[Reasons of changes in drug therapy after hospital discharge - a qualitative study of perception by general practitioners and patients]. / Gründe von Änderungen der medikamentösen Therapie nach Krankenhausentlassung - eine qualitative Studie aus Sichtweise von Hausärzten und Patienten.

BACKGROUND: After discharge from hospital there is often change of medication regimen. Usually, the main results of the inpatient stay and the subsequent treatment recommendations are summarised in a "discharge letter". Based on this, the general practitioner decides on how to proceed taking the individual aspects of his/her patient into consideration. The aim of the study is to trace changes of medication and suggested therapy in the discharge letter, from the GP through to the patient and the reasons/influencing factors for any changes in medication undertaken or retained. METHODS: A prospective qualitative study with successively selected patients, who were put on a new long-term medication, at discharge after a stay in a hospital internal medicine unit was undertaken. Semi-structured interviews were conducted with the patients 4-6 weeks after hospital discharge. Subsequently, interviews were conducted with the patient's GP on details of current medication. The interviews were recorded electronically, based on the consensus method and evaluated with respect to changes in medication and influencing factors. In order to detect discrepancies in drug therapy, discharge letters were included in the analysis. RESULTS: A total of 34 patients and their GPs were interviewed. Few changes of medication changes were registered; however, these were more frequent in the weeks after hospital discharge. Drug therapy recommendations were modified by GPs for different medical or non-medical reasons. Non-medical reasons identified included economic, health policy constraints, personal conviction or non-adhrence of the patient. Reasons for a change in medication by the patient included, questioning of the need for taking the drug, incompatibility, fears and a lack of knowledge about the medication. CONCLUSION: The data demonstrate that the transition from inpatient to outpatient care is a sensitive interface. The data do not allow quantitative estimation of the magnitude of this phenomenon. In this study, the reasons for the modification of the drug demonstrated that these findings could be the basis for further studies or the development of interventions for preventing unwanted medication changes.

[Structures and practice of psychology departments in orthopaedic and cardiac rehabilitation: a comparison of outpatient and inpatient clinics in Germany]. / Strukturen und Praxis der Psychologischen Abteilungen in der orthopädischen und kardiologischen Rehabilitation: Vergleich zwischen ambulanten und stationären Einrichtungen in Deutschland.

We aimed at comparing the present structural quality and practice of psychological services in ambulatory (outpatient) and inpatient rehabilitation in Germany.A nationwide survey of psychological services in orthopaedic and cardiac outpatient rehab centres was carried out. Results were compared to those of an identical study of inpatient services that was conducted simultaneously.Data were obtained from 81 ambulatory centres (return rate: 44%). Structures and practice (e. g., diagnostic procedures, psychological interventions) in ambulatory and inpatient rehabilitation only differed marginally. Differences concern the staff/patient ratio which is slightly better in ambulatory centres and some aspects of working conditions (e. g., less assisting staff or supervision).From its beginning, ambulatory rehabilitation in Germany has followed the standards of the inpatient model as far as structural quality and processes are concerned. Psychological practice in the ambulatory setting reflects that too. It is discussed whether the uniformity of ambulatory and inpatient rehabilitation services really is appropriate, or whether a more flexible model (e. g., regarding treatment duration) is needed in the German rehabilitation system.

[The methodological quality of rehabilitation guidelines]. / Methodische Qualität von Leitlinien in der Rehabilitation.

INTRODUCTION: The concepts of clinical guidelines contribute to the decision-making and improvement in the quality of medical supply. This paper provides a literature research on rehabilitation guidelines and their evaluation by the "German Instrument for Methodological Guideline Appraisal (DELBI)". METHODS: The clinical guideline research was conducted with the help of an online database as well as expert surveys conducted between August and October 2007. The literature research was updated in October 2008. Only those guidelines that satisfied specific criteria were included in the evaluation. RESULTS: Although the research yielded 124 guidelines, only 28 were included in the evaluation after applying the criteria. In total, the evaluation was heterogeneous. With regard to each domain, the mean degree of fulfillment reached between 2.1% and 58.3%. DISCUSSION: Due to an extensive and detailed literature research and expert survey, all relevant clinical guidelines for rehabilitation, which are valid in Germany, could be gathered. A first examination of the guidelines seems to reveal several deficiencies. Possible reasons are discussed. CONCLUSION: This paper reveals a detailed survey of the clinical guidelines for rehabilitation. Compared to acute-care medicine, the number of available guidelines is distinctly smaller. With regard to the DELBI criteria, an enormous development in the quality of guidelines for rehabilitation is still necessary. Some of these might be due to inaccurate documentation, which will have to be considered in a further update.

