Controlled rapid sequence induction and intubation - an analysis of 1001 children.

BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A 'controlled' rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort. METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters. RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as 'difficult' in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of 'silent aspiration' during cRSII. CONCLUSION: Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.

Endoscopic airway findings in children with or without prior endotracheal intubation.

BACKGROUND: Airway alterations found after endotracheal intubation are usually associated with mechanical trauma from the tube. However, no studies are available concerning alterations in airways that have never been intubated before. It was the aim of the study to compare endoscopic findings in the larynx and trachea of children who had undergone prior endotracheal intubation with findings in children who had not been intubated before. METHODS: In 1021 children aged from 0 to 6 years, rigid endoscopies were performed before planned elective endotracheal intubation. The anonymized endoscopy videos were reviewed and graded by five international airway experts. Data was compared between the two groups using the chi-square test (P ≤ 0.05). RESULTS: Endoscopic records of 971 children (473 with prior intubation; 498 without prior airway intubation) were included in the final calculations. Most patients (93.7%) with prior intubation had been intubated with a cuffed tube. The number of intubations ranged from 1 to 27. The median interval between intubation and endoscopy was 0.53 years (0.003-5.57 years). Abnormal findings were observed in 31.7% and 26.8% of patients with and without prior intubation, respectively (P = 0.063). Glottic granulomas were significantly more common after intubation (3.6% vs 1.4%; P = 0.028). The incidence of other abnormal findings was similar in both groups. CONCLUSION: Endoscopic airway alterations can be observed in about one-quarter of children presenting for routine surgery without prior intubation. Except for glottic granulomas, the abnormalities are found with similar frequency in patients with and without prior intubation. No relevant airway damage from short-term endotracheal intubation was found.

Is prevention of atopic eczema with hydrolyzed formulas cost-effective? A health economic evaluation from Germany.

OBJECTIVE: The German Infant Nutritional Intervention (GINI) trial, a prospective, randomized, double-blind intervention, enrolled children with a hereditary risk for atopy. When fed with certain hydrolyzed formulas for the first 4 months of life, the risk was reduced by 26-45% in PP and 8-29% in intention-to-treat (ITT) analyses compared with children fed with regular cow's milk at age 6. The objective was to assess the cost-effectiveness of feeding hydrolyzed formulas. PATIENTS AND METHODS: Cost-effectiveness was assessed with a decision tree model programmed in TreeAge. Costs and effects over a 6-yr period were analyzed from the perspective of the German statutory health insurance (SHI) and a societal perspective at a 3% effective discount rate followed by sensitivity analyses. RESULTS: The extensively hydrolyzed casein formula would be the most cost-saving strategy with savings of 478 € per child treated in the ITT analysis (CI95%: 12 €; 852 €) and 979 € in the PP analysis (95%CI: 355 €; 1455 €) from a societal perspective. If prevented cases are considered, the partially whey hydrolyzed formula is cost-saving (ITT -5404 €, PP -6358 €). From an SHI perspective, the partially whey hydrolyzed formula is cost-effective, but may also be cost-saving depending on the scenario. An extensively hydrolyzed whey formula also included into the analysis was dominated in all analyses. CONCLUSIONS: For the prevention of AE, two formulas can be cost-effective or even cost-saving. We recommend that SHI should reimburse formula feeding or at least the difference between costs for cow's milk formula and the most cost-effective formula.

[Safe use of cuffed tracheal tubes in children]. / Geblockte Tuben bei Kindern - Rationaler und sicherer Einsatz.

In the last 5 years the use of cuffed tracheal tubes in infants and children has become popular worldwide and is accepted by major medical authorities. The advantages of cuffed tracheal tubes in smaller children - in particular the almost 100% chance to insert the right sized tracheal tube at the first attempt and their reliable sealing characteristics within the trachea - makes tracheal intubation and ventilation considerable easier and safer. This certainly compensates for the higher cost of cuffed compared to uncuffed tracheal tubes. The fear that cuffed tracheal tubes cause increased laryngeal damage in small children could not be confirmed, if adequately designed, cuffed tracheal tubes are correctly used. Conditions for the safe use of cuffed tubes in children are the availability of an adequately designed cuffed tube with a proofed recommendation for tube size selection and cuff pressure monitoring. The following rules must be fulfiled when cuffed tubes in children using are: confirmation of an air leak < 20 cmH2O inspiratory pressure with the cuff not inflated, cuff pressure limitation at 20 cmH2O and the avoidance of negative cuff pressures, resulting in sharp, cutting edges of the cuff membrane within the trachea.

