eight pigs were slaughtered and their entire body chemically analysed (CA). Thirdly, magnetic resonance imaging (MRI) was applied on 16 live pigs at different weights. For the entire empty body (without content of the gastrointestinal tract and bladder), allometric prediction equations to predict body composition from empty body water content measured by DT were derived from chemically analysed serial slaughtered pigs. These equations showed high correlations of 0.92, 0.90 and 0.85 for the contents of body water, fat-free substance as well as protein in fat-free substance, respectively. For the soft tissue (empty body without bones and viscera), allometric prediction equation of body composition based on DT and CA showed correlations of 0.91, 0.88 and 0.82 for water content, fat-free substance, and protein content of fat free substance, respectively. Fat tissue content, fat tissue mass, and lean tissue mass measured by MRI showed allometric relationships to lipid content, lipid mass, and protein mass determined by DT with correlations of 0.98, 0.87, and 0.98, respectively. Lean (measured by MRI) and protein (determined by DT) content of soft tissue was best fitted by a linear-quadratic polynomial and resulted in a correlation of 0.86. Allometric coefficients for change of percentages of chemical components, water (b=-0.036) and protein (b=0.106) in fat-free substance of empty body during growth were similar to those in the literature indicating the consistency of accretion rates of chemical components of the fat-free substance in different studies. Means for protein- and lipid-deposition rates (determined by DT) as well as lean tissue- and fat tissue-deposition rates (measured by MRI) ranged from 95 to 154, 147 to 328, 373 to 420 and 129 to 254g in the different weight ranges. Variation between animals in protein (lean tissue) and lipid (fat tissue) deposition rate was large which can be exploited in order to identify QTL of these traits.

[Quality assurance of outpatient nursing services in Baden-Württemberg -- overall view of 6 years of a total survey by the Medical Services of the Statutory Health Insurance (MDK)]. / Qualitätsprüfungen ambulanter Pflegedienste in Baden-Württemberg - Uberblick über die Erfahrungen aus 6 Jahren flächendeckender Untersuchungen durch den MDK.

During the years 1997 to 2003 the medical services of the statutory health insurance in the German Federal State of Baden-Württemberg carried out a total survey regarding structure, process and outcome with regard to the quality of care of outpatients in the German long-term care insurance system. This survey provides information on the development of the quality of care. All outpatient nursing services licensed by the statutory long-term care insurance funds in Baden-Württemberg (n (1997 - 2000) = 863; n (2000 - 2003) = 779) were subjected to a uniform assessment based on a consented concept applied in all German Federal States. Our results demonstrate a tendency to fewer but larger nursing services providing care for an increasing number of patients. Qualification of head nurses and of caregiving staff in general has significantly improved. Information for the patient/consumer on the conditions of contracts which have to be made between a nursing service and the patient is still deficient in more than 20 % of cases. Adherence to proper procedures in the process of nursing has improved, especially with respect to taking a complete medical/nursing history and defining the individual resources of a patient and aims for therapy/nursing. However, only in (1/3) of the cases could we find a documentation of continuous adaptation of the planning of therapy. Efforts of in-house quality management and internal quality assurance by the outpatient nursing services have improved. Regarding the outcome of nursing there has been a decrease in the provision of stimulating care from 87 % of cases to 75 %. The majority of patients of outpatient nursing services do not receive benefits of the long-term care insurance system but of the statutory health insurance. This fact underlines the importance of a general conceptual framework for internal and external quality assurance.

[Expert opinion on prevention and rehabilitation in the German statutory health insurance system]. / Begutachtung von Vorsorge- und Rehabilitationsleistungen in der GKV.

New Directives of the Federal Joint Committee Concerning Medical Rehabilitation Measures ("Rehabilitation Directives") came into force on 1 (st) April 2004. In this context, a survey of the expert assessment given by the Medical Service of the Statutory Health Insurance ("Medizinischer Dienst der Krankenversicherung, MDK") is provided -- as far, as medical prevention and rehabilitation are concerned.

[Quality project in invasive/interventional cardiology]. / Qualitätsprojekt Invasive/Interventionelle Kardiologie.