[Analysis of therapeutic procedures in 5,838 rehab patients following total hip or total knee replacement]. / Ergebnisse einer Analyse der therapeutischen Leistungsdaten (KTL-Daten) von 5,838 Rehabilitandinnen und Rehabilitanden nach Hüft- bzw. Knieendoprothesenimplantation.

In the framework of the Practice Guidelines programme of the German Federal Pension Insurance (DRV Bund) evidence-based standards for rehabilitation following total hip or knee replacement are to be developed. The results of a quantitative analysis of present health-care on the basis of documented treatments (KTL) from 5 838 rehab patients are reported here. Based on a systematic review of international trials, treatment modules were specified and analyzed as to frequency and duration of current treatment. Furthermore, separate analyses were conducted for gender, age, and different clinics. No differences were found among rehab facilities as to exercise therapy, physiotherapy, or health education. However, psychological treatment and specific trainings differed considerably between centres.

Anti-inflammatory treatment may prolong survival in undernourished patients with metastatic solid tumors.

Eicosanoids may be important factors for tumor cell proliferation, metastatic formation, and development of cancer cachexia. The present study has evaluated the effect of anti-inflammatory treatment on tumor progression in clinical cancer. Patients (n = 135) with insidious or overt malnutrition due to generalized malignancy (various kinds of solid tumors) and an expected survival of more than 6 months were randomized by a computer-based algorithm to receive placebo, prednisolone (10 mg twice daily), or indomethacin (50 mg twice daily) p.o. until death. Patient groups were stratified in the randomization procedure for sex, tumor type, stage, nutritional state, and previous tumor treatment, and biochemical, physiological, and some functional variables (Karnowsky index, fatigue and pain score). A majority of these variables was then registered during the follow-up. Indomethacin and prednisolone treatment maintained Karnowsky index, while placebo-treated patients experienced a decreased index. Indomethacin-treated patients suffered less pain and consumed less additional analgetics compared to the other patient groups. Indomethacin prolonged mean survival compared to placebo-treated patients from 250 +/- 28 days to 510 +/- 28 days (P < 0.05). Survival analysis on observations from all patients treated with either indomethacin or prednisolone demonstrated a significantly prolonged survival by anti-inflammatory treatment compared to placebo treatment (log rank, P < 0.03). The results suggest that not only may prostaglandin synthesis inhibition offer palliative support to patients with solid advanced cancer, but it may also impact on pathways that ultimately determine outcome.

Improving diagnostic accuracy of bacterial pharyngitis by near patient measurement of C-reactive protein (CRP)

BACKGROUND: Sore throat or pharyngitis is an extremely prevalent condition in primary care. There is a diagnostic dilemma in differentiating bacterial and non-bacterial infections for adequate use of antibiotics. Standard diagnostic procedures take too long for an immediate decision. AIM: To evaluate, if near patient C-reactive protein measurement in the general practice surgery improves diagnostic accuracy. METHOD: One hundred and seventy-nine consecutive patients with sore throat, from 15 general practitioners (GPs) in southern Germany (phase 1) and 161 consecutive patients from 14 GPs (phase 2), were examined physically and a throat-swab was taken and white blood-cell count (WBC) and CRP-measurement were performed. In phase 1, CRP was measured centrally to assess the method's diagnostic value and the adequate threshold. In the second phase, near patient CRP was measured and CRP values were used to make a diagnosis. RESULTS: Using relative operating characteristics (ROC) analysis, the diagnostic value of CRP measurement was much better than WBC count (area under curve = 0.85 versus 0.68). All diagnostic parameters improved when using the near patient CRP measurement. Sensitivity went up from 0.61 (95% confidence interval = 0.45-0.75) to 0.78 (0.61-0.90), specificity went up from 0.73 (0.65-0.81) to 0.82 (0.73-0.88). Positive and negative predictive value improved significantly as well. Diagnostic accuracy went up from 70.1% to 81.0%. Out of 1000 theoretical patients with sore throat, 109 more will be treated correctly when using CRP measurement as a diagnostic tool. CONCLUSIONS: Use of near patient CRP measurement can improve diagnostic accuracy in the differentiation of bacterial and non-bacterial pharyngitis in primary care, and potentially results in a more adequate use of antibiotics.