[Navigating in evidence-poor waters - how much hydration is needed at the end of life? The recommendations of a Swiss expert group (Bigorio group)]. / Segeln in evidenzarmen Gewässern - wieviel Flüssigkeit braucht es am Lebensende? Die Empfehlungen einer SchweizerischenExpertengruppe (Bigorio-Gruppe).

The dehydration, a physiological disturbance due to fluid depletion of the organism, is a common condition in the elderly and most common in the agonal state if not corrected with medical means. Alas, there is little evidence and a paucity of literature as well if one looks for firm data. Do we generally influence the course and duration of the dying process by hydrating or withholding fluids respectively and in what respect? We don't know. Where there is lack of evidence, ideology blossoms. To shed light on this issue an expert panel of members of palliative.ch convened in the Bigorio Monastery in 2009 with the intention to study existing data in order to formulate a concise guideline. Its title: "Hydration in the Palliative Care Setting: Consensus for Best Practice for Palliative Care in Switzerland". This document is available on the website of palliative.ch as a PDF file (go to Fachportal - Standards - best practice). Far beyond the realms of pure fluid physiology the process of decision making with regard to hydration therapy touches core issues of ethics and systemic communication as well. It poses substantial challenges to care teams as illustrated by a case presented in this article.

Integrating patients' views into health technology assessment: Analytic hierarchy process (AHP) as a method to elicit patient preferences.

BACKGROUND: Patient involvement is widely acknowledged to be a valuable component in health technology assessment (HTA) and healthcare decision making. However, quantitative approaches to ascertain patients' preferences for treatment endpoints are not yet established. The objective of this study is to introduce the analytic hierarchy process (AHP) as a preference elicitation method in HTA. Based on a systematic literature review on the use of AHP in health care in 2009, the German Institute for Quality and Efficiency in Health Care (IQWiG) initiated an AHP study related to its HTA work in 2010. METHODS: The AHP study included two AHP workshops, one with twelve patients and one with seven healthcare professionals. In these workshops, both patients and professionals rated their preferences with respect to the importance of different endpoints of antidepressant treatment by a pairwise comparison of individual endpoints. These comparisons were performed and evaluated by the AHP method and relative weights were generated for each endpoint. RESULTS: The AHP study indicates that AHP is a well-structured technique whose cognitive demands were well handled by patients and professionals. The two groups rated some of the included endpoints of antidepressant treatment differently. For both groups, however, the same six of the eleven endpoints analyzed accounted for more than 80 percent of the total weight. CONCLUSIONS: AHP can be used in HTA to give a quantitative dimension to patients' preferences for treatment endpoints. Preference elicitation could provide important information at various stages of HTA and challenge opinions on the importance of endpoints.

Enhanced light trapping in thin-film solar cells by a directionally selective filter.

A directionally selective multilayer filter is applied to a hydrogenated amorphous silicon solar cell to improve the light trapping. The filter prevents non-absorbed long-wavelength photons from leaving the cell under oblique angles leading to an enhancement of the total optical path length for weakly absorbed light within the device by a factor of kappa(r) = 3.5. Parasitic absorption in the contact layers limits the effective path length improvement for the photovoltaic quantum efficiency to a factor of kappa(EQE) = 1.5. The total short-circuit current density increases by DeltaJ(sc) = 0.2 mAcm(-2) due to the directional selectivity of the Bragg-like filter.

Information on ethical issues in health technology assessment: how and where to find them.

BACKGROUND: Comprehensive health technology assessments (HTAs) include thorough reflections on ethical issues associated with health technologies, their use, and value-based decisions in the assessment process. As methods of information retrieval for effectiveness assessments are not applicable to information retrieval on ethical issues, a specific methodological approach is necessary. OBJECTIVES: In the absence of existing adapted methods, our objective was to develop a methodological approach for the systematic retrieval of information on ethical issues related to health technologies. METHOD AND RESULTS: A literature search was conducted to verify the non-existence of published comprehensive methodological approaches for the information retrieval on ethical issues for HTAs, and resulted in no hits. We, therefore, developed a step-by-step workflow following the workflow of information retrieval for effectiveness assessments: Step 1: Translation of the search question using the PICO scheme and additional components. Step 2: Concept building by modeling and linking search components. Step 3: Identification of synonyms in all relevant languages. Step 4: Selection of relevant information sources. Step 5: Design of search strategies for bibliographic databases. Step 6: Execution of search strategies and information seeking, including hand-searching. Step 7: Saving of retrieval results and standardized reporting of the process and results. Step 8: Final quality check and calculation of precision and recall. CONCLUSIONS: Systematic searching for information on ethical issues related to health technologies can be performed following the common retrieval workflow for effectiveness assessments, but should be performed separately applying adapted procedures and search terms on ethical issues relevant to the research question.

