[Perspectives in rehabilitation. General position paper on future trends and challenges in rehabilitation by the Health Advisory Board of the German Federal Association for Rehabilitation]. / Perspektiven der Rehabilitation. Ein Positionspapier des Arztlichen Sachverständigenrates der Bundesarbeitsgemeinschaft f ü r Rehabilitation (BAR) zur Weiterentwicklung der Rehabilitation.

The Health Advisory Board of the German Federal Association for Rehabilitation (BAR) describes future trends and challenges in rehabilitation as deriving from the socio-demographic development in Germany and the structural characteristics of its Social and Health Care Insurance System. The focus is on elder employees to sustain and regenerate their capacity for employment, on people which are no longer employed to activate their autonomy and ability for self-support, and on rehabilitation as a holistic and integrative process extending through the social security and health insurances. There is an urgent need and a real chance to benefit from already existing scientific findings more frequently and to integrate them effectively into adequate further education and training programmes for professionals. Finally the conclusion summarises 8 theses to facilitate rehabilitation as an integral and essential part of the German social security and health sector. This paper was fully accredited by the members of the BAR Managing Board.

[Health, social, societal and organizational political effects of the implementation of the ICF on integrated rehabilitation--a vision of the conversion and its consequences]. / Gesundheits-, sozial-, gesellschafts- und organisationspolitische Auswirkungen der Anwendung der ICF auf eine integrierte Rehabilitation - Vision der Umsetzung und ihrer Folgen.

Fundamental joint principles on expert opinions according to the social law code no. IX (SGB IX) and their application to a virtual individual case history were published recently in this journal. They are based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). A visionary review of the chances and prospects for the further development of the rehabilitative system is outlined and the necessary steps for their implementation are demonstrated.

[Aspects of expertise which are jointly valid for German sociomedicine and statutory health care]. / Trägerübergreifende Aspekte der Begutachtung nach dem SGB IX - Teil II: Fallbeispiel -

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurance. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[Aspects of expertising which are jointly valid for German sociomedicine and statutory health care]. / Trägerübergreifende Aspekte der Begutachtung nach dem SGB IX--Teil I: Grundlagen.

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurances. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[100 years physical therapy and rehabilitation]. / 100 Jahre Physikalische Therapie und Rehabilitation.

Physical medicine and rehabilitation received powerful impulses from orthopaedic surgery, which organizes its pragmatic and scientific interests since 100 years in its own association. A point of breakthrough was reached at the beginning of the 20th century, when progress in surgical and conservative orthopaedics enabled a comprehensive rehabilitation of physically disabled. On the other hand, the professionalisation of care for the handicapped (Krüppelfürsorge) has decisively supported the advancement of orthopaedics. Next to the storming development of orthopaedic surgery step by step the scientific foundations and clear indications for physiotherapy were achieved. The strategy of treatment was adapted to the increasingly active approach to orthopaedic ailments and traumata. This relates as well to wide ranges of rehabilitation and developed the training of specialists. Orthopaedic surgeons were significantly involved in this development as well as the framing of legal regulations safeguarding the entitlement of the disabled.

[Challenges in social medicine counseling and expert assessment]. / Herausforderungen der sozialmedizinischen Beratung und Begutachtung.

The services of expert testimony and professional consultation in sociomedicine are considerably challenged. It is not so much the question of maintaining their traditional functions but of developing them in order to maintain at least the status quo. These challenges consist for example of the lack of a scientific basis for the complex function of allocation, piloting and control of medical resources. Some new approaches are offered by the ICIDH, by new instruments of medical assessment and by quality management including "evidence-based medicine". Furthermore the services of expert testimony must bridge the gap between patients and social services in a way which is satisfactory for the population. Nevertheless, these services must maintain strict independence.

[The laryngeal mask with > 1900 general anesthesias--report of experiences]. / Die Kehlkopfmaske bei > 1900 Allgemeinanästhesien--Erfahrungsbericht.

Since November 1990 until January 1993, the laryngeal mask airway was employed for 1925 general anaesthesias, i.e. 19.6% of all general anaesthesias in our hospital. On the basis of the protocols the age distribution of the patients, the practice of anaesthesia (premedication with oral benzodiazepines, induction with thiopental, anaesthesia sustained with enflurane/nitrous oxide/oxygen) and the complications are reported. The complications not directly related to the laryngeal mask were: hypotension (5.92%), dysrhythmias (3.17%) and hypertensive states (1.71%). Other complications directly related to the laryngeal mask (bronchospasm, laryngospasm, difficult insertion of the mask, intraoperative vomiting) were less than 1.3% each. One aspiration was recorded, but could not be attributed to the laryngeal mask. Complications with major influence on the postoperative course and hospital stay were not seen.

Capnometry for continuous postoperative monitoring of nonintubated, spontaneously breathing patients.

