Medical savings accounts: a core feature of Singapore's health care system.

In 1984 Singapore adopted a system of Medisave accounts, individually owned accounts used to pay for many of the health care expenditures that in Germany would normally be covered by the obligatory or private health insurance. The fact that people are spending their own money rather than that of a third-party insurer has helped to curtail Singapore's health care costs, which were about 2.6% of gross domestic product in 1999 (Germany: 10.5%). Even with these low expenditures, the income of Singapore physicians is about the same in relation to average wages as physician income in Germany or the United States, and patients have easy access to such technology as computerised axial tomography, organ transplants and bypass surgery.

[Laparoscopic single patient use instruments: expensive outsourcing of product quality?]. / Laparoskopische Einweg-Instrumente: Kostspieliges Outsourcing von Produktqualität?

The supply of medical goods is an important critical success factor in German hospitals. One major managerial area in the procurement concerns the decision between single patient use (SPU) and multiple patient use (MPU) products. Especially laparoscopic instruments which are generally expensive are a field of interest for decision makers. Due to a lack of quantifiable factors describing the two different forms of supply alternatives with their effects on effectivity and efficiency of the procurement process and the final use are often not taken into account. Since it is expected that in the future more and more laparoscopic instruments will be needed there is a necessity for finding a concept allowing the identification of the "right" product. The Center for Hospital Management (CKM) has the aim to develop a corresponding approach but needs the help of the reader.

[Interpersonal communication as a factor in successful development of a decision-oriented information systems model in the hospital]. / Kommunikation als Erfolgsfaktor für die Entwicklung einer entscheidungsorientierten Informationsverarbeitung im Krankenhaus.

The success of a decision-oriented hospital information system is primarily depending on the way of integration of the involved professionals in the development. The technical realisation of those systems is already supported by several tools. Interpersonal interactions on the other hand which take about 40 percent of the time of development are still methodically ignored. The medVista method promotes the active integration of all persons involved and supports the realisation of a technological model simultaneously. Substantial corrections usually arising after implementation are no longer necessary and the system will be accepted by users.

Dalteparin for deep venous thrombosis: a hospital-in-the-home program.

OBJECTIVE: To assess the efficacy, safety and cost savings of home treatment of lower-limb deep venous thrombosis (DVT). SETTING: A hospital-in-the-home treatment program. PATIENTS: One hundred patients with acute lower limb DVT (53 proximal, 47 distal), and no contraindication to home treatment, were entered into the program from March 1995 to February 1997. INTERVENTION: All patients received dalteparin, 200 units/kg subcutaneously, once daily for a minimum of five days, with commencement of oral anticoagulation (warfarin) on Day 2. Patients with proximal DVT had lung ventilation-perfusion scans performed and were admitted to hospital for at least 24 hours. Patients with distal DVT were discharged directly to home treatment. MAIN OUTCOME MEASURES: Clinical responses and the results of sequential duplex ultrasonography at one week, one month, three months and six months. RESULTS: There were no major, but six minor, bleeding complications, two of which led to dalteparin being withdrawn. Sixteen patients had lung ventilation-perfusion scans showing a high probability of pulmonary embolism. All were asymptomatic, and follow-up for at least three months showed no symptomatic thromboembolic events. Duplex ultrasonography showed progression of thrombosis in the first week of therapy in 13.2% of distal and 2.7% of proximal thromboses. Thereafter, distal DVT improved at a much greater rate than proximal DVT; after six months complete resolution was seen in 60.7% of distal and 18.5% of proximal thromboses, respectively. Cost saving was $197 per bed-day equivalent compared with inpatient care. At 15 months' follow-up, swelling and/or pain was reported by 49% of patients with distal DVT and 66% of those with proximal DVT. CONCLUSIONS: Once-daily dalteparin therapy for DVT in a hospital-in-the-home setting was safe, efficacious and cost effective. However, DVT resolution is a slow process, with significant long term morbidity.

[Virtual workshop for hospital management]. / Virtueller Workshop zum Krankenhaus-Management.