Comparison of awake spinal with awake caudal anesthesia in preterm and ex-preterm infants for herniotomy.

BACKGROUND: Spinal anesthesia (SA) is widely used for awake regional anesthesia in ex-preterm infants scheduled for herniotomy. Awake caudal anesthesia (CA) is suggested as an alternative approach for these patients and type of surgery. The aim of this study was to compare efficacy and complications of the two different techniques. METHODS: Two historical populations of 575 ex-preterm infants undergoing herniotomy under awake SA (n = 339; 1998-2001) and under awake CA (n = 236; 2001-2009) were investigated. Data are compared using t-test and chi-square tests (P < 0.05). RESULTS: The SA group consisted of 339 patients, they were born after 32.0 (3.3) weeks of gestation on average with a mean birth weight of 1691 g (725). The CA group consisted of 236 patients born after 32.1 weeks (3.7) with a mean birth weight of 1617 g (726). At the time of operation, the total age was 41.37 (3.6) and 41.28 (4.0), respectively, for SA and CA patients, and the corresponding weights were 3326 (1083) g and 3267 (931) g for SA and CA patients, respectively. For SA, significantly more puncture attempts were needed (1.83 vs 1.44, P < 0.001). Surgery was performed under pure regional anesthesia in 85% (SA) and 90.1% (CA) (ns). A change to general anesthesia was necessary in 7.7% (SA) and 3.9% (CA) (ns). Overall, intra- and postoperative complications were not statistically different. CONCLUSIONS: Caudal anesthesia was shown to be technically less difficult than SA and to have a higher success rate. Its application as awake regional anesthesia technique in these patients seems more appropriate than SA.

Direct non-medical and indirect costs for families with children with congenital cardiac defects in Germany: a survey from a university centre.

INTRODUCTION: Parents of children with congenital cardiac disease suffer from psychological stress and financial burdens. These costs have not yet been quantified. MATERIALS AND METHODS: In cooperation with paediatricians, social workers, and parents, a questionnaire was devised to calculate direct non-medical and indirect costs. Direct non-medical costs include all costs not directly related to medical services such as transportation. Indirect costs include lost productivity measured in lost income from wages. Parents were retrospectively queried on costs and refunds incurred during the child's first and sixth year of life. The questionnaire was sent out to 198 families with children born between 1980 and 2000. Costs were adjusted for inflation to the year 2006. Children were stratified into five groups according to the severity of their current health status. RESULTS: Fifty-four families responded and could be included into the analysis (27.7%). Depending on severity, total direct non-medical and indirect costs in the first year of life ranged between an average of euro1654 in children with no or mild (remaining) cardiac defects and an average euro2881 in children with clinically significant (residual/remaining) findings. Mean expenses in the sixth year of life were as low as euro562 (no or mild (remaining) cardiac defects) and as high as euro5213 (potentially life-threatening findings). At both points in time, the highest costs were lost income and transportation; and day care/ babysitting for siblings was third. DISCUSSION: Families of children with congenital cardiac disease and major sequelae face direct non-medical and indirect costs adding up to euro3000 per year on average. We should consider compensating families from low socioeconomic backgrounds to minimise under-use of non-medical services of assistance for their children.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

[Decision-making relating to cardio-pulmonary resuscitation attempts]. / Der Reanimationsentscheid.

A 78-year-old previously healthy and very active patient is urgently admitted to a hospital on a late Saturday evening for his first attack of angina pectoris. Referring to a previously drafted living will (kept at home) he refuses his consent for transfer to the intensive care unit (ICU). A DNAR (Do Not Attempt Resuscitation) order is entered in the patient's chart. After his condition has stabilized in the emergency room the patient is transferred to an ordinary ward. By the next morning the patient has been admitted to the ICU after successful cardiopulmonary resuscitation following cardiac arrest, which had occurred on the ward while the patient was left unobserved for a moment. In fact, he is intubated and artificially ventilated. He is in a critical state and his neurological outcome is uncertain. A number of hotly debated issues arise: Was it wrong to resuscitate the patient? Focusing on the DNAR order, how should the decision-making process look like, and what about the further management of the case? Could any help be expected from the new guidelines on DNAR decision-making recently published by the Swiss Academy of Medical Sciences (www.samw.ch)? The case presented illustrates the ethical complexity of modern clinical practice in general. It is true that the article raises a lot of unanswered questions, but at the same time it is looking ahead and gives insights into what a structured ethical decision-making process looks like. The article is meant to stimulate involvement with practical clinical ethics; which is why it has been placed at the beginning of the present issue of Therapeutische Umschau.

