[Availability and integration of palliative medicine at certified lung cancer centers]. / Verfügbarkeit und Integration von Palliativmedizin an zertifizierten Lungenkrebszentren.

BACKGROUND: It is the aim of the certification system for Organ Cancer Centers of the German Cancer Society to ensure that oncology patients receive therapy meeting high quality standards. Lung cancer patients require comprehensive palliative care due to their high symptom load. The purpose of the present study was to identify the existing palliative care structures at 39 certified lung cancer centers. METHODS: The survey tool used was an 18-question questionnaire sent by surface mail to the respective centers. RESULTS: A total of 30 centers took part in the survey. A physician with the additional qualification 'palliative care' was employed at 21 of the centers, a certified palliative care nurse worked at 24 centers. A palliative care unit was available at 9 centers. The cited obstacles to the delivery of palliative care included a shortage of qualified palliative care staff, a lack of refinancing, and the concern that the suggestion of palliative care might cause negative emotions in the respective patients. CONCLUSIONS: Certified lung cancer centers had a wide range of palliative care structures. Openness to and interest in extending existing palliative care services were most commonly identified. A number of serious obstacles in achieving this goal were nevertheless cited.

[Work place health promotion programmes of the statutory German Pension Insurance]. / Betriebsnahe Präventionsprogramme der Deutschen Rentenversicherung.

BACKGROUND: In 2009, the amendment of § 31 Abs. 1 Nr. 2 SGB VI gave the German Pension Insurance the opportunity to provide outpatient medical treatments for insured people who have an occupation with particularly high risk of health. Ever since, the German Pension Insurance has developed various work place prevention programmes, which have been implemented as pilot projects. This article aims at systematically recording and comparatively analyzing these programmes in a synopsis which meets the current state of knowledge. METHODS: We developed an 8 page questionnaire focusing on work place prevention programmes by the German Pension Insurance. This questionnaire was sent to people in charge of all programmes known to us. RESULTS: All programmes have been drafted -across indications. They are aiming at insured people who already suffer from first health disorders but who are not in imminent need of rehabilitation. However, the concrete target groups at which the specific programmes are aimed differ (shift workers, nurses, elderly employees). Another difference between the various programmes is the setting (in- or outpatients) as well as the duration. CONCLUSION: All programmes are using existing structures offered by the German Pension Insurance. They provide measures in pension insurance owned rehabilitation centers. It would be desirable to link these performances with internal work place health promotion and offers of other social insurances.

VCSEL-based, high-speed, in situ TDLAS for in-cylinder water vapor measurements in IC engines.

We report the first application of a vertical-cavity surfaceemitting laser (VCSEL) for calibration- and sampling-free, high-speed, in situ H2O concentration measurements in IC engines using direct TDLAS (tunable diode laser absorption spectroscopy). Measurements were performed in a single-cylinder research engine operated under motored conditions with a time resolution down to 100 µs (i.e., 1.2 crank angle degrees at 2000 rpm). Signal-to-noise ratios (1σ) up to 29 were achieved, corresponding to a H2O precision of 0.046 vol.% H2O or 39 ppm · m. The modulation frequency dependence of the performance was investigated at different engine operating points in order to quantify the advantages of VCSEL against DFB lasers.

[Empirically derived recommendations for measuring patient-reported change in rehabilitation studies]. / Empirisch gestützte Empfehlungen für die patientenberichtete Veränderungsmessung in der medizinischen Rehabilitation.

Diverse methods are available for evaluation of (medical) interventions. In each case one has to decide on a specific method. Our aim was to analyze typical problems involved in the measurement of change. Different methods are delineated, and their specific pros and cons are set out. Subsequently, empirically derived recommendations are outlined on which method should be employed for which problem and under which circumstances. A characteristic of rehab treatment is that as a rule a multitude of problems are addressed, and accordingly, treatment goals are heterogenic. Straightforward recommendations for one or the other method cannot be given.

