[Development of Social Medicine and Public Health in Germany]. / Entwicklungslinien der Sozialmedizin und Öffentlichen Gesundheit in Deutschland.

Social medicine in Germany has multiple lines of tradition, which are marked by the presence of 2 German states and their re-unification and by the (re-)establishment of multidisciplinary public health by the end of the twentieth century. At the same time, a differentiation within the applied fields of social medicine into several thematic topics can be observed. These can be grouped in a first step into the domains of clinical social medicine, of social medicine for social insurance purposes and of a population-oriented social medicine. For social medicine as a scientific discipline within the broad context of medicine, the requirement of a context-adequate development, which encompasses the special methods of multidisciplinary public health, poses big challenges. For successfully meeting these challenges and going beyond population-oriented public health and for bridging the gap between the individual and the social medical institutions of the health system, it is indispensable for social medicine to be independent of other disciplines within the array of medical specialties. The present study argues for strengthening social medicine within the medical faculties. Chairs for social medicine and public health are not only in the interest of the applied fields of social medicine, but represent also an indispensable scientific discipline which can relate and contribute to all specialties of medicine.

[The "Barthel Index": alternative to expertising in compulsory care insurance?]. / Der Barthel-Index: eine Alternative zum Begutachtungsverfahren in der Pflegeversicherung?

Measuring the level of care needed is difficult and since the introduction of nursing care insurance in Germany in 1995 the assessment method applied by the MDK (Medizinischer Dienst der Krankenversicherung) has repeatedly been criticised. The method is very costly and not broadly tested for its validity and reliability. The question arises whether similar results can be obtained by applying another instrument, like the Barthel Index (BI), which is easier to use and more reliable. In this article the authors show - based on a preliminary study in 1999 - that by using the Barthel Index a discriminance analysis will show identical results in 80 % of all cases. The authors regard this identical measurement of care needs, which is reached by scoring only ten items (BI) versus thirty (MDK's assessment method) and with a presumingly higher reliability, as a major progress and reason enough for further discussion and studies of the use of the Barthel Index for care needs assessment.

[Managed care--a possibility for German Health Insurance?]. / Managed care--eine Perspektive für die GKV?

Health services systems in nearly all developed countries face similar problems. This fact raises the question whether concepts used in different countries can be changed without affecting the historically grown foundations of national health services as have been accepted by majority. A group of experts of the German Medical Services of the Statutory Health Insurance were asked to analyse whether the managed care approach could play a substantial role in reforming the German "Bismarck model", given that the advisory responsibility of the social medical service for the sick funds is respected in such a consideration and that basic essentials of the system are maintained. The group concludes, in brief, that managed care and the "German model" are contradictory in respect of preconditions, aims and assumed results. Furthermore, the experts share the view that the "German model" incorporates sufficient to cope with its problems without changing the nature of health services, based on principles of solidarity in Germany. The system needs structural reforms rather than changes in monetary mechanisms.

Poor predictive value of hematocrit and hemodynamic parameters for erythrocyte deficits after extensive elective vascular operations.

Fluid resuscitation and transfusion therapy are particularly critical in patients undergoing extensive vascular operations because of diffuse atherosclerosis and the risk of perioperative myocardial infarction. Sophisticated perioperative monitoring has reduced the mortality rate substantially, but indications for transfusion remain controversial. We determined erythrocyte volume, (EV), total blood volume (TBV) and plasma volume (PV) preoperatively and 18 to 24 hours postoperatively in 41 elderly patients (68.8 +/- 1.3 years) undergoing elective vascular operations (30 abdominal aortic aneurysmorrhaphy, ten aortofemoral bypass and one carotid endarterectomy). EV was measured using 51chromium-labeled autologous erythrocytes; TBV and PV were calculated from EV and total body hematocrit (peripheral venous hematocrit [HCT] x 0.89). Ideal blood volumes were calculated from nomograms based on body surface area and gender. Relationships between body volumes (percentage of ideal), simultaneously measured peripheral venous HCT and hemodynamic parameters heart rate, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index and systemic vascular resistance index were studied by stepwise regression. In 24 patients, blood volumes and hemodynamic parameters were also measured in the recovery room. HCT significantly correlated with EV at all three time periods (p less than 0.001), but the ability of HCT to predict EV in an individual patient was relatively poor (r = 0.50 preoperatively; r = 0.54 in recovery room and r = 0.66 24 hour postoperatively). By 24 hours postoperatively, EV had decreased to 78.3 +/- 2.4 percent of ideal EV (range of 47 to 112 percent). However, only two patients had HCT less than 30 despite the fact that 13 of 41 patients had an EV deficit of greater than 30 percent. No patient had a HCT of less than 25 percent. Hemodynamic parameters did not contribute to the prediction of EV, PV or TBV at any time. Two patients had myocardial infarctions postoperatively associated with 24 hour EV deficits of 18.5 and 29.6 percent. One patient died of a pulmonary embolus. Because of these findings, the concept of a "transfusion trigger" must be viewed with caution, since many patients undergoing vascular operations will have considerable EV deficits despite an "acceptable" HCT.

