[Process-oriented cost calculation in interventional radiology. A case study]. / Prozessorientierte Kostenrechnung in der Interventionellen Radiologie. Eine Fallstudie.

PURPOSE: Currently used costing methods such as cost centre accounting do not sufficiently reflect the process-based resource utilization in medicine. The goal of this study was to establish a process-oriented cost assessment of percutaneous radiofrequency (RF) ablation of liver and lung metastases. MATERIAL AND METHODS: In each of 15 patients a detailed task analysis of the primary process of hepatic and pulmonary RF ablation was performed. Based on these data a dedicated cost calculation model was developed for each primary process. The costs of each process were computed and compared with the revenue for in-patients according to the German diagnosis-related groups (DRG) system 2010. RESULTS: The RF ablation of liver metastases in patients without relevant comorbidities and a low patient complexity level results in a loss of EUR 588.44, whereas the treatment of patients with a higher complexity level yields an acceptable profit. The treatment of pulmonary metastases is profitable even in cases of additional expenses due to complications. CONCLUSION: Process-oriented costing provides relevant information that is needed for understanding the economic impact of treatment decisions. It is well suited as a starting point for economically driven process optimization and reengineering. Under the terms of the German DRG 2010 system percutaneous RF ablation of lung metastases is economically reasonable, while RF ablation of liver metastases in cases of low patient complexity levels does not cover the costs.

[Market and competitive positioning of specialized practices: competitive advantages through strategic productivity planning]. / Markt- und Wettbewerbspositionierung fachärztlicher Praxen : Wettbewerbsvorteile durch strategische Leistungsplanung.

The provision of outpatient services will be confronted by increased market concentration. Under these circumstances, individual medical practices are predicted to have a minimal chance for survival since by nature the specialized physician can only accommodate the considerably heterogeneous needs of the patients up to justifiable limits. Due to patients' higher rate of mobility in the elective process, specialty physicians in rural areas are obliged to transform their practices into professional service enterprises. While hospitals are attempting to combat a continuing economization of the health care sector, in part by applying aggressive leadership and management methods, an increasing polarization can be noted in the outpatient setting. Also in the field of urology, patients consider themselves medical treatment clients who are unwilling to be relegated to cases of the often criticized"5-minute medicine."

Long-term reduction in local inflammation by a lipid raft molecule in atopic dermatitis.

BACKGROUND: The complex pathogenesis of atopic dermatitis (AD) is guided by cell surface receptor-mediated signal transduction regulated in lipid rafts. Miltefosine is a raft-modulating molecule targeting cell membranes. With this controlled clinical study, the clinical and immunomodulatory efficacy of miltefosine was investigated in patients with AD in comparison with a topical corticosteroid treatment. METHODS: Sixteen patients with AD were treated topically with miltefosine and hydrocortisone localized on representative AD target lesions for 3 weeks. To assess the clinical efficacy, the three item severity (TIS) score was evaluated before, during and after treatment as well as after 4-week-follow-up period. To study the anti-inflammatory effect of miltefosine on the cellular T cell pattern, skin biopsies were analysed before and after treatment. RESULTS: The TIS score dropped in both groups significantly after treatment. A carry-over effect was exclusively seen for miltefosine after discontinuing the treatment. These findings were substantiated by thermographic imaging with a significant decrease in the maximum temperature (T(max)) after miltefosine application (P = 0.034, DeltaT(max) = 1.7 degrees C [2.1-3.9]). Immunohistochemically, a reduction in lesional CD4(+)-infiltrating T cells was observed in both treatments. Moreover, increased FoxP3(+) cells were present in the skin after miltefosine treatment (before 5.4% [1.9-9.8], after 6.2% [3.5-9.5]). CONCLUSION: We demonstrate that miltefosine is locally active in patients with AD and led to a sustained clinical improvement in local skin inflammation. Moreover, the increased frequency of FoxP3(+) cells in the skin of patients with AD suggests its immunomodulatory properties.