[Use of trajectories for measuring change in medical rehabilitation: a contribution toward comparison of different methods of outcome measurement]. / Verwendung von Verlaufstypen zur Veränderungsmessung in der medizinischen Rehabilitation: Ein Beitrag zum Vergleich verschiedener Methoden der Ergebnismessung.

OBJECTIVE: The question of which methods should be used to assess the effects of medical rehabilitation has a long and controversial history. With regard to this background the project "Outcome measurement in medical rehabilitation" aimed at developing a better understanding of the process of change and its assessment. We also looked into possible causes for discrepancies between the results of direct and indirect measures of change. Aims of our study were: (1) to picture trajectories of change in a simple and descriptive way, (2) to compare the resulting solutions, (3) to highlight relations with direct measurement of change and/or global estimation of effects, (4) to compare the predictive value of different measurements of change. METHODS: We used available data from rehabilitation research which covered direct and indirect measurement of change as well as global measurement of effects and which therefore enabled us to compare different methods of outcome measurements. The well documented record includes data from n=466 patients with chronic back pain. Different trajectories (3 and 5 groups) were defined using their pre/post data. RESULTS: Depending on limits chosen for positive or negative courses and chosen outcome 20% to almost 40% of the patients showed improvements over the follow-up period. About the same percentages changed for the worse. However, two-thirds of the patients improved at least in one outcome. Compared with those, who did not experience improvements in any outcome, this group indicated better global rehabilitation effects. The different types of trajectories (3 and 5 groups) substantially contribute to the explained variance of catamnestic status at 12 months beyond other predictors as well as beyond initial status. The same applies to the prediction of disability days. CONCLUSION: The description of trajectories of change yields useful results. In contrast to complex statistical methods we were able to identify groups of patients that can easily be described.

["Scores of Independence for Neurologic and Geriatric Rehabilitation (SINGER)" - development and validation of a new assessment instrument]. / "Selbständigkeits-Index für die Neurologische und Geriatrische Rehabilitation (SINGER)" - Entwicklung und Validierung eines neuen Assessment-Instruments.

In the context of developing and testing a procedure for "Outcome-oriented payment for rehabilitation after stroke", we found that the instruments commonly used to measure the outcomes of rehabilitation after stroke (e. g., Barthel-Index or FIM) were not meeting the special requirements of the new payment system. Therefore the "Scores of Independence for Neurologic and Geriatric Rehabilitation" (SINGER) was developed as a new assessment instrument. This instrument is based on the ICF and measures 20 aspects of "independence in activities of daily living". The characteristic feature of the SINGER is, above all, the way all items are graded in 6 steps: the gradation does not refer to the degree of disability but to the kind and amount of help required for the respective activity, i. e.: 0 = totally dependent on professional help; 1 = professional contact help needed; 2 = contact help by (instructed) lay persons sufficient; 3 = preparation or supervision by lay persons still needed; 4 = independent with assistive device or still slow; 5 = independent without assistive device. For experienced personnel in neurologic rehabilitation, these gradations are "intuitively plausible". A manual moreover describes each grade in detail for each item so that the instrument can be used in rehabilitation facilities without extensive training. The SINGER has been tested and validated in a pilot study (n = 100) and in 2 subsequent studies with large case numbers in neurologic rehabilitation (n = 1058 and n = 700 patients after stroke in all categories of severity). Factor analyses showed that the instrument contains 2 dimensions which can be interpreted as "physical activities" and "activities of communication and cognition". Each of these 2 dimensions can be split into 2 sub-dimensions that can be assigned to the tasks of therapeutical professions in care/Occupational Therapy, physiotherapy, logopedics, and neuro- psychology. The test criteria of reliability, sensitivity, convergent validity, floor and ceiling effects as well as sensitivity to change show good to very good results. Particular emphasis can be given to the high degree of interrater reliability and the wide range of possible applications in clinical practice as well as in research. A limitation of the instrument to be taken into account is the fact that the SINGER has not yet been tested and validated in geriatric rehabilitation facilities.

