Geriatric assessment in the inpatient sector : 20 years quality assurance of the Geriatrics in Bavaria Database.

BACKGROUND: Geriatric assessment is an integral part of geriatrics and leads to various improvements in the treatment of geriatric patients. MATERIAL AND METHODS: Analysis of assessment data and patient characteristics in a large inpatient geriatric patient population. Evaluation of data from the Geriatrics in Bavaria Database (GiB-DAT) over 20 years as well as a cross-sectional study from 2020. Presentation of data for patients in inpatient acute geriatrics as well as continuing geriatric rehabilitation. RESULTS: The number of patient records and participating hospitals has steadily increased for both inpatient care types to 821,913 (status 31 March 2021). The Barthel index and other assessment results show differentiated values between acute geriatrics and continuing geriatric rehabilitation. CONCLUSION: The results demonstrate the differences in patient outcomes between the two types of care as well as changes in the setting over time. The constancy of the applied assessment instruments contributes to the comparability of the different hospitals; however, it is necessary to introduce new and alternative assessment instruments and to further develop inpatient geriatrics.

[Effectiveness of geriatric rehabilitation in the oldest old: evaluation of South German observational data]. / Wirksamkeit geriatrischer Rehabilitation bei Hochbetagten : Eine Auswertung süddeutscher Versorgungsdaten.

BACKGROUND: Geriatric rehabilitation might be the only way for the very old to maintain their participation in social life, since in many cases self care, everyday skills and basic activities of daily living can only be recovered by an integrative treatment approach using a multiprofessional team setting. At the same time limited financial resources in health care have to be considered to make appropriate allocation decisions in geriatric rehabilitation. PURPOSE: The goal of this work was to determine whether chronological age is a limiting factor for functional outcome in geriatric rehabilitation. MATERIALS AND METHODS: Data from the state of Baden-Württemberg (KODAS data set) from the years 2005-2011 for nonagenarians and data for centenarians from the Geriatrics in Bavaria database (GiB-DAT) project from the years 2003-2011 were compared to the data of the younger seniors undergoing geriatric rehabilitation. For the KODAS data collection, 31 geriatric rehabilitation clinics in Baden-Württemberg were involved. The GiB-DAT project included 59 geriatric rehabilitation clinics in Bavaria. Both databases compare the results of the geriatric assessment at the beginning and at the end of geriatric rehabilitation. RESULTS: The analyzed data are presented with regard to the functional outcome in the very elderly and are discussed with respect to policy implications.

[Geriatrics for internists in primary care]. / Geriatrie in der ambulanten Versorgung durch hausärztlich tätige Internisten.

Internal medicine specialists involved in primary care will have a leading part in the treatment of geriatric patients with complex healthcare needs in the future. Approved models like specialized geriatric practices, ambulant or mobile geriatric rehabilitation and special geriatric services for nursing homes are available. Essential is a geriatric qualification that fits with the tasks of an internist in primary care. An incentive payment system has to be created for this purpose to improve the treatment of elderly patients.

[Geriatric rehabilitation. Inpatient, day patient and outpatient]. / Rehabilitation in der Geriatrie. Stationär, teilstationär und ambulant.

Geriatric rehabilitation is a cornerstone of every treatment plan in elderly persons in the inpatient, day clinic and outpatient settings. Geriatric patients tend to be more in need of care and to have a loss of domestic independence due to multimorbidities. The goal of geriatric rehabilitation is to preserve and/or restore the disease-related functional deficits in order to guarantee mobility and activities of daily living (ADL) in addition to curative treatment. Structural prerequisites in all geriatric units are the comprehensive geriatric assessment (CGA) and the existence of an interdisciplinary geriatric team. Geriatric rehabilitative treatment is based on functionality (ICF) and is therefore indicated in a wide spectrum of diseases. The demographic shift necessitates an increase in geriatric treatment structures with innovative concepts such as geronto-traumatological interdisciplinary units or geriatric outpatient office groups with a better networking of different care structures.

[Economic consequences of complications in abdominal and thoracic surgery in the German DRG payment system]. / Betriebswirtschaftliche Bedeutung von Komplikationen in der Viszeral- und Thoraxchirurgie im DRG-System.

