Virtual Reality Therapy in Palliative Care: A Case Series.

OBJECTIVES: Virtual reality (VR) opens a variety of therapeutic options to improve symptom burden in patients with advanced disease. Until to date, only few studies have evaluated the use of VR therapy in the context of palliative care. This case series aims to evaluate the feasibility and acceptability of VR therapy in a population of palliative care patients. METHODS: In this single-site case series, we report on six palliative care patients undergoing VR therapy. The VR therapy consisted of a one-time session ranging between 20 to 60 minutes depending on the patient's needs and the content chosen for the VR sessions. A semi-structured survey was conducted and the Edmonton Symptom Assessment System (ESAS) and the Distress Thermometer were performed pre- and post-intervention. RESULTS: Overall, VR therapy was well accepted by all patients. Five out of six patients reported having appreciated VR therapy. There were individual differences of perceived effects using VR therapy. The semi-structured survey revealed that some patients felt a temporary detachment from their body and that patients were able to experience the VR session as a break from omnipresent worries and the hospital environment ("I completely forgot where I am"). There was a considerable reduction in the total ESAS score post-treatment (T0 ESASTot = 27.2; T1 ESASTot = 18.8) and a slightly reduction in distress (T0 DTTot = 4.4; T1 DTTot = 3.8). However, two patients were more tired after the intervention.Significance of Results: Our preliminary results demonstrate that VR therapy is acceptable, feasible and safe for use within a palliative care population and appears to be a viable treatment option. Clinical trials are both warranted and necessary to confirm any therapeutic effects of VR therapy, as is the need to tailor VR systems better for use in palliative care settings.

[The Preventive Home Visit as a Preventive Intervention to Reach the Elderly--Effectiveness and Cost-Effectiveness of Different Ways of Approach]. / Der präventive Hausbesuch als zugehende Präventionsmaßnahme im Alter--Effektivität und Kosteneffektivität von Zugangswegen.

The aim of the study was a systematical further development of targeted approaches. Research questions were how elderly women and men could be motivated to participate in a preventive intervention and by which approaches elderly with different health risks could be reached. In several stages a specific motivational material was developed. Afterwards two different approaches to the elderly (general practice, health insurance) were tested and evaluated considering its (cost) effectiveness.

[Multimorbid general practice patients - what's really important?]. / Multimorbide Patienten in der Hausarztpraxis - wem ist was wichtig?

The German PRISCUS study amongst others investigated in the different priority setting of patients and their doctors. General practice patients aged 72 and above were given a comprehensive geriatric assessment. On the basis of the results, patients and their physicians independently rated the importance of each problem disclosed by the assessment. Whereas patients had their focus on psychosocial aspects and health problems with impact in their daily lives, their doctors assessed importance mainly for patients' medical care. We assume open communication about patients' preferences as a key factor for a successful health care for older multimorbid patients.

[Use and acceptance of a basic geriatric assessment in primary care setting]. / Das geriatrische Basisassessment in der Hausarztpraxis.

BACKGROUND: Aim of this study was to evaluate the acceptance and use of a basic geriatric assessment (BGA), as it is covered by the German pay system, in primary care practices. METHODS: We conducted qualitative interviews and collected quantitative data by an online questionnaire. RESULTS: A total of 17 (10 men) general practitioners (GPs) agreed to be interviewed; 161 patients (134 men) completed the online questionnaire. GPs mainly performed BGA to substantiate the suspicion of cognitive impairment. Most of the German general practices accomplished not more than 5-10 BGA per quarter. Although those GPs who conducted BGA were convinced of its usefulness with regard to further patient care, concrete interventions were rarely named. The tests used within the BGA were not always in line with recommendations from the specific guidelines. The main reasons not to conduct BGA were the amount of time required and the lack of therapeutic consequences. CONCLUSION: Hitherto BGA is not an established tool in German primary care practices. The question, which single instruments are most suitable for older general practice patients, still needs clarification.

Prerequisites for a new health care model for elderly people with multimorbidity: the PRISCUS research consortium.

BACKGROUND: Multimorbidity, the concurrent manifestation or presence of multiple chronic conditions, poses huge challenges to affected patients, their relatives, physicians, and practitioners alike. The growing number of affected persons and the complexity of their needs places just as much of a burden on the health care system as does the plethora of often poorly coordinated interventions. The Chronic Care Model developed for different chronic diseases is suited for improving medical care. The PRISCUS research consortium was established to create the prerequisites for a new care model for multimorbid, elderly patients oriented along those lines. METHODS: The research consortium utilizes data gathered in a large-scale epidemiological study on peripheral arterial disease (getABI study) and from the Dortmund and Münster stroke registries, by extracting epidemiologic and health economic data, quality-of-life parameters, and data on the extent and quality of medication. Additional projects evaluate the implementation of a multidimensional geriatric assessment in primary care, the functional consequences of multimorbidity in stroke patients along with options for prevention and therapy afforded by physical activity. Systematic reviews of the literature are used to describe quality of life and patient preferences. Experts will work on an initial draft treatment standard for patients with multimorbidity and a list of potentially inappropriate medication for the elderly in Germany. CONCLUSION: The results of the PRISCUS research consortium will enable an epidemiologic characterization and description of consequences of multimorbidity, while illustrating new approaches towards prevention, diagnosis, and management of multimorbid patients. With this, some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model will be fulfilled.

