Altered functional connectivity within the central reward network in overweight and obese women.

BACKGROUND/OBJECTIVES: Neuroimaging studies in obese subjects have identified abnormal activation of key regions of central reward circuits, including the nucleus accumbens (NAcc), in response to food-related stimuli. We aimed to examine whether women with elevated body mass index (BMI) show structural and resting state (RS) functional connectivity alterations within regions of the reward network. SUBJECTS/METHODS: Fifty healthy, premenopausal women, 19 overweight and obese (high BMI=26-38 kg m(-2)) and 31 lean (BMI=19-25 kg m(-2)) were selected from the University of California Los Angeles' Oppenheimer Center for Neurobiology of Stress database. Structural and RS functional scans were collected. Group differences in grey matter volume (GMV) of the NAcc, oscillation dynamics of intrinsic brain activity and functional connectivity of the NAcc to regions within the reward network were examined. RESULTS: GMV of the left NAcc was significantly greater in the high BMI group than in the lean group (P=0.031). Altered frequency distributions were observed in women with high BMI compared with lean group in the left NAcc (P=0.009) in a medium-frequency (MF) band, and in bilateral anterior cingulate cortex (ACC) (P=0.014, <0.001) and ventro-medial prefrontal cortex (vmPFC) (P=0.034, <0.001) in a high-frequency band. Subjects with high BMI had greater connectivity of the left NAcc with bilateral ACC (P=0.024) and right vmPFC (P=0.032) in a MF band and with the left ACC (P=0.03) in a high frequency band. CONCLUSIONS: Overweight and obese women in the absence of food-related stimuli show significant structural and functional alterations within regions of reward-related brain networks, which may have a role in altered ingestive behaviors.

[Is there a voucher for the impact of quality assurance/-improvement methods in foreign countries?]. / Gibt es Belege für den Impact qualitätssichernder/-fördernder Verfahren in anderen Ländern?

AIMS: Internationally, the implementation of diagnosis-related group systems has underlined the importance of quality assurance and improvement in health care systems. Support is expected by various concepts based on different theories and traditions. Published experience and knowledge of other countries with long-standing DRG systems and data in literature are studied to see whether there is an evidence-based impact of quality assurance and quality improvement on health care systems. METHODS: Relevant data was searched for in the Cochrane-database, the INAHTA-databases DARE, NHSEED and HTA, in DIMDI and the Medline-database of the NIH as well as generally in the internet, addressing the different countries. RESULTS: Several tools of quality assurance and quality improvement like accreditation, evidence-based medicine and guidelines exist in most of the 18 countries studied. Some of them, such as registries and audits, have marked national characteristics. Similar problems in provision of health care are reported internationally. There is broad consensus as to the aspects to be addressed in quality improvement concepts. Though international consensus on effective organization and methods of external assessment is growing there is only limited evidence for efficiency and general applicability of the different tools. Their cost impact, too, has not undergone systematic evaluation. Procedures like feedback strategies and reflection have been identified as having the potenzial to change the practice of health care professionals on a local level, but evidence for system-related impact is missing. Above all, for all concepts of quality improvement there is no real evidence of clinical benefit in the sense of better patient outcomes. CONCLUSIONS: None of the various tools for quality improvement in health care proves superior so far. It remains unclear which tool suits best for which intended improvement and in which context. Although quality improvement as a strategy meets with wide approval and appears to be a correct health policy, it remains doubtful whether it really improves clinical outcome and patient-centred health care. Public health research should address these questions. New concepts (e. g. integrating different tools of quality assurance and improvement or DMP systems) need evaluation prior to their broad implementation. Social medicine is called upon to mediate between the consented health care aims of society and medicine.

[Evidence-based scientific analysis of fundamental Medical Services of Statutory Health Insurance internal principle assessment]. / Die evidenzbasierte wissenschaftliche Analyse als Grundlage MDK-interner Grundsatzgutachten.

In Germany, the increasing relevance of Evidence-based medicine (EbM) is not only a consequence of growing economic limitations in the health care system but of a changed jurisdiction, too: liability of the statutory health insurances (SHI) to pay for medical care depends on the proof of its effectiveness. This is of special importance for the Medical Services in their role as an advisor of the SHI. The article depicts the basic assignments of the Medical Services of the Statutory Health Insurance, their legal frame and the role of EbM in sociomedical expertising. The way of fundamental sociomedical expertising, its internal and external effects, the personnel and technical/logistic requirements are described as well as potential of improvement.