Waiting times for elective treatments according to insurance status: A randomized empirical study in Germany.

BACKGROUND: Health insurance coverage for all citizens is often considered a requisite for reducing disparities in health care accessibility. In Germany, health insurees are covered either by statutory health insurance (SHI) or private health insurance (PHI). Due to a 20%-35% higher reimbursement of physicians for patients with PHI, it is often claimed that patients with SHI are faced with longer waiting times when it comes to obtaining outpatient appointments. There is little empirical evidence regarding outpatient waiting times for patients with different health insurance status in Germany. METHODS: We called 189 specialist practices in the region of Cologne, Leverkusen, and Bonn. Practices were selected from publicly available telephone directories (Yellow Pages 2006/2007) for the specified region. Data were collected for all practices within each of five specialist fields. We requested an appointment for one of five different elective treatments (allergy test plus pulmonary function test, pupil dilation, gastroscopy, hearing test, MRT of the knee) by calling selected practices. The caller was randomly assigned the status of private or statutory health insuree. The total period of data collection amounted to 4.5 weeks in April and May 2006. RESULTS: Between 41.7% and 100% of the practices called were included according to specialist field. We excluded practices that did not offer the requested treatment, were closed for more than one week, did not answer the call, did not offer fixed appointments ("open consultation hour") or did not accept any newly registered patients. Waiting time difference between private and statutory policyholders was 17.6 working days (SHI 26.0; PHI 8.4) for allergy test plus pulmonary function test; 17.0 (25.2; 8.2) for pupil dilation; 24.8 (36.7; 11.9) for gastroscopy; 4.6 (6.8; 2.2) for hearing test and 9.5 (14.1; 4.6) for the MRT of the knee. In relative terms, the difference in working days amounted to 3.08 (95%-KI: 1,88 bis 5,04) and proved significant. CONCLUSION: Even with comprehensive health insurance coverage for almost 100% of the population, Germany shows clear differences in access to care, with SHI patients waiting 3.08 times longer for an appointment than PHI patients. Wide-spread anecdotal reports of shorter waiting times for PHI patients were empirically supported. Discrepancies in access to care not only depend on accessibility to comprehensive health insurance cover, but also on the level of reimbursement for the physician. Higher reimbursements for the provider when it comes to comparable health problems and diagnostic treatments could lead to improved access to care. We conclude that incentives for adjusting access to care according to the necessity of treatment should be implemented.

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.

OBJECTIVE: The aim of this study was to quantify and classify errors associated with the repackaging of residents' medications in long-term care facilities in Germany. METHODS: This was a prospective 8-week study conducted in 3 long-term care facilities. Pill organizers, each of which contained all repackaged solid oral dosage forms of long-term medications for a particular resident for an entire day, were inspected and checked against residents' medication sheets by the investigator-pharmacist. On agreement between the pharmacist and the registered nurse responsible for residents' medications, all errors were rectified before medications were administered. The primary study measure was the overall rate of incorrectly repackaged medications relative to all repackaged medications. Secondary measures were the proportion of all pill organizers with medication errors and the proportion of residents who would have been affected by these errors. Errors were categorized by type as follows: wrong time of administration, wrong dose, wrong medication, omission of a medication, extra dose, incorrect halving of tablets, and damaged medication. RESULTS: One hundred ninety-six residents were included in the study, representing 8798 daily pill organizers and 48,512 inspected medications. Residents received a mean of 5.4 solid oral dosage forms of long-term medications per day. Six hundred forty-five errors were detected, for an error rate of 1.3%; the errors involved 7.3% of daily pill organizers and 53.0% of residents. The largest proportion of errors involved incorrect halving of tablets (49.1%), followed by omission of a medication (22.0%), extra dose (9.8%), wrong time of administration (8.4%), damaged medication (6.4%), wrong dose (4.2%), and wrong medication (0.2%). These results may underestimate true rates of repackaging errors across long-term care facilities in Germany, as the conditions in the 3 facilities in this study were near-optimal in terms of the environment, process, and quality of repackaging. CONCLUSIONS: Among 48,512 medications inspected over 8 weeks in 3 German long-term care facilities, the rate of repackaging errors was 1.3%, involving 7.3% of daily pill organizers and the medications of 53.00% of residents. The largest proportion of errors involved incorrect halving of tablets.