BACKGROUND: The Surgical Department of the University Hospital Grosshadern has been making a systematic record of complications since 2005. With respect to the ongoing problem of under-financing from DRG reimbursements, an analysis of the relationship between surgical cases with severe complications and insufficient reimbursement warranted a detailed analysis. MATERIAL AND METHODS: Out of 16 762 in-house patients during 2005-2007 we assigned 6707 cases into four divisions - hepato-pancreato-biliary, colorectal, minimal invasive and general abdominal surgery as well as 1469 cases of thoracic surgery, for costs and reimbursement. In all groups patients with mandatory treament of complications were compared to the remaining cases without complications. Within these, further subgroups were analysed: patients with a need for artificial ventilation (partition A of the G-DRG system), cases with excessive loss (underfunding above 10 000 Euro) and their intersections. RESULTS: With the exception of minimal invasive surgery, each division featured 10-15 % of serious complications. Losses for these cases ranged from 159 % (thoracic surgery) to 102 % (other abdominal surgery) of the overall loss in each division. Cases with excessive losses, representing 1.5 % of all patients, caused 80 % to 100 % of this deficit. Complicated cases alloted to DRGs for artificial ventilation still represented 50 % of the under-fund-ing. CONCLUSION: Cases with mandatory complication treatment can be discerned as separate economic entities. They are considerably overlapping cases with excessive underfunding, so further analysis might lead to an improved reimbursement policy. In addition, the connection between quality management and economic efficiency is highlighted.

Molecular monitoring of inactivation efficiencies of bacteria during pulsed electric field treatment of clinical wastewater.

AIMS: The applicability of an alternative wastewater disinfection concept based on the pulsed electric field (PEF) treatment is tested with molecular biology techniques using clinical wastewaters. METHODS AND RESULTS: Hospital wastewater was treated with the PEF technology. The inactivation efficiencies of bacteria were successfully monitored with real-time polymerase chain reaction (PCR). As the differentiation between living and dead bacterial cells is important for the determination of the disinfection efficiency, propidium monoazide (PMA) was applied. PMA selectively penetrates cells with compromised membranes and intercalates into the DNA inhibiting a subsequent PCR amplification. The rates of reduction were examined for specific pathogens and wastewater populations using PCR-denaturing gradient gel electrophoresis. The results showed that the main part of the bacterial population could be inactivated efficiently with the PEF treatment. Moreover, it was demonstrated that naturally occurring nuclease activities were not affected by the PEF treatment in contrast to a thermal treatment. CONCLUSIONS: The results indicated that the PEF treatment is an appropriate alternative disinfection concept for the treatment of clinical wastewaters and surpass the disadvantages of other disinfection methods. SIGNIFICANCE AND IMPACT OF THE STUDY: With the use of propidium monoazide for live-dead distinction, a new concept could be developed for the evaluation of disinfection methods.

Putting the pieces together: using "off-the-shelf" software to safely transfer medical data.

We describe a new computer-based, network-driven system for administering, transferring, and evaluating reports of spontaneous adverse drug reactions and serious adverse events. The system consists of three regional centers, one coordinating center, and a central database at the national drug regulatory authority. In view of its high level of data security, reliability, easy expandability, and inexpensiveness due to the use of standard shareware products, the system can serve as a model for a clinical health information network.

First results from an intensified monitoring system to estimate drug related hospital admissions.

AIMS: An intensified monitoring system was set up to identify drug related hospital admissions and estimate population-based incidences for commonly prescribed medications. METHODS: Pharmacovigilance-centres systematically screened nonelective admissions to emergency rooms or departments of internal medicine for drug related hospitalizations (DRH). Clinical pharmacologists used standardized causality assessment. Service areas of each acute care hospital were defined by 5 digit postal codes that covered 60% of all admissions. Drug dispensing information was available through claims processed by regional pharmacy computing centres. Quarterly incidences were estimated by dividing the number of events by the number of treated patients. RESULTS: 435 DRHs were reported during five quarters. The incidence of ADRs leading to admissions varied for specific drug groups from 1.5/10 000 treated patients to 24/10 000. Quarterly variation of incidences was moderate except for insulin and calcium antagonists. 95% confidence intervals overlap for all quarters within each group. Incidences are sensitive to changes in the definition of the source population. CONCLUSIONS: Our pharmacovigilance monitoring system allows comparisons of population-based incidences of drug-related hospitalizations among drugs and over time. It provides important information for risk management and monitoring outcomes of pharmaceutical quality management programmes.