Smooth pursuit eye movements to isoluminant targets.

At slow speeds, chromatic isoluminant stimuli are perceived to move much slower than comparable luminance stimuli. We investigated whether smooth pursuit eye movements to isoluminant stimuli show an analogous slowing. Beside pursuit speed and latency, we studied speed judgments to the same stimuli during fixation and pursuit. Stimuli were either large sine wave gratings or small Gaussians blobs moving horizontally at speeds between 1 and 11 degrees /s. Targets were defined by luminance contrast or color. Confirming prior studies, we found that speed judgments of isoluminant stimuli during fixation showed a substantial slowing when compared with luminance stimuli. A similarly strong and significant effect of isoluminance was found for pursuit initiation: compared with luminance targets of matched contrasts, latencies of pursuit initiation were delayed by 50 ms at all speeds and eye accelerations were reduced for isoluminant targets. A small difference was found between steady-state eye velocities of luminance and isoluminant targets. For comparison, we measured latencies of saccades to luminance and isoluminant stimuli under similar conditions, but the effect of isoluminance was only found for pursuit. Parallel psychophysical experiments revealed that different from speed judgments of moving isoluminant stimuli made during fixation, judgments during pursuit are veridical for the same stimuli at all speeds. Therefore information about target speed seems to be available for pursuit eye movements and speed judgments during pursuit but is degraded for perceptual speed judgments during fixation and for pursuit initiation.

Docosahexaenoic acid (DHA) supplementation in atopic eczema: a randomized, double-blind, controlled trial.

BACKGROUND: The increasing prevalence of atopic eczema has been linked to the alteration of the Western diet, namely the reduced consumption of omega-3 (n-3) polyunsaturated fatty acids (PUFA) and an increased omega-6 (n-6) PUFA intake. OBJECTIVES: The aim of the pilot study was to determine the efficacy of dietary n-3 PUFA docosahexaenoic acid (DHA) in patients with atopic eczema. METHODS: Fifty-three patients suffering from atopic eczema aged 18-40 years were recruited into this randomized, double-blind, controlled trial and received either DHA 5.4 g daily (n = 21) or an isoenergetic control of saturated fatty acids (n = 23) for 8 weeks. At weeks 0, 4, 8 and 20 the clinical outcome was assessed by the SCORAD (severity scoring of atopic dermatitis) index. IgE production and activation of peripheral blood mononuclear cells (PBMC) were analysed. Plasma fatty acids were measured by gas chromatography. RESULTS: DHA, but not the control treatment, resulted in a significant clinical improvement of atopic eczema in terms of a decreased SCORAD [DHA: baseline 37.0 (17.9-48.0), week 8 28.5 (17.6-51.0); control: baseline 35.4 (17.2-63.0), week 8 33.4 (10.7-56.2)]. A significant reduction of anti-CD40/interleukin 4-mediated IgE synthesis of PBMC was detected in the DHA group only. Supplementation led to a modulated activation status of PBMC in both groups. The DHA group showed an increase of plasma n-3 PUFA and a decrease in the n-6/n-3 PUFA ratio. CONCLUSIONS: Our data suggest that dietary DHA could be bioactive and might have a beneficial impact on the outcome of atopic eczema, but our results need to be confirmed in a larger study.

Modulation of lymphocyte phenotype and function by immunoglobulins.

BACKGROUND: Immunoglobulins have immune-modulating capacities and are used for the treatment of different dermatological diseases. They have also been reported for the treatment of severe atopic dermatitis (AD). OBJECTIVES: To determine the effects of immunoglobulins on the phenotype and function of peripheral T and B lymphocytes from patients with AD in comparison with healthy donors (HD) as controls. METHODS: We studied lymphocyte activation and T-cell cytokine production from 12 patients with AD and 10 HD by multicolour flow cytometric analysis in the presence of immunoglobulins. RESULTS: Immunoglobulins significantly inhibited T-cell activation (CD69), by 71% (AD) and by 62% (HD). Production of interferon-gamma and interleukin-4 was also significantly inhibited, by 44%/24% (AD) and 38%/10% (HD), respectively. In addition, CD86 expression on B lymphocytes was downregulated by 30% in AD and by 29% in HD, whereas CD23 expression was decreased without reaching statistical significance. CONCLUSIONS: Our data demonstrate that, in vitro, immunoglobulins modulate the activation and cytokine production of peripheral blood lymphocytes from both HD and patients with AD.