[Efficiency of computer-based documentation in long-term care--preliminary project]. / Effizienz der computergestültzten Dokumentation in Pflegeheimen--eine Pilotstudie.

In Germany the documentation of processes in long-term care is mainly paper-based. Planning, realization and evaluation are not supported in an optimal way. In a preliminary study we evaluated the consequences of the introduction of a computer-based documentation system using handheld devices. We interviewed 16 persons before and after introducing the computer-based documentation and assessed costs for the documentation process and administration. The results show that reducing costs is likely. The job satisfaction of the personnel increased, more time could be spent for caring for the residents. We suggest further research to reach conclusive results.

Tracheobronchial foreign body aspiration in children - diagnostic value of symptoms and signs.

OBJECTIVE: Tracheobronchial foreign body (TFB) aspiration is a common cause of respiratory compromise in early childhood. Research indicates that a high number of children are missed with TFB aspiration. The aim of this study was to identify predictors of potential TFB aspiration. STUDY DESIGN: We analysed 370 endoscopic reports of children admitted to our emergency department who underwent explorative rigid bronchoscopy to exclude/remove a TFB (1989-2003). Patient characteristics, history, clinical, radiographic and bronchoscopic findings were noted. Sensitivities and specificities for TFB aspiration were calculated for patient history, clinical and radiographic findings. RESULTS: The median age was 1.8 years. In 59.7% of patients a TFB was found and removed. A group analysis was performed on children with symptoms less than 2 weeks (group A) and those more than 2 weeks (group B). The results showed that unilateral diminished breath sounds and unilateral overdistension on chest X-ray were the most sensitive (53-79%) and specific (68-88%) findings in both groups. The clinical triad of acute choking/coughing, wheezing and unilateral diminished breath sounds had a high specificity (96-98%) in both groups. In contrast, a positive history of acute choking/coughing in group A or a permanent cough in group B showed a low specificity (8-16%). CONCLUSION: In a paediatric respiratory compromise, the presence of unilateral diminished breath sounds, pathological chest X-ray or clinical triad is a powerful indicator for occurred TFB aspiration. Since no single or combined variables can predict TFB aspiration with full certainty, bronchoscopic exploration should be performed if TFB aspiration is suspected.

Next-generation applications in healthcare digital libraries using semantic service composition and coordination.

Healthcare digital libraries (DLs) increasingly make use of dedicated services to access functionality and/or data. Semantic (web) services enhance single services and facilitate compound services, thereby supporting advanced applications on top of a DL. The traditional process management approach tends to focus on process definition at build time rather than on actual service events in run time, and to anticipate failures in order to define appropriate strategies. This paper presents a novel approach where service coordination is distributed among a set of agents. A dedicated component plans compound semantic services on demand for a particular application. In failure, the planner is reinvoked to define contin- gency strategies. Finally, matchmaking is effected at runtime by choosing the appropriate service provider. These combined technologies will provide key support for highly flexible next-generation DL applications. Such technologies are under development within CASCOM.

Evidence-based medicine is rooted in Protestant exegesis.

Evidence-based medicine (EbM) has been practised for about a decade now. Until now, it has generally been accepted that EbM has its roots in medical thinking of mid-19th century France. Due to the startling fact that France never was a centre of EbM, historical tradition was reconsidered. Since EbM has mainly been flourishing in Protestant countries, a qualitative historical investigation was conducted according to the approach of Max Weber's "The Protestant Ethics". Thus, it could be shown that there are three major prerequisites for EbM to evolve apart from current technical developments, such as the computer and the internet: (1) historical critical exegesis functioned as a methodology to balance contradictory passages; (2) both an equality based relationship among physicians and a Protestant concept that lay people are considered equal in the theologic debate were fundamental to EbM as a new approach of medical thinking; (3) mostly nationally funded health care systems are prone to practise EbM as they are obliged to provide health care which is both fair in access and allocation to the whole population. Against the background of historical exegesis, it has to be taken into account that EbM implies a twist in medicine towards a concept of textual criticism rather than the mere introduction of statistics. Moreover, it both relies upon and enhances a more equal relationship between physicians.