Due to a survey of the CKM insufficient communication among different professional groups is one of the main causes for unused quality reserves and neglected potentials of efficiency in German hospitals. An essential reason for this insufficiency lies in the traditional concepts of education which are designed for the specialties of the different professional groups. With this these concepts only impart key qualifications such as social authority, ability for communication and ability for problem-solving in a small amount. The goal of the virtual workshop is to train students and trainees in communication and interdisciplinary problem-solving early by working together on a practical case in a Virtual Workshop team. On the other hand all relevant persons to talk to are involved in order to support a qualified preparation of decisions: employees of the project hospital, partners from industry and members of universities.

Clinical and vascular laboratory determinants for outcome after infrainguinal atherectomy.

Three surgeons performed 180 atherectomy procedures in 161 patients using the Transluminal Extraction Catheter in 144 and the Auth Rotablator in 36. The primary patency rate was 55% at 1 year and 46% at 2 years, and failure was caused by stenosis in 28 (15.6%) and occlusion in 61 (33.7%) limbs. Multivariate Cox regression analysis showed significantly better outcome if the indication was claudication, the lesion was short or there was associated stenting. Vascular laboratory surveillance was performed in 93 limbs in 83 patients. Cox regression analysis in this subgroup also showed a significant relationship between outcome and the maximum peak systolic velocity from a duplex scan at the last study performed. Receiver operating characteristics curves showed that a raised maximum peak systolic velocity best predicted late failure (sensitivity 84%, specificity 66% for > 200 cm/s; sensitivity 72%, specificity 84% for > 250 cm/s); the velocity ratio at the stenosis to that in the segment above or the resting ankle/brachial pressure index were less predictive. For 50 procedures studied in the vascular laboratory which remained successful to the end of the study, maximum peak systolic velocities were > 250 cm/s from the first postoperative study, suggesting residual stenosis in 6%, or increased to become > 250 cm/s by the last study, suggesting recurrent stenoses in 12%. For 43 procedures which were studied and later failed, velocities were > 250 cm/s from the first test in 26% or increased to > 250 cm/s by the last test before failure in 40%. Vascular laboratory surveillance helps to predict outcome after atherectomy. Failure may be a result of residual disease from the time of the procedure or from restenosis. The apparent high incidence of clinically manifest or developing stenoses raises doubts as to the benefit of atherectomy over balloon dilatation alone.

Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux.

PURPOSE: Patterns of flow in superficial and deep veins and outward flow in medial calf perforators were studied by duplex ultrasonography scanning in 1653 lower limbs in 1114 consecutive patients. This study compares results in 776 limbs with primary uncomplicated varicose veins with those in 166 limbs with the complications of lipodermatosclerosis or past venous ulceration. METHODS: Duplex scanning determined whether superficial and deep veins were occluded or showed reflux and whether outward flow occurred in medial calf perforators with calf muscle contraction. RESULTS: Two proximal deep veins were occluded. When limbs with primary uncomplicated varicose veins, lipodermatosclerosis, or past ulceration were compared, superficial reflux alone was seen in 55%, 39%, and 38%, deep reflux alone was seen in 2%, 7%, and 8%, and combined superficial and deep reflux was seen in 18%, 34%, and 48%, respectively. Superficial reflux affected the long saphenous system alone in 58%, 57%, and 40%, the short saphenous system alone in 18%, 18%, and 26%, and both the long and short saphenous systems in 24%, 25%, and 34%, respectively. Limbs with ulceration more frequently showed superficial reflux (p < 0.05), and all limbs with complications more frequently showed short saphenous reflux (p < 0.05) and deep reflux (p < 0.01) specifically in the posterior tibial veins (p < 0.01). Outward flow was seen in medial calf perforators in 57%, 67%, and 66%, respectively; it occurred more frequently in all limbs with complications (p < 0.05). Isolated outward flow in perforators without superficial or deep reflux was seen in 10%, 10%, and 2%, respectively. CONCLUSIONS: Most limbs with complications had superficial reflux either alone or combined with deep reflux, and few had deep reflux alone. Reflux was more frequent in posterior tibial veins for limbs with complications compared with those with uncomplicated primary varicose veins. Outward flow in perforators was common in limbs with complications and with uncomplicated primary varicose veins, but isolated outward flow in perforators was uncommon. Treatment directed to the superficial veins alone may be sufficient for most patients with complications.

