[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]. / Komplexfallpauschalen in der Herzchirurgie--ein Modellprojekt zur Frührehabilitation.

BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

Effect of an exercise training program on endothelial dysfunction in diabetic and non-diabetic patients with severe chronic heart failure.

BACKGROUND: Endothelial dysfunction is found both in patients with chronic heart failure and in patients with insulin-treated type 2 diabetes mellitus. This endothelial dysfunction leads to a significant reduction in endothelium-derived vasodilation. Physical exercise can have a positive effect on endothelial dysfunction in patients with coronary artery disease, chronic heart failure and diabetes mellitus. It is not clear, however, whether an exercise program influences endothelial function in diabetics with chronic heart failure. Our study was thus aimed at investigating whether a special exercise program would affect endothelial function. Comparisons were made with insulin-treated type 2 diabetics and with non-diabetics suffering from chronic heart failure. METHODS: 42 patients with severe chronic heart failure (LVEF < or = 30%), insulin-dependent diabetics (n=20, mean age 67+/-6 yrs, 16 male, 4 female), non-diabetics (n=22, mean age 68+/-10 yrs, 20 male, 2 female) participated in a 4-week exercise program consisting of ergometer and special muscle strength training. Before (T1) and at the end (T2) of the training program endothelium-dependent and endothelium-independent vasodilatory capacity were assessed by brachial artery diameter measurement. RESULTS: At the end of the training program, there were no significant results within the two groups. The endothelium-dependent vasodilation changed between T1 and T2 as follows: In the diabetic group, the endothelium-dependent vasodilation at T1 and T2 was 5.1+/-3.6 and 4.9+/-2.5%, respectively. For the non-diabetics, the endothelium-dependent vasodilation was 6.8+/-4.5 and 7.6+/-4.0% at T1 and T2, respectively. The endothelium-independent vasodilation in the diabetics was 10.5+/-5.6 at T1 and dropped to 8.7+/-4.1% at T2. The results for the non-diabetics were 13.2+/-5.8 and 12.3+/-6.3% at T1 and T2, respectively. The LVEF in the diabetics was 24.2+/-3.4% at T1, increasing to 27.8+/-5.8% at T2. In the non-diabetics, the LVEF was 22.9+/-3.8 at T1 vs. 28.6+/-6.9% at T2. In the groups of diabetics, the maximum oxygen uptake (VO2-max) was 10.3+/-3.9 at T1 vs. 11.4+/-2.8 ml/kg/min at T2 and in the group of non-diabetics 10.0+/-3.1 vs. 13.5+/-5.0 ml/kg/min. No correlations were found between the change in endothelium-dependent vasodilation and the increase in oxygen uptake. CONCLUSION: In our study, a program of physical exercise had no influence on endothelium-dependent or endothelium-independent vasodilation in insulin-treated type 2 diabetics or in non-diabetics with considerably reduced ejection fraction. In both groups, however, an exercise-related influence on medical parameters and physical performance could be observed.

Effects of education, self-care instruction and physical exercise on patients with chronic heart failure.

BACKGROUND: Evidence is now evolving of the importance of team management for patients with chronic heart failure. This includes education, patient self-care and physical exercise training. How such programs should be implemented is still under discussion. AIM: To assess the efficacy of an in-hospital rehabilitation clinic-based program, we studied its influence on cardiopulmonary parameters and quality of life in an outpatient setting. METHODS AND RESULTS: 75 patients (62 male, 13 female, mean age 65+/-8 years) underwent an exercise program including education, bicycle ergometer, muscle strength training and the 6-min walk test as a training unit for 4 weeks. Patients were studied at baseline (T1), before discharge (T2) and after a follow-up period of 29.9+/-5.5 weeks (T3). Baseline data (T1): left ventricular ejection fraction (LVEF): 33.8+/-7.6%, left ventricular end-diastolic volume (LVEDV): 130+/-51 ml, peak VO(2): 12.3+/-4.3 ml/kg, maximum work load (Watt max): 71+/-27 W. At discharge (T2) and follow-up (T3) LVEF increased to 36.8+/-8% and 41.8+/-9.2%, LVEDV decreased to 127+/-43 ml and 114+/-40 ml, peak VO(2) increased to 14.1+/-5.1 ml/kg and 15.2+/-5 ml/kg, and Watt max increased to 84+/-28 Wand 98+/-42 W (all p<0.01). Quality of life improved significantly at discharge and follow-up in nearly all domains and in the summary score for physical health. There were no significant changes for anxiety and depression at T2 and T3. CONCLUSION: A specialized in hospital rehabilitation program including education, patient self management and training has a sustained positive effect on cardiopulmonary parameters and physical well-being.

Loss of function of the tissue specific transcription factor HNF1 alpha in renal cell carcinoma and clinical prognosis.

BACKGROUND: Human renal cell carcinogenesis is associated with loss of expression of tissue-specific genes and loss of function of tissue-specific transcription factors such as HNF(hepatic nuclear factor)1 alpha. MATERIALS AND METHODS: In this study HNF1 alpha DNA-binding activities and protein amounts were determined by gel retardation assay and Western blot analysis, respectively, in 42 non-metastasized renal cell carcinomas and paired normal tissues. RESULTS: 36 tumors out of 42 (86%) showed diminished binding activity of HNF1 alpha. In most cases (26 out of 42) this appeared to be due to decreased amounts of HNF1 alpha protein, but 10 tumors contained equal or even higher amounts of HNF1 alpha, in spite of reduced binding to DNA. Only 6 tumors out of 42 had unaltered HNF1 alpha binding activity. A clinical follow-up was obtained for 40 patients. Over an average follow-up period of 39 months no significant differences in the survival rate were observed between patients having lost or retained HNF1 alpha function. However, since most of the patients with retained function are still alive, long-term follow-up might be warranted. CONCLUSIONS: The very high incidence of loss of HNF1 alpha function indicates the important biological role of this change in renal cell carcinoma.