Neuropsychological impact of cerebral microemboli in ablation of atrial fibrillation.

BACKGROUND: Clinically silent lesions on cerebral magnet resonance imaging have been found in larger numbers after pulmonary vein isolation (PVI) especially with phased radio frequency (pRF) using all ten electrodes. However, the neuropsychological effects of cerebral microembolism during the procedure remain unclear and data regarding this issue so far are inconsistent. METHODS: Between August 2011 and June 2012, 76 patients undergoing their first PVI were randomized to ablation with either phased (40) or irrigated (36) radio frequency (iRF). A comprehensive neuropsychological test battery was performed the day before and after PVI as well as 6 months after ablation. The occurrence of cerebral microemboli during the procedure was performed via a transcranial Doppler ultrasound device. RESULTS: PVI using pRF was associated with increased number of microembolic signals (MES) compared to iRF (1530.0 ± 979.8 vs. 645.7 ± 448.7; p < 0.001). Neuropsychological assessment did not reveal any changes in correlation with the used ablation technique. Besides an age-related effect there was a diffuse, sub-clinical impairment of neurologic function depending on age and the number of MES. CONCLUSIONS: There was no clinical overt cognitive deficit and no significant difference in cognitive function correlating with the used ablation technique. The number of MES correlated with a subtle, diffuse post-procedural impairment of neuropsychological function highlighting the need to reduce microemboli during ablation.

[Cardiac rehabilitation in Germany: a successful model with promising prospects]. / Kardiologische Rehabilitation in Deutschland: Erfolgsmodell mit Perspektive.

Over the past 20 years the German Pension Insurance has rehabilitated nearly 800,000 patients with coronary heart disease. In particular, phase-II rehabilitation has been established as an integral part of cardiac patient care. However, the decreasing number of participants in phase-III must be seen critically. Today's cardiac rehabilitation is characterised by evidence-based treatment modules and a sophisticated quality assurance system that ensures quality orientation in all aspects, from access to rehabilitation through to aftercare. Future developments such as vocationally-oriented medical rehabilitation and the use of new technologies will further improve cardiac rehabilitation. Positive patient feedback and scientific evidence of the effectiveness of cardiac rehabilitation are further incentives to maintain this forward-looking approach.

[Medical rehabilitation. Basic function of the German pension insurance]. / Medizinische Rehabilitation. Kernaufgabe der Rentenversicherung.

Medical rehabilitation is an important part of the German health care system in addition to medical and nursing care. For people with impairments, especially with chronic diseases, rehabilitation aims at emancipated participation in social life. The German pension insurance carries out rehabilitation mainly for gainfully employed people. To be entitled to these benefits legal and personal (medical) requirements must be fulfilled. The rehabilitation concepts of the German pension insurance are interdisciplinary, following the bio-psycho-social model of health and illness. Concepts of rehabilitation are presented exemplarily for musculoskeletal, oncologic, heart/circulation, metabolic/gastrointestinal, and neurological diseases as well as mental disorders. Elements of structure, process, and outcome quality are illustrated. Research topics in rehabilitation are presented.

[Prevention as a pension insurance task: innovative models complementing proven concepts]. / Prävention als Aufgabe der Rentenversicherung: Innovative Modelle ergänzen bewährte Konzepte.

Health-related strategies aimed at ensuring long-term participation in working life are gaining increasing importance against a background of longer working lives and demographic change. Medical and vocational rehabilitation under the German statutory pension insurance scheme are among these strategies. For a long time already, preventive concepts have been taken into account in rehabilitation so that the pension insurance's prevention approach is mainly based on the experience gained with preventive-modules in rehabilitation and follow-up care. Having so far only been able to offer in-patient prevention benefits, the statutory pension insurance scheme now can offer out-patient prevention measures, given the amendment it initiated to change Section 31 (1) no. 2 of Book 6 of the German Social Code which came into effect on January 1, 2009. The common guidelines of the statutory pension insurance institutions directed at ensuring continued working capacity were revised relative to the preventive benefits contained and were supplemented by recommendations for their use. The changing occupational demands in modern service society have thus been taken into account, and prevention benefits can be implemented in a more flexible manner following successful trials. The concept of out-patient prevention measures following along at the workplace and during leisure time is intended to enhance sustainability of acquired health-promoting behaviours in every day (working) life. At present this new concept is being tried out in various circumscribed pilot projects by several pension insurance institutions, partly in combination with in-patient components. On account of their specific know-how and their regional networks with enterprises, rehabilitation facilities are destined as locations for carrying out pension insurance prevention benefits.

[Present status and future possibilities of adjuvant pharmacotherapy for aphasia]. / Pharmakologische Zusatzbehandlung in der Aphasietherapie : Status quo und Perspektiven.