Regional reporting of adverse drug reactions: a new computer-based network.

The use of drugs is always accompanied by the risk of adverse drug reactions (ADRs) and adverse events (AE). Generally physicians, pharmaceutical manufacturers, and pharmacists use a paper-based form for sending spontaneous ADR and AE reports to the national drug regulatory authority. Besides underreporting, reporting lag-time and errors through data transformation are a major issue. In order to improve the current reporting situation we have set up a new computer-based, network-driven system for storing, transferring, and evaluating ADR reports. The system consists of three regional centres, one coordinating centre, and the central ADR database of the national drug regulatory authority. In the regional centres, clinical pharmacologists collect ADR data in local databases. There is a comfortable user-interface with an online help-function available. New reports are sent automatically to the Federal Agency using EUROSCAPE as a standardized electronic report form of the EU. The coordinating centre in Munich is responsible for overall performance and quality assurance. This model for a clinical health information network is of a high level of data security, is reliable and easily expandable through the use of standard tools, is fast and also inexpensive by using standard shareware products.

Osteoporosis-pseudoglioma syndrome, a disorder affecting skeletal strength and vision, is assigned to chromosome region 11q12-13.

Osteoporosis-pseudoglioma syndrome (OPS) is an autosomal recessive disorder characterized by severe juvenile-onset osteoporosis and congenital or juvenile-onset blindness. The pathogenic mechanism is not known. Clinical, biochemical, and microscopic analyses suggest that OPS may be a disorder of matrix homeostasis rather than a disorder of matrix structure. Consequently, identification of the OPS gene and its protein product could provide insights regarding common osteoporotic conditions, such as postmenopausal and senile osteoporosis. As a first step toward determining the cause of OPS, we utilized a combination of traditional linkage analysis and homozygosity mapping to assign the OPS locus to chromosome region 11q12-13. Mapping was accomplished by analyzing 16 DNA samples (seven affected individuals) from three different consanguineous kindreds. Studies in 10 additional families narrowed the candidate region, supported locus homogeneity, and did not detect founder effects. The OPS locus maps to a 13-cM interval between D11S1298 and D11S971 and most likely lies in a 3-cM region between GSTP1 and D11S1296. At present, no strong candidate genes colocalize with OPS.

[The mid-growth spurt--a pre-puberty growth spurt. Review of its significance and biological correlations]. / Der Mid-Growth-Spurt (MGS)--ein präpubertärer Wachstumsschub. Uberblick über seine Bedeutung und mögliche biologische Zusammenhänge.

The MGS is a growth phenomenon during early childhood, expressed by a mild transitory acceleration of growth velocity between five and eight years of age. It appears to be more pronounced in boys than in girls. It is probably caused by the functional maturation of the adrenals ("adrenarche") which leads to an increased androgen production during this age. Interactions with the pituitary growth hormone, also presenting with increased secretion rates at this particular period, are very probable. A hypothesis is offered for the explanation of individual differences and distinctness of the MGS. Although the MGS cannot be interpreted as a very first step of puberty, some additional biochemical facts suggest fundamental changes in the organism. Therefore, the MGS could be regarded as a "marker" within the biological development of the child.

A computer program for drawing structure formulas of the hormonal steroids used most frequently in endocrinology.

A BASIC program has been developed for plotting planar structure formulas of steroid hormones. The structure formulas can be designed either by selecting distinct root-molecule shapes for further figuration of the wanted formula, i.e. androstane, 4-androstene, estrogen, cholestane, pregnane or 4-pregnene structures, or by editing detailed information concerning the molecule to be designed, starting with the number of carbon atoms, etc. The position of hydroxy and/or keto groups, as well as some stereochemical details, are also freely selectable according to the systematic steroid name. Graphs are displayed on the screen and can be printed. The program is supported by most of the conventional BASIC versions running on personal computers with graphic abilities, since graphic symbols are predominantly used for drawing the structure formulas instead of lettering the symbols.