[The DEGAM guidelines "Dysuria" by the German Society of General Practice and Family Medicine (DEGAM)--possible consequences of the implementation in general practice]. / Die DEGAM-Leitlinie "Brennen beim Wasserlassen"--mögliche Konsequenzen der Umsetzung in der allgemeinärztlichen Praxis.

INTRODUCTION: In Germany, there are hardly any reliable data on patient care in the primary care setting which warrant the development and implementation of clinical guidelines. In this paper, data generated by a prospective observational study of patients with urinary tract symptoms are compared to the recommendations of an evidence-based clinical guideline. PATIENTS AND METHODOLOGY: Over a period of 6 months all patients consulting one of 6 General Practitioners in southern Germany with symptoms of dysuria have been documented on a standardised patient record. Data were compared to the recommendations of the guideline "Dysuria" by the German Society of General Practice and Family Medicine (DEGAM) to assess the relevance and feasibility of the guideline. In a scenario, compliance with the guideline is extrapolated to the realm of primary care. RESULTS: Basic demographic and epidemiological data agree with basic assumptions of the guideline. As far as diagnostic and therapeutic strategies are concerned there are significant discrepancies between the recommendations and the realm of primary care. Microbiologic cultures are ordered far less then recommended, second line drugs are prescribed far more often then recommended, macroscopic urinoscopy is performed widely but not covered by the guideline at all. If GPs complied completely with the guideline, many more diagnostic procedures would be performed and a different palette of antimicrobial drugs would be prescribed. CONCLUSION AND OUTLOOK: The "Dysuria-Guideline" of DEGAM was developed for a prevalent and relevant topic in primary care in Germany. There are significant discrepancies between the recommendations and the realm of primary care. Post-hoc-analysis is an informative and feasible tool to identify potential obstacles against implementation of guidelines.

[The surface status of the gastric mucosa in retinol deficiency]. / Sostoianie poverkhnosti slizistoi obolochki zheludka v usloviiakh defitsita retinola.

Changes of the stomach mucosa in retinol deficiency of the organism were studied by methods of scanning and transmission electron microscopy. Observation of stomach mucosa state of the animals was performed in dynamics (in proportion with increase of the vitamin deficiency). The disturbance of integrity of the apical part of the external cell membrane of the superficial epithelium and development of apical erosions in cells were established. Disturbance of integrity of the external membrane apical part in epitheliocytes provides erosions and ulcers development in retinol deficiency.

[The ultrastructure of the main exocrinocytes in the glands proper of the gastric mucosa in A avitaminosis]. / Ul'trastruktura glavnykh ékzokrinotsitov sobstvennykh zhelez slizistoi obolochki zheludka pri A-avitaminoze.

The electron microscopic and morphometrical methods were used to study the ultrastructural organization of main exocrinocytes of the proper glands of the mucous membrane of the stomach of rats under conditions of A-avitaminosis. Deficiency of vitamin A causes dystrophic alterations of main exocrinocytes. The fragmentation, degranulation and considerable dilatation of cisterns of the granular endoplasmic reticulum, destruction of the Golgi complex membranes, disturbance of the membranous organization of secretory vacuoles were observed. A conclusion is made of disturbances of the protein-synthesizing function of main exocrinocytes under conditions of A-avitaminosis.