Anatomical examination of leg telangiectases with duplex scanning.

BACKGROUND: Earlier studies using Doppler ultrasound suggested that thigh telangiectasia might be associated with reflux in the larger subcutaneous veins. OBJECTIVE: The aim of the study was an accurate description of the anatomy of the venous drainage from thigh telangiectases and evaluation of the extent of venous valvular incompetence using a noninvasive imaging method. METHOD: High-definition color duplex ultrasonography was used to achieve the objective. RESULTS: Thirty-seven legs with lateral and/or medial thigh telangiectasia were examined. Patients studied were those without saphenofemoral, saphenopopliteal, or deep venous abnormalities on Doppler ultrasound examination. Altogether 53 sites were tested. In 89% reticular vein incompetence was found close to telangiectases. Often reticular vein incompetence was associated with reflux in larger epifascial veins. In 15% incompetent perforating veins were detected between reticular veins and the deep venous system. CONCLUSION: An accurate, functional reconstruction of the subcutaneous venous drainage was accomplished. It was found that telangiectasia was rarely an isolated condition, but was usually associated with incompetence in other elements in the venous drainage of the subcutaneous tissue.

[Tumor marker diagnosis in non-seminomatous testicular tumors using human chorionic gonadotropin (HCG) and alpha fetoprotein (AFP)]. / Tumormarkerdiagnostik bei nicht-seminomatösen Hodentumoren mittels Humanchoriongonadotropin (HCG) und Alpha-Fetoprotein (AFP).

In 28 patients with non-seminomatous testicle tumour the tumour markers human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) were determined radioimmunologically and enzymeimmunologically, respectively. While tumours with chorionic carcinoma (n = 8) always were marker-positive, in the embryonic carcinoma in 2 out of 10 cases falsely negative findings appeared. On 5 patients the biochemical monitoring of the course of the testicle tumour disease is demonstrated in detail by means of HCG and AFP and estimated as very helpful method. Advantages and problems of the marker diagnostics are shown and discussed. The positive marker findings were absolutely evident for a metastasation. On the other hand, marker negativation was not always to be equated with absence of a tumour and demanded a further control of the patient by means of all other available methods of diagnostics up to the second-look-operation.

[Lymphocyte depletion after irradiation of the chest region dependent on irradiation technics]. / Lymphozytendepression bei Bestrahlung im Thoraxbereich in Abhängigkeit von der Bestrahlungstechnik.

In a prospective alternating study, the mediastinum of patients with bronchial carcinomas was preoperatively irradiated with 2000 cGy in ten fractions for an isodose of 80% by Co-60 stationary field or pendulum therapy. The leucocyte and lymphocyte blood count was determined every day. It was found out that the lymphocyte depression was significantly higher after pendulum therapy than after stationary field therapy. This is explained by the fact that the lymphocyte depression is caused rather by the irradiation of lymphocytes in the blood stream than by the irradiation of bone marrow.

Enzymatic tests in the prognosis and course controls in bronchial carcinoma patients.

In 117 bronchial carcinoma patients hospitalized to receive radiation therapy, the serum levels of aldolase, LDH, alkaline phosphatase, GOT and GPT were checked prior to, during, and following radiation therapy at intervals of 4--6 weeks. Among the enzymes tested, aldolase proved to provide the best screening test for judging prognosis, course of disease and probable occurrence of recurrence or metastases.

[The CEA-concentration in plasma of patients with colorectal carcinoma and polyps has been determined by radioimmunoassay (RIA, Z-gel-method)]. / Zur CEA-Bestimmung im Plasma von Patienten mit Karzinomen und Polypen des Kolons und Rektums.

82% of the cancer patients and 52% of the patients with polyps showed CEA levels above the upper normal limit of 2,5 microgram/1. CEA-values of more than 10 microgram/1 could only be detected in patients with carcinoma. Complete removal of the tumour by surgery has been followed by a marked decrease of prior increased plasma-CEA to values in the normal range, which could not be observed in the cases with tumour residues or metastases. In the patient's follow-up recurrence or metastases could be recognized several months before clinical detection by a renewed increased of the CEA-level in plasma.