The osteoporosis pseudoglioma syndrome. Update and report on two affected siblings.

Two siblings (male, 29 years, and female, 13 years) with the rate autosomal recessive osteoporosis pseudoglioma syndrome are reported in detail. All essential signs and symptoms of the full clinical picture were present and are documented by impressive X-ray pictures. Some aspects of our patients are compared with relevant findings of previous reports. Collagen studies (skin biopsies) failed to reveal any significant disorder of the main collagen types composition. Striking similarities with established genetic disorders of collagen (like the osteogenesis imperfecta group and the Ehlers-Danlos syndrome) suggest, however, that the OPS could be a primary collagen disorder. Genetic counselling and devoted socio-medical care for these handicapped children is presently the only help which can be offered.

Familial pseudohypoaldosteronism.

The clinical course of two siblings with a severe form of pseudohypoaldosteronism was followed over a period of seven and five years respectively. Both children persistently had a high sodium-potassium excretion ratio in the urine, sweat, saliva, and stools as well as high serum concentrations of aldosterone and renin and an increased urinary excretion of tetrahydroaldosterone. Despite sustained treatment with sodium chloride (10-40 mmol/kg/d) and cation exchange resin (sodium polystyrole sulfonate 0.5-2 g/kg/d) they repeatedly developed episodes of salt wasting and hyperkalemia which occurred mainly during uncomplicated respiratory tract infections. Aldosterone receptor characteristics were studied in the cytosol of the rectal mucosa at ages 2.5 years and 6 months respectively. Compared to age matched controls there was a decreased affinity for aldosterone at the low affinity binding site. Among the members of the family, the father and one of his sisters had high concentrations of sodium in the sweat and an increased urinary excretion of tetrahydroaldosterone.

Radio gas chromatography for evaluation of sub-cellular hormone synthesis in the androgen insensitivity syndrome.

This paper gives a description of a radio gas-liquid chromatographic method for the evaluation of androgen hormone synthesis patterns in the testicular tissue of a patient suffering from the androgen insensitivity syndrome (AIS). A modified dual-column gas chromatography system, equipped with column switching facilities and a radioactivity monitor run parallel to a flame ionisation detector, enables the monitoring of radioactive intermediates of testosterone anabolism and catabolism, generated from a labelled precursor. Tissue preparations were incubated with tritiated pregnenolone for 45 min at 37 degrees C. Steroid hormones were stripped from the aqueous phase by solvent extraction and analysed by gas chromatography as methoxitrimethylsilyl (MO-TMS) derivatives on a 15 m X 0.32 mm I.D. fused-silica capillary column coated with DB-5. The results reveal abnormal enzyme kinetics due to accelerated precursor utilisation. The findings reflect the pathophysiology of AIS at the sub-cellular level of the androgen hormone target organ.

The subcellular defects in the androgen insensitivity syndrome.

The androgen insensitivity syndrome (AIS) was studied with consideration of the complexity of mechanisms involved on the intracellular level: testosterone (T) and dihydrotestosterone (DHT) receptors and the androgen-5 alpha-reductase (A5R). Five children with "normal" female external genitalia (group A) and three patients with variable forms of ambiguity (group B), ages 1 to 18 years, were studied. Tissue specimens from genital skin were analysed for the Kd- and N max-values of the cytosolic and nuclear T- and DHT-receptors, as well as for the Km- and Vmax-data of the tissue specific A5R. The enzyme analyses were performed with a kinetic method. Results show that patients from group A mainly lack action of the nuclear DHT receptor, combined with reduces binding capacity in the cytosol. T binding was poor in both, cytosolic and nuclear fractions, respectively. Results of group B proved to be more inhomogeneous, ranging from total absence of a DHT receptor to normal binding capacities in the nuclear fractions, accompanied by decreased cytosolic N max values for that ligand. T binding was poor in all patients of group B in the cytosolic and nuclear fractions, respectively. A5R was qualitatively normal in all patients examined, except one, but decreased enzyme activities could be observed in a wide range. In summary, the study confirms the complex mechanisms, presenting as AIS clinically. Moreover a close relationship between abnormalities of androgen receptor function and changes in A5R activity could be evaluated, thus confirming the recent theories about intracellular androgen action.