[The ultrastructure of the parietal exocrinocytes of the glandulae propriae in the gastric mucosa in A avitaminosis]. / Ul'trastruktura parietal'nykh ékzokrinotsitov sobstvennykh zhelez slizistoi obolochki zheludka pri A-avitaminoze.

Electron microscopic and morphometric methods were used to study the state of the parietal exocrinocytes of the proper glands of gastric mucosa in dynamics of A avitaminosis. The experiment was performed in 80 albino rats taken from mother's feeding with the initial body mass 40-50 g, divided into 2 groups. In animals of the first group A-avitaminosis was induced by feeding the animals with semisynthetic diet devoid of vitamin A. The 2nd control group was given the same semisynthetic diet but with retinol acetate (45 units a day for each animal). Ultrastructural findings showing the elevated production of hydrochloric acid at early stages of the development of A avitaminosis were obtained: hyperplasia of the internal mitochondrial membrane, dilatation of the intracrystal space and considerable enlargement of the area of secretory membranes of tubulovesicles and microvilli of the intracellular tubules. Deep deficiency of vitamin A disturbs the stability of intracellular membranes and leads to irreversible destructive alterations in the proper gastric glands by the end of the experiment. The facts obtained are of importance for both the understanding of specific nature of secretion of hydrochloric acid and for mechanisms of development of erosion and ulcers of gastric mucosa in A avitaminosis.

[Free amino acids in rat blood serum during A-hypovitaminosis]. / Svobodnye aminokisloty syvorotki krovi krys pri A-gipovitaminoze.

A pool of free aminoacids of the blood serum has been studied in growing rats with a decreased retinol content in the liver tissue (to 5 g/g). The study shows a reliable drop in the concentrations of all essential aminoacids, except for phenylalanine. It is determined that the total amount of essential aminoacids decreases by 31%. At the same time concentrations of replaceable aminoacids increase, namely: glutamic acid and arginine--by 15.7%, ornithine and histidine--by 24%-45%, though proline concentration decreases abruptly by 31%. A disturbance in ultrastructural organization of microvilli in the apical membrane cells absorptive epithelium of the small intestine has been found. The results of the study confirm changes in a free aminoacid pool of the blood serum in growing rats and these changes occur first of all due to the disturbance of the absorption processes in the small intestine.

[Effect of various casein contents of the diet on nitrosodimethylamine-induced carcinogenesis in rats]. / Vliianie razlichnogo soderzhaniia kazeina v diete na kantserogenez u krys, vyzvannyi nitrozodimetilaminom.

Comparative morphological analysis of the animal groups given 8 and 20% casein in the diet has shown that the general nature and the trend of morphological changes in rat organs, induced by nitrosodimethylamine (NDMA) appeared similar. At the same time the reduction of casein content in the diet from 20 to 8% significantly raised the number of NDMA-induced tumors, changed their sites and times of development.

[The morphological aspects in a biomedical assessment of hydrobionts]. / Morfologicheskie aspekty v mediko-biologicheskoi otsenke gidrobiontov.

The morphological data are presented on the condition of internal organs in experimental animals during hygienic examination of a number of traditional fish species, as well as the results of the morphological study of the nature of pigment spots on the skin of perch. The problem has been considered on the importance of morphological investigations in the study of harmlessness of hydrobionts. A conclusion has been made on the necessity of conducting thorough morphological investigations of hydrobionts and those structural changes that can be induced by their usage.

[Effects of a new saccharose-containing powder on the indicators of carbohydrate and lipid metabolism in animals]. / Vliianie novogo sakharosoderzhashchego poroshka na pokazateli uglevodnogo i lipidnogo obmenov u zhivotnykh.

Experimental animals were fed with semisynthetic rations with sugar-containing powder (40% of carbohydrate energy value) during 10 months. It has been found that this ration does not influence the levels of glucose in the blood, glycogen in the liver, and the content of triglycerides, total cholesterol and alpha-lipoprotein cholesterol in the blood serum. Similar quantity of refined sugar in the ration led to elevation of the levels of glucose in the blood, of triglycerides and total cholesterol in the blood serum by the end of the experiment. Correlation between biochemical and morphological investigation data has been recorded.