Aphasia is one of the most frequent and disabling consequences of stroke. Poor spontaneous recovery and the limited success of conventional speech therapy bring up the question of how current treatment approaches can be improved. Besides increasing training frequency-with daily sessions lasting several hours and high repetition rates of language materials ("massed training")-adjuvant drug therapy may help to increase therapy efficacy. In this article, we illuminate the potential of monoaminergic (bromocriptine, levodopa, d-amphetamine) and cholinergic (donepezil) substances for treating aphasia. For a final evaluation of combined massed training and adjuvant pharmacotherapy, randomized, placebo-controlled (multicenter) clinical trials with sufficient numbers of patients are needed. Furthermore, results of experimental animal studies of functional recovery in brain damage raise hopes that neurotrophic factors or stem cells might find a place in recovery from aphasia in the intermediate future.

[Guidelines for the sociomedical assessment of performance in patients suffering from inflammatory bowel disease]. / Leitlinien zur sozialmedizinischen Leistungsbeurteilung bei chronisch entzündlichen Darmkrankheiten.

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice, criteria and attributes to guide decisions for a systemization of the sociomedical assessment of performance in inflammatory bowel disease (Crohn's disease, ulcerative colitis) were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent -- e. g. for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of inflammatory bowel disease and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual.

[Practice guidelines in rehabilitation: infringement upon physicians' autonomy or foundation for better outcomes?]. / Leitlinien in der Rehabilitation: Einschränkung der Therapiefreiheit oder Grundlage für bessere Ergebnisse?

Clinical practice guidelines - seen as an aggregation of scientific evidence - and evidence based medicine are of relevance and importance for everybody involved in health care. Nevertheless, the discussion of their pros and cons is controversial. Major criticisms concern methodological aspects, a disregard of the patients' perspective, potentially increasing costs and the limitation of doctors' autonomy possibly caused by streamlining therapy. Supporters emphasize the improvement of care that comes with using proven therapies, patients' empowerment, cost reduction and equity in the distribution of resources. Following medical practice guidelines the liability for medical malpractice may be limited, but non-adherence to guidelines does not entail liability per se. Clinical practice guidelines in the rehabilitative sector differ from those in curative medicine by being required to achieve more complex goals than maintenance, recovery and improvement of health. Activities in the rehabilitation sector address two main topics: The integration of rehabilitation into curative guidelines, e. g. by participating in the German clearing process for guidelines, and the development of guidelines specific to rehabilitation. There are a number of guideline initiatives, e. g. with the Association of the Scientific Medical Societies (AWMF), the Federation of German Pension Insurance Institutes (VDR) and the Federal Insurance Institute for Salaried Employees (BfA). The BfA project is the first to allow integration of evidence based medicine into the quality assurance programme of the German Pension Insurance complementing it with differentiated criteria for the assessment of therapeutic processes. Taking evidence based medicine increasingly into consideration and the continuous process of introducing rehabilitative clinical practice guidelines are going to improve health care for people with chronic diseases.

[Guidelines for the sociomedical assessment of performance in patients suffering from chronic obstructive lung diseases (COPD) and bronchial asthma. II: Sociomedical assessment of performance, Annex Part B, bibliography see Part I, Gesundheitswesen 2004, 66: 263f]. / Leitlinien zur sozialmedizinischen Leistungsbeurteilung bei chronisch obstruktiven Lungenkrankheiten (COPD) und Asthma bronchiale - Teil II: Sozialmedizinische Leistungsbeurteilung, Anlagen Teil B, Literatur siehe Teil I, Gesundheitswesen 2004, 66: 263f -

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice, criteria and attributes to guide decisions for a systemisation of the sociomedical assessment of performance in chronic obstructive pulmonary diseases (COPD) and bronchial asthma were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent - e. g. for the assessment of applications for decreased earning capacity benefits. Part II outlines assessment of the individual's capacity, taking occupational factors into account. Following the determination of dysfunctions the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual.

[Guidelines for the sociomedical assessment of performance in patients suffering from chronic obstructive lung diseases (COPD) and bronchial asthma]. / Leitlinien zur sozialmedizinischen Leistungsbeurteilung bei chronisch obstruktiven Lungenkrankheiten (COPD) und Asthma bronchiale. Teil I: Sozialmedizinische Bedeutung, Klassifikation, Sachaufklärung, Anlagen Teil A, Nachwort, Literatur.

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice, criteria and attributes to guide decisions for a systematization of the sociomedical assessment of performance in chronic obstructive pulmonary diseases (COPD) and bronchial asthma were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent - e. g. for the assessment of applications for decreased earning capacity benefits. Part I of the guidelines gives information on the classification of chronic obstructive pulmonary diseases (COPD) and bronchial asthma and on the number of pensions due to limited earning capacity. The guidelines summarise typical manifestations of chronic obstructive pulmonary diseases (COPD) and bronchial asthma and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated.

[Aspects of expertise which are jointly valid for German sociomedicine and statutory health care]. / Trägerübergreifende Aspekte der Begutachtung nach dem SGB IX - Teil II: Fallbeispiel -

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurance. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[Aspects of expertising which are jointly valid for German sociomedicine and statutory health care]. / Trägerübergreifende Aspekte der Begutachtung nach dem SGB IX--Teil I: Grundlagen.