[Prerequisites for a new health care model for elderly people with multiple morbidities: results and conclusions from 3 years of research in the PRISCUS consortium]. / Voraussetzungen für ein neues Versorgungsmodell für ältere Menschen mit Multimorbidität: Ergebnisse und Schlussfolgerungen aus 3-jähriger Forschung im PRISCUS-Verbund.

BACKGROUND: The concurrent presence or manifestation of multiple chronic conditions, i.e. multimorbidity, poses a challenge to affected patients and their relatives, physicians, and practitioners, and to the health care system in general. Aiming to improve medical care for different chronic diseases, the Chronic Care Model also appears to be suited for multimorbidity. The established research consortium PRISCUS is trying to create some of the prerequisites for a new care model for multimorbid, elderly patients oriented along the lines of the Chronic Care Model. METHODS AND RESULTS: Four out of seven subprojects of the research consortium provide an overview of some of their findings. Topics in a sports medicine subproject were the assessment of physical activity by means of a newly developed questionnaire and the development and feasibility testing of an exercise program for elderly people with chronic conditions and mobility impairment. Partners from family medicine implemented geriatric assessment in a primary care setting and evaluated its consequences. In a pharmacological subproject, potentially inappropriate medication as well as drug-drug interactions and dosing errors were addressed. The health economic subproject investigated quality of life impairment due to multiple chronic diseases and the effects of multimorbidity on costs. CONCLUSIONS: The results of the PRISCUS research consortium allow a better description of consequences of multimorbidity and illustrate at least some new approaches towards prevention, diagnosis, and treatment of patients suffering from multimorbidity. Ongoing projects will test the efficacy of a physical activity program and a new complex intervention to reduce potentially inappropriate medication in the elderly. With this, the research consortium will create some prerequisites for a new health care model for patients with multimorbidity comparable to the Chronic Care Model.

Prevalence and predictors of polypharmacy among older primary care patients in Germany.

BACKGROUND: Older people consume an increasing amount of medication. Polypharmacy is associated with an elevated risk of adverse health outcomes resulting in hospitalizations and sometimes death. OBJECTIVES: To describe the prevalence of prescribed and over-the-counter (OTC) medications among older general practice patients living in the community. To determine predictors of polypharmacy (five or more prescribed drugs) from a variety of patient- and doctor-related factors. METHODS: Sixty-seven randomly selected practices in two areas of Germany and 466 of their older patients (70+ years) were recruited for a geriatric assessment study. A cross-sectional analysis of health problems, GPs' awareness and their interventions was conducted. In this post hoc analysis, we assessed the medication use as reported by older patients and compared it with doctors' perceived medication regimens for their respective patients. The detailed assessment of patients' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection. RESULTS: Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs. In all, 26.7% of patients used five and more chronically prescribed drugs. A set of five determinants predicted polypharmacy best: breathlessness, hypertension, dependency on instrumental activities of daily living, low subjective health and medication disagreement between doctors and patients. CONCLUSION: This older general practice population in Germany is among the top pharmaceutical user group of European study samples. Apart from disease-specific determinants, GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.

[Home visits in German general practice: findings from routinely collected computer data of 158,000 patients]. / Hausbesuche: Versorgungsforschung mit hausärztlichen Routinedaten von 158.000 Patienten.

INTRODUCTION: Home visits are an integral part of general practice. However, information on this subject is lacking in Germany. Therefore we aim to describe the quantity of home visits, the target population and the workload for general practitioners on the basis of computerised data routinely collected in general practices. METHODS: The routine care data originate from 136 practices of the areas of Göttingen and Freiburg. Electronic patient records provided billing codes for home visits and consultations, patients' anonymous identification number, age, gender and ICD codes. RESULTS: 84 practices with complete datasets of 158,383 patients were available for the cross-sectional analysis in 2002. 12% of all patients required at least one home visit - significantly more elderly and female patients. Half of all patients visited at home requested one visit, whereas nearly 5% needed at least fortnightly visits throughout the year. 2/3 of all visited patients received an emergency visit. The quantity and nature of diseases also influenced home visit status. The workload of an average practice contained 9 visits per 100 consultations. 15 practices provided datasets between 1997 and 2001. In this period the total number of home visits declined. Within the same period, the target group has increasingly been restricted to old patients. CONCLUSION: Old age, female gender, quantity and nature of diseases positively influence home visit status. Compared to general practices in other European countries, the workload caused by house calls seems high in this German sample. Over recent years the frequency of home visits has decreased. In view of the demographic changes, decisions will have to be made as to who will care for the growing numbers of old patients requiring home visits.

Novel HLA allele, HLA-B*4013, identified from a potential bone marrow recipient. Putative gene conversion events with donor sequence.

A new B40 allele was identified in a leukemic Caucasian patient. This allele, designated B*4013, differs in alpha 1 domain from B*4002 at six amino acidic positions: 67, 77, 80, 81, 82 and 83. Most of this substitutions could alter the antigen binding site of the HLA-B molecule. B*4013 may have originated by gene conversion or reciprocal recombination involving B*4002 as the recipient allele of sequence donated by B*4406. The new allele was serologically typed as a "blank" associated with the Bw4 epitope.