[The hygienic evaluation of modified Alaska pollack protein based on pathomorphological research]. / Gigienicheskaia otsenka modifitsirovannogo belka mintaia na osnove patomorfologicheskikh issledovanii.

It has been established that daily inclusion of modified Alaska pollack protein into the rat ration as a 10% substitute of casein does not induce any changes in the body. A long term (during 12 months) feeding of rats with the rations containing 50 and 100% of Alaska pollack protein, as casein substitute, results in significant changes in the histological structure of the kidneys and liver. The data of electron microscopy enabled the authors to make a conclusion on the presence of a toxic factor in the protein product studied.

[Characteristics of structural changes in the internal organs of animals after administration of dried yeast]. / Kharakter strukturnykh izmenenii vnutrennikh organov zhivotnykh pod vliianiem gribnogo poroshka.

Morphofunctional analysis of the state of internal organs was made in rats which received varying amounts of mushroom powder. It has been established that the new product induces development of endovasculitis, dystrophy and lympho-histiocytic infiltrates of parenchymatous organs. The data obtained have evidenced the development of delayed allergic reactions to mushroom powder. A conclusion has been made on the necessity of its limited inclusion into food ration.

[The possible carcinogenic action of a protein concentrate from Saccharomyces yeasts grown on molasses]. / Izuchenie vozmozhnogo kantserogennogo deistviia belkovogo kontsentrata iz drozhzhei-sakharomitsetov, vyrashchennykh na melasse.

A testing was done in a chronic experiment on 300 rats and 360 mice of both sexes for carcinogenic potential of a new protein product from Saccharomyces yeast grown in melasse. The production procedures and techniques of the above product have been worked out at the Ukrainian Research Institute of Spirits and Biotechnology of Food Stuffs of Gospishcheprom (State Food Industry) of Ukraine. The studies made showed the new protein product has no carcinogenic effect.

[Possibility of endogenous dimethylnitrosamine synthesis in rats administered dimethylamine and nitrite with the food]. / Izuchenie vozmozhnosti éndogennogo sinteza dimetilnitrozamina pri vvedenii krysam s pishchei dimetilamina i nitrita.

Concurrent peroral administration of dimethylamine (DMA) and sodium nitrite to rats produced necrosis of liver parenchyma and increased the activity of glutamicoalanine transaminase. Similar changes were recorded after administering dimethylnitrosamine (DMNA) that points to potential synthesis of this carcinogen from the precursors. Prolonged (over 2.5 years) feeding with DMA and nitrite resulted in part of the rats in tumours of the lungs and in other neoplasms. Ascorbic acid that blocks the endogenous synthesis of DMNA interfered with the development of tumour and pretumour lesions that emerged as a result of concurrent feeding with DMA and nitrite.

[The possible hypolipidemic action of the dietary fiber from barley meal]. / Izuchenie vozmozhnogo gipolipidemicheskogo deistviia pishchevykh volokon iz muchki iachmenia.

A possible hypocholesteremic property was studied of food fibers from barley in a subchronic experiment on 60 white nondescript male rats under developing hypercholesterolemia of alimentary genesis. An aggravated dose of the above fibers has been shown to reduce deviations from the reference level brought about by administration of exogenous cholesterin. On completing the clinical trials, the studied product may be used in nourishment of those individuals presenting with disordered lipid metabolism.

[Medico-biological evaluation of sodium salt of nitrofurylacrylic acid as a food additive]. / Mediko-biologicheskaia otsenka natrievoi soli 5-nitrofurilakrilovoi kisloty kak pishchevoi dobavki.

Nitrofurylacrylic acid sodium salt is a substance of moderate toxicity. Its LD50 for male rats after oral administration comprises 1220 mg/kg, for female rats--1400 mg/kg. The minimal toxic dose, in case of long-term administration comprises 14 mg/kg. At the level of doses from 0.04 to 4.0 mg/kg no mutagenic effect was detected. Oral and subcutaneous administration of minimal tolerance doses of the agent induced formation of malignant neoplasms developing, predominantly, from the epithelial tissue, with localization depending on the route of the agent administration. A conclusion has been made on impossibility of using this substance as a food additive.