["Deficiencies in the mandatory health insurance system"--possibilities and limits of medical expert assessment]. / "Mangel des gesetzlichen Leistungssystems"--Möglichkeiten und Grenzen der medizinischen Sachverständigentätigkeit.

In Germany, the Federal Committee of Physicians and Health Insurance Agencies is responsible for assessing which medical procedures are covered by the insurance agencies (therapeutic/economic value). The failure to evaluate certain medical procedures which promise therapeutic benefit may be considered a failure in the system of statutory health insurance as decreed by the German Federal Social Court. In cases of system failure the assessment of medical procedures is taken over by social courts. Evidence of therapeutic value will continue to be the decisive criterion of evaluation. In special cases, however, it may be replaced by the particular procedure's rate of incidence in everyday medical practice, as reflected by a widespread resonance in medical discussion and its use by a considerable number of physicians. Medical experts may face various difficulties in handling these alternative criteria. They usually lack reliable data on the frequency of the procedure, i.e. its distribution. Even if such data and data on secondary factors--such as disease incidence etc.--were available to them, they would still not be able to come up with a definite conclusion on the degree (widespread, considerable) of dissemination, as defined by the German Federal Social Court. Nevertheless, on request of statutory health insurances, social medical experts may investigate facts in order to establish basic knowledge for later decisions that are to be done by others. Factual investigation includes clarification of etiology, incidence, importance and natural history of the particular disease processes. Potential deficiencies in the medical services rendered for specific diseases as well as the characteristics of the procedure under scrutiny, and special requirements for evaluating the outcome have to be investigated as well. Additional attention needs to be paid to the quality of related publications (analysis of statistical data), possible recommendations for therapy (e.g. guidelines and their scientific basis), as well as to economic aspects. The result of such an investigation has to be stated without use of court criteria (widespread/considerable).

Ruptured aneurysms of the sinus of Valsalva.

From 1964 to 1984, 10 male and 5 female patients with ruptured aneurysms of the sinus of Valsalva (ASVs) underwent surgical correction. These procedures constituted 0.23% of the 6,350 surgical procedures that used cardiopulmonary bypass during this period. Five patients had an inflammatory condition (bacterial endocarditis, 4; syphilis, 1), and 1 had an ASV relapse 5 years after her first operation. Coexistent lesions included aortic valve regurgitation in 5 patients, ventricular septal defect in 3 (1 of whom had mitral insufficiency), patent foramen ovale in 2, and atrial septal defect in 1. Ninety-three percent were symptomatic (sudden onset of symptoms, 5 patients; gradual onset, 9 patients), commonly with shortness of breath, fatigability, chest pain, and tachycardia. The following connections occurred: noncoronary sinus to right atrium (RA) (5 patients); right coronary sinus (RCS) to RA (5 patients); and RCS to right ventricle (5 patients). There were no early or late postoperative deaths. One patient underwent reoperation after an ASV relapse. The mean follow-up period (+/- standard deviation) was 7.9 years (range, 10 months to 20.1 years). Eighty percent of the patients were found to be in New York Heart Association class I, and 20% were in class II. Apart from ASV relapse, late complications are determined by prosthetic valve dysfunction or evidence of valve disease. Early surgical intervention is justified in patients with ruptured ASV.

Late pulmonary embolization of a retained pacemaker electrode fragment after attempted transatrial extraction.

Embolization of pacemaker electrode fragments into the pulmonary circulation is a rare complication following transvenous pacemaker implantation. One such case is reported here. In a 67-year-old patient, a battery pocket infection developed after transvenous pacemaker implantation and subsequent surgical revision. After removal of the pacemaker and ventricular pacing lead, the atrial lead broke within the superior vena cava when prolonged traction was applied after frustrating attempts to extract the electrode. Attempts to extract the fragment transvenously using endoscopic forceps were unsuccessful. Due to firm fixation of the electrode by extensive fibrous scar tissue in the atrial wall, a further attempt to remove the retained electrode fragment by atriotomy also failed. On the first postoperative day, the fragment migrated to the left pulmonary artery, from where it was successfully extracted by means of a Dormier basket.

Reduction of postoperative donor blood requirement by use of the cell separator.

In a prospective, randomized study of 20 patients undergoing elective open-heart surgery, up to c. one-third of the total intraoperative and postoperative transfusion requirement could be provided by autologous centrifuged blood. Retransfusion of washed, packed red blood cells freed from cellular debris, heparin and activated clotting factors significantly reduced blood loss during and after surgery. The cell separator is a valuable aid in autotransfusion technique.