Visual shape recognition with contour propagation.

A neural architecture is presented that encodes the visual space inside and outside of a shape. The contours of a shape are propagated across an excitable neuronal map and fed through a set of orientation columns, thus creating a pattern which can be viewed as a vector field. This vector field is then burned as synaptic, directional connections into a propagation map, which will serve as a "shape map". The shape map identifies its own, preferred input when it is translated, deformed, scaled and fragmented, and discriminates other shapes very distinctively. Encoding visual space is much more efficient for shape recognition than determining contour geometry only.

[A graded composite material for use in the area of the cranial and facial skull]. / Ein gradierter Kompositwerkstoff für den Einsatz im Bereich des Hirn- und Gesichtsschädels.

For the reconstruction of complex skull defects with individual prefabricated CAD/CAM-implants titanium is well established as bone substitution material. The aim of our studies was to optimize a composite material from polyesters and calcium phosphate. Therefore two different operating procedures (hot pressing and gas-flushing) were combined. As a result the graded composition and porosity of the implants allow a spatial guided degradation progress and cell ingrowth. First biocompatibility tests in vitro with primary human osteoblasts showed a much better pH-characteristic and a better biocompatibility of the composites in comparison with the pure polymers. Degradation experiments in vitro confirmed the different expected degradation rates of the composite materials. As a next step in vivo experiments in ovine skulls are in progress.

Silicon synaptic depression.

The recent quantitative description of activity-dependent depression in the synaptic transmission between cortical neurons has lead to many interesting suggestions of possible computational implications. Based on a simple biological model, we have constructed an analog circuit that emulates the properties of short-term depressing synapses. The circuit comprises only seven transistors and two capacitors per synapse, and is able to reproduce computational features of depressing synapses such as the 1/F law, the detection of long intervals of presynaptic silence and the sensitivity to redistribution of presynaptic firing rates. It provides a useful basis for implementing neural networks with dynamical synapses.

Forward- and backpropagation in a silicon dendrite.

We have developed an analog very-large-scale integrated (aVLSI) electronic circuit that emulates a compartmental model of a neuronal dendrite. The horizontal conductances of the compartmental model are implemented as a switched capacitor network. The transmembrane conductances are implemented as transconductance amplifiers. The electrotonic properties of our silicon cable are qualitatively similar to those of the ideal passive cable that is commonly used to model mathematically the electrotonic behavior of neurons. In particular the propagation of excitatory postsynaptic potentials is realistic, and we are easily able to emulate such classical synaptic integration models as direction selectivity. We are also able to emulate the backpropagation into the dendrite of single somatic spikes and bursts of spikes. Thus, this silicon dendrite is suitable for incorporation in detailed silicon neurons operating in real-time; in particular for the emulation of forward- and backpropagating electrical activities found in real neurons.

Silicon synaptic conductances.

We have developed compact analog integrated circuits that simulate two synaptic excitatory conductances. A four-transistor circuit captures the dynamics of an excitatory postsynaptic current caused by a real AMPA conductance. A six-transistor circuit simulates the effects of a real voltage-dependent NMDA conductance. The postsynaptic current dynamics are modeled by a current mirror integrator with adjustable gain. The voltage dependence of the silicon NMDA conductance is realized by a differential pair. We show the operation of these silicon synaptic conductances and their integration with the silicon neuron (Mahowald and Douglas, 1991).