Influence of medium composition on penicillin V production in a stirred tank reactor.

Penicillin production with a high-producing strain Penicillium chrysogenum was investigated under well-controlled conditions in a stirred tank reactor with complex media containing lard oil and lactose on the one hand, and lactose on the other hand. With lard oil, cell growth and product formation rates were higher, and the production time was shorter by 40 h than without lard oil. On account of the longer production time without lard oil, the amount of beta-lactam compounds was higher (29.93 g l-1), but the mole fraction of the decomposed products (penicilloic acid and penilloic acid) was larger (0.282) than the amount of penicillin V (23.25 g l-1) and the decomposed mole fraction (0.0747) with lard oil. The final product concentrations were about the same (20.86 g l-1 or 35,462 IU ml-1 with lard oil, and 20.43 g l-1 or 34510 IU ml-1 without lard oil). The mole fractions of the by-product (p-OH-penicillin V) were 0.0365 and 0.066. The substitution of lard oil with lactose is possible without a considerable reduction of process performance.

The influence of preculture on the process performance of penicillin V production in a 100-l air-lift tower loop reactor.

The influence of stirrer speed in the third preculture on the performance of penicillin V production by Penicillium chrysogenum in complex medium in a 100-l air-lift tower loop reactor was investigated. The process performance in the main culture was improved by increasing the stirrer speed from 500 to 750 rpm: the pellet size was reduced to half, the cell growth was influenced only slightly, but the production phase was extended considerably, and the final penicillin concentration was increased from 5.1 g l-1 to 10.4 g l-1.

[Measurement of epidemiological facts in dentistry]. / Die Messung epidemiologischer Sachverhalte im Anwendungsfall der Stomatologie.

Recent epidemiological investigations about caries report about phenomenons like "caries increase" or "caries decline". This kind of observation bases on prevalence-studies. But describing such phenomenons does not give the opportunity to explain the observations. For that purpose the modern methodology of epidemiology should be used. Despite of the fact that epidemiology differs exactly between incident and prevalent cases, the use of incidence studies seems to be extremely seldom in stomatology. This paper discusses the problems, which occur in incidence-studies about caries and especially in cohort-studies. The authors show the difficulties to adopt terms like incidence density and cumulative incidence to studies about caries. A proposal is given in order to adopt the modern methodology of epidemiology to the special problem of caries.

[Future needs in health protection and preventive health]. / Aspekte künftiger Gestaltungsbedingungen für den Gesundheitsschutz und die Prophylaxe.

Health protection is a social political program and dosely connected with the social development. It is pointed out that progress in health protection demands progress in social development. One of the main problems of preparing health protection strategies is to assess the numberless risks for health. Because of the fact that risk assessment is full of social implications people have to be involved in assessing risks. Stressing this fact it is concluded that concepts of health protection mainly reflect ideas about people and social life more than ideas about health and illness. Promoting health protection in the GDR four key problems of major concern are summarized: 1) improving information and education, 2) netting the responsibility of the whole society, 3) further progress in socialist democracy and communal life, 4) increasing the role of health protection in the whole social-political activities.

The safety and therapeutic effectiveness of human red cells stored at -80 degrees C for as long as 21 years.