[Rehabilitation from the patient perspective--a qualitative analysis of the treatment beliefs of patients in inpatient orthopedic and psychosomatic rehabilitation]. / Rehabilitation aus Patientensicht--Eine qualitative Analyse der subjektiven Behandlungskonzepte von Patienten in der stationären orthopädischen und psychosomatischen Rehabilitation.

PURPOSE: As the common sense self-regulation model (CSM) was further developed in the late 1990s, its focus was, along with subjective illness perceptions, the treatment representations of patients, in particular medication-related perceptions. However until now, only few studies have dealt with subjective concepts regarding non-medication treatment. The objective of this study was to explore the core content areas of the treatment concept of rehabilitation patients as a basis for developing a questionnaire to survey rehabilitation-related treatment beliefs. METHODS: In 5 inpatient rehabilitation centres for psychosomatic and musculoskeletal diseases, guided focus groups were conducted with a total of n=25 rehabilitation patients. Some 56% of the participants were female; the average age was 52.8 years (SD=10.8). The interviews were transcribed and analyzed using the computer programme Atlas.ti based on the method recommended by Mayring in a multi-stage qualitative content analysis procedure. RESULTS: In the analysis of the discussion transcriptions, a total of 579 patient statements were categorized with 49 codes that were assigned to the areas (1) expectations and beliefs with respect to the rehabilitation process, (2) expectations of results, and (3) fears associated with rehabilitation. The process expectations were the most frequently discussed topic, constituting 58.2% of all patient statements. It was found that the patients associate not only numerous individual treatments with rehabilitation but also have concrete perceptions about the specific form rehabilitation should have, their own role in the rehabilitation process, and features of the overall rehabilitation concept. The outcome expectations are related to the areas activities of daily life and job, psyche, soma, and effectiveness of rehabilitation. Fears with respect to rehabilitation generally played only a subordinate role for those surveyed. The indication-specific analyses showed that the perceptions regarding the realization and form of rehabilitation differed among the various diagnosis groups, but the patients named similar categories for expectations of results and fears, with only some variation in importance. CONCLUSION: The focus groups allowed good insights into the patient perspectives of rehabilitation. Simultaneously, a good basis was created for generating contents of items for a questionnaire on the rehabilitative treatment concept, so that along with literature analyses, the qualitative method proved to be a suitable approach and good source for developing a questionnaire.

[Development, implementation and use of an intervention procedure for providing needs-based patient information for rehabilitation patients]. / Entwicklung, Implementierung und Umsetzung einer Intervention zur bedarfsgerechten Patienteninformation für Rehabilitandinnen und Rehabilitanden.

PURPOSE: Patients have a great need for information that is often not satisfied by providing "standard" information. In order to reach the patients better, it is increasingly necessary to tailor patient information to the individual needs of patients and make stronger use of patients' "common sense" models. This article reports on the development and implementation of an intervention procedure for providing needs-based patient information as well as on initial results of its use. METHODS: Both the intervention concept and the operationalization of its contents are based on the common sense self-regulation model (CSM). The intervention aims to link the information given to patients to the existing illness beliefs and treatment beliefs of the rehabilitation patients. To do this, the illness and treatment representations held by the patients before rehabilitation are assessed, automatically analyzed using a computer programme, and aggregated in a "response questionnaire". This feedback is then passed on to the information-providing therapists well in advance of admission of the rehab patients. The contents and key organizational data of the intervention procedure were discussed with the treatment providers in a feasibility analysis before implementation. In addition, intervention training was also conducted before the start of the intervention. Since August 2009 the procedure has been implemented and evaluated in 9 cooperating rehab centres. Process documentation provides criteria relative to the feasibility of the intervention. RESULTS: The results on implementation of the intervention as well as on its feasibility have thus far been relatively encouraging. The treatment providers ascribe high relevance to the contents of the intervention and assess the major components to be generally feasible. From the treatment provider viewpoint, the rehabilitation patients benefit from the intervention, and it is also considered to be helpful for planning further treatment. CONCLUSION: The intervention procedure for needs-based patient information presents an option for making information available to patients as needed. It is based on theory and accepted by treatment providers. The strengths and weaknesses of the intervention are discussed.