Molecular biology of androgen action: testosterone/dihydrotestosterone receptor and androgen 5 alpha-reductase in the human foreskin.

Receptors for testosterone (T) and dihydrotestosterone (DHT) as well as the tissue specific androgen-5 alpha-reductase (A5R) were studied in the foreskin of 52 healthy boys (ages 1-14 years), in order to gain molecular endocrinological data and information about the ontogeny and cytogeny, respectively, of androgen specific target organs. Enzyme determinations were carried out in tissue homogenates by an enzyme kinetic method for the evaluation of Km- and Vmax-values. Reactions velocities were calculated from the turn over rates of T to DHT, 5 alpha-androstane-3 alpha,17 beta-diol and 5 alpha-androstane-3,beta,17 beta-diol. The precursor (T) was used in increasing concentrations, ranging from 8 to 208 nM. Separation of reaction products was done by thin-layer chromatography and verification of specific radioactivity of metabolites by means of radio gas chromatography on capillary columns. Results of the enzyme analyses: Km = 94.9 +/- 3.5 [nM], and Vmax = 15.8 +/- 1.9 [pmol/mg.h]. Receptors were examined in the cytosolic and nuclear fractions of the tissue specimens. Saturation analyses and calculation of binding data led to specific receptors for T and DHT in the cytosolic (T: Kd = 1.56 +/- 0.12 [nM], Nmax = 122.4 +/- 11.6 [fmol/mg]; DHT: Kd = 1.9 +/- 0.1 [nM], Nmax = 493.3 +/- 77.8 [fmol/mg]) and the nuclear fractions (T: Kd = 1.43 +/- 0.13 [nM], Nmax = 28.7 +/- 3.5 [fmol/mg]; DHT: Kd = 1.37 [nM], Nmax = 196.9 +/- 22.5 [fmol/mg]), Kd-values proved to be quite homogenous (coeff. var. = 0.15-0.21), whereas maximum specific receptor binding activities (Nmax) showed age dependent fluctuations (coeff. var. = 0.35-0.45). Binding capacities of both T- and DHT-receptor, respectively, in cytosolic and nuclear fractions showed peak values in the age group 10-11 years and additional "spikes" of binding rates at age 4-5 years. It is noteworthy that Vmax-values also reached maximum levels in the latter age group. Concerning the ontogeny of the androgen receptor a change of binding properties from the cytosol to the nuclear fraction was observed with the onset of puberty. A comparison of enzyme- and receptor data lead to the theory, that subcellular hormone actions depend on interrelational regulatory mechanisms between androgen receptors (T as well as DHT) and specific enzyme systems (A5R).

Analysis of androgen-5 alpha-reductase by an enzyme kinetic method.

Analysis of androgen-5 alpha-reductase (A-5 alpha-R) is commonly done by measuring distinct testosterone (T) metabolites after tissue incubation. In the present study, A-5 alpha-R analysis was performed according to the principles of Michaelis-Menten, i.e. by evaluation of KM and Vmax data of the enzyme. 48 tissue samples (foreskin) of healthy boys in the age group 6 months to 8 years were examined. Incubation was carried out using increasing concentrations of 3H-T (8-208 nM) as substrate, followed by extraction and thin layer chromatography (TLC) of the reaction products. Zone detection and quantitation of radioactivity was done by a computing TLC scanner. The specific radioactivity of the metabolites was evaluated by high resolution radio gas chromatography. KM values ranged from 81.8 to 118.1 nM and Vmax from 8.9 to 30.1 pmol/mg . h. Coefficient of variation was smaller for KM (0.1) than for Vmax (0.38). It is recommended to do A-5 alpha-R analysis by evaluation of the enzyme kinetics as this is a reproducible method giving accurate biochemical data of the qualitative and quantitative characteristics of the enzyme.