With installing a new catheterization laboratory, a quality project with focus on indications for invasive/interventional procedures was implemented. Health insurance companies as budget holders were involved in the project, external control is accomplished by their medical service (MDK). The focus on indications is new, since most approaches in this area deal with structure and/or process quality. The actual concept of this quality project makes medical performance transparent with regard to adequate indication as the first and important step to excellent quality of results. Further, the concept contains a rational approach to the controversial discussion about the increasing frequency of catheter-based coronary interventions.

[Quality control in ambulatory health care. Results of an area-wide study by the public medical service of the Baden-Württemberg health insurance]. / Qualitätsprüfung ambulanter Pflegedienste. Ergebnisse einer flächendeckenden Untersuchung durch den Medizinischen Dienst der Krankenversicherung Baden-Württemberg.

Discussions surrounding the quality of nursing care, fueled by recurring press reports, prompted the State Nursing Insurance Associations in Baden-Wuerttemberg to request the Health Insurance Medical Service to perform a quality control of outpatient nursing care services in the state. Based on a coordinated concept and for the first time in the Federal Republic of Germany, all authorized ambulatory institutions area-wide were subjected to a uniform assessment (total survey) during an official inquiry time period. The end results of these controls failed to verify the judgement often propagated by the press based on individual cases that high-quality nursing care can no longer be afforded under the present circumstances. On the average, 55% of the personnel provided to patients by outpatient nursing services were health care professionals. What is more, this professional staff rendered 75% of all nursing care services. The evaluation of the accompanied medical visits indicated that the vast majority attempted to take active nursing care into account. With regard to quality assurance, a great optimisation potential was indicated primarily in the area of nursing documentation. Only in about 35% of the nursing documents inspected was the nursing procedure always clearly evident. A future problem could arise from the fact that of all nursing professionals with leadership responsibilities, at the time of the survey only about 37% had completed the requisite professional training qualification programme of 460 training hours. If the time before the interim deadline (March 31, 2002) is not utilised, the institutions in question could face consequences that could threaten their very existence. It is evident that a large number of outpatient nursing care services in the state of Baden-Wuerttemberg do not have their economic foundation in the domain of the Nursing Care Insurance Law, which affects both patient structure and care intensity. As a consequence, there is no quality control or inspection whatsoever for the majority of nursing care services rendered by ambulatory nursing care services at present because they are not under the jurisdiction of the German Federal Social Legislation SGB XI.

Ifosfamide and mesna: effects on the Na/H exchanger activity in renal epithelial cells in culture (LLC-PK1).

Ifosfamide (IF) is an alkylating cytostatic with urotoxic and tubulotoxic side effects which may result in the development of Fanconi syndrome in children. While the urotoxicity of IF is effectively prevented by the uroprotective thiol compound sodium-2-mercaptoethanesulfonate (Mesna), tubulo-toxicity of IF may occur even in the presence of Mesna and in the absence of any signs of urotoxicity. Using the renal tubular cell line LLC-PK1, we investigated whether there is a protective effect of Mesna or of its major dimeric metabolite Dimesna against metabolites of IF with respect to the Na/H exchanger activity. We tested the major IF metabolites 4-hydroperoxy-IF (4-OOH-IF), chloroacetaldehyde (CAA), and acrolein. All metabolites significantly inhibit the Na/H exchanger activity. Half-maximal inhibition of transport occurs at concentrations of 120 mumol/l (4-OOH-IF), 80 (CAA), and 60 mumol/l (acrolein) after 2 h of incubation. The onset of the inhibitory effect of all three metabolites is rapid. Complete inhibition of Na/H exchange by acrolein and CAA is present after a 6-hour exposure to 100 mumol/l of the respective metabolite, while 100 mumol/l 4-OOH-IF causes only 50% inhibition after 24 h of incubation. Dimesna, which the proximal tubular cell has to reduce to Mesna at the expense of intracellular glutathione before it exerts a uroprotective effect, has no protective effect in LLC-PK1 cells. Dimesna (0.3 mmol/l) displaces the dose-response curve for acrolein to the left, indicating an increased toxicity of the combination of acrolein plus Dimesna. Mesna (0.3 mmol/l) has a complete protective effect with respect to acrolein and CAA, while the protective effect versus 100 mumol/l of 4-OOH-IF is incomplete. We conclude that the function of the Na/H exchanger in LLC-PK1 cells is altered by metabolites of IF. The incomplete protection against the toxic effect of 4-OOH-IF by Mesna may explain the pathomechanism by which IF causes tubulotoxicity in the absence of urotoxicity.