Human red cells frozen by various methods have been stored in the frozen state at -80 degrees C for as long as 21 years. This report discusses: red cells frozen with 42 percent weight per volume (wt/vol) glycerol in an ionic medium in a polyvinylchloride (PVC) plastic bag using the Cohn method; red cells frozen with 45 percent wt/vol glycerol in a low ionic medium in a PVC plastic bag using the Huggins method; red cells frozen with 40 percent wt/vol glycerol in an ionic medium in a polyolefin plastic bag using the Meryman-Hornblower method; and red cells frozen with 40 percent wt/vol glycerol in an ionic medium in a standard 600-ml or an elongated 800-ml PVC plastic primary collection bag with an adapter port using the Naval Blood Research Laboratory (NBRL) method. After frozen storage for as long as 21 years by the four methods described above, the thawed red cells were deglycerolized with 50 to 150 ml of 12 percent sodium chloride and 1.5 to 2.0 l of sodium chloride-glucose or sodium chloride-glucose-phosphate solution. After washing and storage at 4 degrees C for 24 hour, the red cells had a mean freeze-thaw-wash recovery value of 90 percent, a mean 24-hour posttransfusion survival value of 85 percent, a mean index of therapeutic effectiveness of 75 percent, normal or slightly impaired oxygen transport function, and minimal hemolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of pulse oximetry and capnometry in postoperative ventilatory weaning.

We examined the ability of capnometry and pulse oximetry to identify potential respiratory problems by comparing oxyhemoglobin saturation (O2Sat) as measured by pulse oximetry and end-tidal CO2 (PetCO2) with arterial blood gas (ABG) determinations in 40 mechanically ventilated ICU patients. Hemoglobin saturation as measured by pulse oximetry correlated significantly with PaO2 (r = .65, p less than .0001); more importantly, an oximeter O2 Sat less than 95% showed 100% sensitivity in identifying hypoxemia (i.e., PaO2 less than 70 torr). PetCO2 tended to correlate strongly with PaCO2 for individual patients, but not when evaluated as a screening tool for identifying ventilatory abnormalities in the overall group (r = .52, p less than .0001). A PetCO2 less than 26 torr identified hypocarbia (defined as PaCO2 less than 30 torr) with a sensitivity of 85%. However, a PetCO2 of greater than 40 torr predicted hypercarbia (PaCO2 greater than 45 torr) with a sensitivity of only 28%. The efficacy of pulse oximetry and capnometry in monitoring respiratory status during postoperative ventilatory weaning was examined in a subset of 24 patients who had undergone elective cardiac surgery. All patients were weaned by intermittent mandatory ventilation, but each was assigned randomly to either a control group monitored with periodic ABG sampling or to an experimental group, monitored by following PetCO2 and O2 Sat via pulse oximetry. In the experimental group, ABG values were obtained on ICU admission, but thereafter only if a) O2 Sat less than 95%, b) PetCO2 less than 26 or greater than 40 torr, or c) felt to be clinically indicated by ICU staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients.

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Trauma and pulmonary insufficiency: mediators and modulators of adult respiratory distress syndrome.

Adult respiratory distress syndrome is a complex disease resulting in lung dysfunction secondary to a primary nonpulmonary catastrophic event. Many mediators are involved in the destructive chain of events occurring at the cellular level. Investigation of ARDS continues, with efforts directed toward blocking those mediators and thereby alleviating the lung damage and hypoxia once this cascade has been initiated. Even with these advances, however, current optimal therapy is directed toward reversing the primary inciting event and providing the supportive care required to survive the acute episode.

Adult respiratory distress syndrome induced by salicylate toxicity.

Noncardiogenic pulmonary edema induced by salicylate toxicity is becoming a well-recognized entity. However, the diagnosis can be easily missed early in the disease course. We report here adult respiratory distress syndrome (ARDS) in a 54-year-old man found to have salicylate toxicity one day after admission to the alcohol detoxification service at a community hospital. He had been taking one enteric-coated aspirin tablet twice a day for more than one year. He also had a 40 pack-year history of cigarette smoking. The list in any standard medical text of factors triggering ARDS is quite lengthy. Over the past few years, salicylate toxicity has been added to this list. As the case reported here illustrates, it is most important that salicylate toxicity be considered in the differential diagnosis for any patient with acute onset of pulmonary edema and normal cardiac function.