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurances. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[The significance of clinical guidelines for rehabilitation]. / Zur Bedeutung von Leitlinien für die Rehabilitation.

Clinical practice guidelines are relevant to all parties involved in the health system. For rehabilitation under the German pension insurance scheme, there are two main aspects: the integration of rehabilitation into the curative guidelines in terms of "local tailoring" on the one hand and the development of guidelines for rehabilitative processes, demand-oriented control of rehabilitation access, and rehabilitative aftercare on the other hand. The elaboration of effective standards is aimed at avoiding over-provision, under-provision or misdirected provision of care and, simultaneously, at ensuring that quality assured treatment is offered to the rehabilitees. Also, it is intended to increasingly implement evidence-based medicine in a sector of the health system in which research has so far been underrepresented. Implementation of guidelines in the rehabilitative sector will allow to disseminate existing knowledge in targeted manner, to systematically fill the gaps and to broaden the knowledge base as a whole. Furthermore, guidelines can facilitate integration of the different sectors in health care provision by operationalising the interfaces both with curative medicine and primary prevention. Throughout the process of guideline development for rehabilitation the specific characteristics of this sector must be kept in mind. Since therapeutic interventions are multidisciplinary and multimodal in nature guidelines have to be comprehensible and applicable for all members of the multiprofessional team. Corresponding to the relative paucity in rehabilitation research there is no sufficient evidence base for numerous therapeutic interventions. Accordingly, guidelines in rehabilitation will--initially--consist of a mixture of evidence- and consensus-based recommendations. Also, the specific goal of rehabilitation under the German pension insurance scheme, namely maintenance or recovery of the capacity at work, has to be borne in mind. There are many initiatives by the providers of rehabilitation as well as the scientific medical societies to develop and implement rehabilitative clinical practice guidelines, e. g. the guidelines programme of the BfA (Federal Insurance Institute for Salaried Employees), which is aimed at developing rehabilitation process guidelines for selected indications, the guidelines activities of the VDR (Federation of German Pension Insurance Institutes), and the input of the "Guidelines" commission of the DGRW (German Society of Rehabilitation Science). It is hoped that in the years to come the parties involved in German health care provision will be open to the advantages of clinical practice guidelines. Rehabilitation under the German pension insurance scheme, with respect to its experience with quality assurance, its responsibilities for structure and concept and a growing acceptance on the part of care providers, already holds a well-founded starting position.

[Guidelines for the sociomedical assessment of performance in patients suffering from discopathy or associated diseases]. / Leitlinien zur sozialmedizinischen Leistungsbeurteilung bei Bandscheiben- und bandscheibenassoziierten Erkrankungen.

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice, criteria and attributes to guide decisions for a systemisation of the sociomedical assessment of performance in discopathy or associated diseases were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent -- e. g. for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of discopathy or associated diseases and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination, and for diagnostic tests are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally, inferences are drawn regarding the occupational capacity of the individual. Guidelines for the sociomedical assessment of performance in coronary heart disease (CHD) have been published in Gesundheitswesen 2002, 64: 451-465.

[Documentation and treatment of mental impairment in somato-medical rehabilitation]. / Erfassung und Behandlung psychischer Beeinträchtigungen in der somatisch-medizinischen Rehabilitation.

Using routine data collected in 2000 for the quality assurance programme of the German Pension Insurance subjective mental impairment and disorders documented in discharge letters of patients undergoing rehabilitation funded by the Federal Insurance Institute for Salaried Employees (BfA) (n = 19,272) were correlated with psychological treatment and inpatient somato-medical rehabilitation provided. The results show discrepancies between self-evaluation, original diagnosis and treatment received. The frequency of treatments varies between hospitals. The differences in treatment are attributed rather to a varying quality of implementation of the bio-psycho-social concept than to a lack of human resources.

[Guidelines for the sociomedical assessment of performance in patients suffering from coronary heart disease (CHD)]. / Leitlinien zur sozialmedizinischen Leistungsbeurteilung bei koronarer Herzkrankheit (KHK).

The following guidelines were developed for the medical assessment services of the German Federal Insurance Institute for Salaried Employees (BfA). Starting from day-to-day practice criteria and attributes to guide decisions for a systemisation of the sociomedical assessment of performance in coronary heart disease (CHD) were compiled. The guidelines aim at standardising the sociomedical assessment of performance and help to make the decision-making process more transparent - e.g. for the assessment of applications for decreased earning capacity benefits. The guidelines summarise typical manifestations of CHD and describe the necessary medical information for the sociomedical assessment of performance. Relevant assessment criteria for the medical history, clinical examination and for diagnostic tests - especially of myocardial functioning - are illustrated. The assessment of the individual's capacity is outlined, taking occupational factors into account. Following the determination of dysfunctions the remaining abilities and disabilities, respectively, are deduced and compared with occupational demands. Finally inferences are drawn regarding the occupational capacity of the individual.