[Development of a questionnaire to assess treatment representations in rehabilitation patients]. / Entwicklung eines Fragebogens zur Erfassung des subjektiven Behandlungskonzepts von Rehabilitanden.

PURPOSE: The purpose of the study was to develop a generic questionnaire for assessing the patients' rehabilitation treatment representations on the theoretical basis of the Common Sense Model of self-regulation and analogous with established assessment instruments for illness representations and medication-related treatment representations. METHODS: Using theory-based and empirical patient and provider input, a pool of 115 items on the patients' rehabilitation treatment representations was generated. The items were first pre-tested on n=182 rehabilitation patients in nine rehabilitation centres for the indications musculoskeletal diseases and psychosomatic illnesses. The next step was the factor analytical reduction of the item pool. The resulting factors were analyzed for unidimensionality, and the remaining items were analyzed for distribution of values. Internal consistency and the "known groups validity" were used to determine reliability and validity, respectively. Finally, patient acceptance of the questionnaire was assessed. RESULTS: The item pool was considerably reduced by factor analysis and the remaining items were grouped under four factors. After eliminating other single items on the basis of modification indices and indicator reliability, the unidimensionality of these factors was assessed as good. The majority of the remaining 23 items showed an asymmetrical distribution, which was also reflected by low item difficulty. The contents of the scales can be interpreted as "somatic outcome expectation", "psychological outcome expectation", "process expectations", and "concerns". The internal consistency of the scales (Cronbach's alpha) lies between 0.80 and 0.84 for the entire sample. The treatment representations for psychosomatic patients differ in the anticipated direction from those of orthopaedic rehabilitation patients. Patient acceptance of the questionnaire was very positive. CONCLUSION: The questionnaire developed allows aspects of the patients' rehabilitation treatment representations to be measured, the features of which are highly relevant for providers as a basis for providing individualized patient information. However, the results of the pretest have to be tested confirmatory and also indicate that there is still potential for improving the instrument and making it more precise.

[Quality assurance in outpatient medical rehabilitation - concept and results of a pilot project to develop a quality assurance programme for musculoskeletal and cardiac diseases]. / Qualitätssicherung in der ambulanten medizinischen Rehabilitation: Konzeption und Ergebnisse eines Pilotprojekts zur Entwicklung eines Qualitätssicherungsprogramms für die Indikationsbereiche muskuloskeletale und kardiologische Erkrankungen.

PURPOSE: The concept and results of a pilot project to develop a quality assurance programme for outpatient medical rehabilitation in musculoskeletal and cardiac diseases are discussed. The processes developed and the results that were achieved using the instruments in 24 pilot institutions are described. METHODS: The quality of structure was assessed by defining and applying basic and detailed criteria; a version of peer review for outpatient treatment was developed to test the quality of process. The quality of results was determined by means of a prospective study with two or three measurement times and implementation of generic and disease-specific measurement instruments. The process was tested on n=1475 patients with musculoskeletal diseases and n=843 patients with cardiac diseases. RESULTS: The level of the quality of structure in the participating centres is quite high; 89-93% of the structure features required were fulfilled. The peer review indicated that the process had 25-40% serious shortcomings in cardiology and 15-20% for musculoskeletal diseases. The quality of results measurements show that the participating outpatient rehab centres achieved medium effects for the majority of the core rehab dimensions for the respective indications, but the findings also showed that at the time the follow-up reports were made there was often a reduction of positive effects and high effects were quite rare. While there were marked differences in quality of structure and process among the various institutions, there were only slight differences among the outpatient centres regarding quality of results. CONCLUSIONS: A scientifically sound quality assurance programme was developed that covers specific aspects of outpatient rehabilitation, to a great extent using the same structures that have been implemented in the quality assurance programmes for inpatient treatment. To implement the results presented here, the scientific findings will need to be evaluated in the respective committees of the cost-carriers. The tests of the programme in 24 pilot institutions showed an overall high level of quality, but also revealed potential for improvement in some areas.

The effect of low intensity pulsed ultrasound applied to rabbit tibiae during the consolidation phase of distraction osteogenesis.

The purpose of this study was to determine if low intensity pulsed ultrasound (LIPU) accelerated the maturation of regenerate bone when applied after distraction in a rabbit model. A mid-tibial osteotomy was performed in 26 New Zealand white rabbits and an external fixator applied anteromedially. After a seven day latency period, the tibiae were distracted 0.5 mm every 12 h for 10 days. Thirteen of the rabbits received LIPU for 20 min/day (treatment group) and 13 received sham LIPU (control group) from day 17 until sacrifice on day 37. Radiographs were taken weekly after distraction and the total and mineralized areas of the callus were measured. After sacrifice, dual-energy X-ray absorptiometry, torsional testing to failure, and histomorphometry were performed. Ultrasound-treated tibiae were a mean of 68.8 +/- 3.8% as stiff as and 68.2 +/- 6.0% as strong as the contralateral tibiae. Control tibiae were 78.7 +/- 7.0%, as stiff as and 70.2 +/- 7.9% as strong as the contralateral tibiae. The differences in stiffness and strength were not significant (p = 0.39 and 0.81, respectively) with the number of the animals tested in the study. The treatment group was 91.6% as dense as the contralateral side and the control group was 88.5% as dense as the contralateral side (p = 0.84). Radiographs revealed a significantly larger callus in the LIPU-treated tibiae at 1, 2 and 3 weeks after distraction compared to control tibiae (p < 0.01, 0.008 and 0.05, respectively). Histomorphometry revealed significantly less fibrous tissue in the LIPU-treated tibiae (p < 0.05) and a strong trend towards more bone in the LIPU-treated tibiae compared to controls (p = 0.06). LIPU was found to increase the size of the distraction callus and it might alter the composition of regenerate bone but it did not have a positive effect on the mechanical properties or density of regenerate bone when applied during the consolidation phase of distraction osteogenesis.

[Early ambulation and rehabilitation following heart surgery from the viewpoint of the cardiologist for adults]. / Frühmobilisation und Rehabilitation nach Herzoperation aus der Sicht des Erwachsenenkardiologen.

Traditional concepts about the early phase of postoperative remobilization after cardiac surgery favor physical inactivity--as did earlier concepts for rehabilitation after myocardial infarction like the armchair treatment philosophy. For an overwhelming majority of our patients, however, this concept does not hold, according to our experience during the last decade. In contrast, we propose a model of stepwise mobilization and rehabilitation starting the first postoperative days. At the end of the first week most patients are able to climb staircases. In the second week group physical therapy can be started. At the 14th postoperative day, discharge from the surgical ward is warranted. During this step of early mobilization some exceptions have to be made and some special aspects have to be considered. Early mobilization must be postponed in patients with overt heart insufficiency, a low ejection fraction, complex ventricular arrhythmias or pericardial effusions. Cautious mobilization is also required in patients with mitral valve replacement and persistent elevation of pulmonary pressure and resistance. This holds also for patients with valve replacement during acute endocarditis, patients with repair of a dissecting aneurysm of the aorta and patients with perioperative myocardial infarction. The stage of early postoperative mobilization usually ends after the second week and is followed by the next step, the rehabilitation phase during weeks 3 to 6. The goals of the rehabilitation program are; increasing the physical fitness of the patient, thereby increasing his self-assurance and self-esteem; establishing a health-education program, increasing the patients health competence and his coping capacities.(ABSTRACT TRUNCATED AT 250 WORDS)