We continuously monitored spontaneous respiration after extubation by end-tidal CO2 tension (PETCO2) in 19 patients aged 20 to 72 years who had undergone major operations. The respiratory gas was sampled from the nasopharynx via a special nasal catheter and analyzed by a side-stream analyzer. In each case, optimal placement of the nasal catheter was determined by CO2 waveform and the capnograms were recorded for waveform analysis and trend monitoring. PETCO2 was compared with arterial CO2 tension (PaCO2) two to four times during the 2- to 19-hour observation periods by simultaneous measurements. For 65 simultaneous measurements, mean PETCO2 was 38.9 +/- 5.7 mm Hg (range, 26.3 to 48.3 mm Hg) and mean PaCO2 was 38.9 +/- 5.7 mm Hg (range, 26.8 to 46.0 mm Hg; r = 0.82; p less than 0.01). While the mean values for PETCO2 and PaCO2 were similar, several patients had large differences for PaCO2 to PETCO2. The differences of the individual patients did not differ significantly between the various times of measurement. We conclude that this form of capnometry is well suited for continuous, noninvasive monitoring of respiration in nonintubated, spontaneously breathing patients.

[The reliability and sources of error in basic clinical documentation--a critical report of experiences]. / Zuverlässigkeit und Fehlerquellen in einer klinischen Basisdokumentation--ein kritischer Erfahrungsbericht.

Since 1. 1. 1985, computer-aided basic medical documentation has been routine at the University Orthopedic Clinic in Friedrichsheim, near Frankfurt. In addition to data on patient's histories, all data needed to satisfy the criteria of the Federal Directive on Operating Cost Rates are gathered. The diagnoses are stored in clear text, in a modified Eichler code, and according to ICD 9. Conversion from the Eichler code to ICD 9 is almost fully automated. In a study covering 100 hospitalized cases the following findings were obtained relating to sources of error and reliability: Without any additional in-house plausibility checks, the rate of error in the ID code, created by coding family name, date of birth, and sex, was 7%. In clear text all diagnoses except one and all forms of therapy were correctly reproduced as contained in the medical report. On the other hand, 7% of the conversions into the Eichler code contained errors. The reason for the difference in the quality of data is pointed out. In some of the other surveys, e.g., of infection rates, the rates of error were very high; most errors had been caused by the ward physicians. Data quality is enhanced by exploitation of routine process data when these control administrative procedures or are used for communication between physicians, since they then become relevant to actions and decisions and hence have to be reliable, regardless of documentation purposes.

[Intraoperative monitoring in artificial respiration of premature and newborn infants. I. Monitoring of respiratory parameters and alveolar ventilation]. / Intraoperatives Monitoring der Beatmung bei Früh-und Neugeborenen. I. Uberwachung der Beatmungsparameter und der alveolären Ventilation.

Monitoring of ventilation serves to ensure adequate alveolar ventilation and arterial oxygenation, and to avoid pulmonary damage due to mechanical ventilation. Basic clinical monitoring, i.e., inspection, auscultation (including precordial or oesophageal stethoscope) and monitoring of heart rate and blood pressure, is mandatory. Mechanical ventilation is monitored by ventilation pressures (peak pressure, plateau pressure and endexpiratory pressure), ventilation volumes (measured at the in/expiratory valve of the respirator and by hot-wire anemometry at the tube connector), ventilation rate, and inspiratory oxygen concentration (FiO2). Alveolar ventilation should be continuously and indirectly recorded by capnometry (pECO2) and by measurement of transcutaneous pCO2 (tcpCO2), whereas oxygenation is determined via measurement of transcutaneous pO2 (tcpO2). Invasive monitoring of gas exchange is essential in prolonged or intrathoracic interventions as well as in neonates with cardiopulmonary problems. paCO2 may be estimated by capillary or venous blood gas analysis; arterial blood gas analysis is required for exact determination of paCO2 as well as arteriocutaneous pCO2 (atcDCO2) and arterio-end-expiratory (aEDCO2) gradients.

[Intraoperative monitoring in artificial respiration of premature and newborn infants. II. Monitoring of arterial oxygenation]. / Intraoperatives Monitoring der Beatmung bei Früh-und Neugeborenen. II. Uberwachung der arteriellen Oxygenierung.

Monitoring of adequate arterial oxygenation serves to avoid periods of hypoxaemia and hyperoxaemia with potentially life threatening or organ-damaging sequelae. Basic clinical monitoring, i.e., inspection and auscultation, is mandatory. In all infants, paO2 may be continuously and indirectly monitored by measurement of transcutaneous pO2 (tcpO2). The use of pulse oximetry for non-invasive measurement of arterial oxygen saturation (SaO2) is still undergoing clinical testing. Invasive monitoring of gas exchange is essential in prolonged or intrathoracic interventions as well as in neonates with cardiopulmonary problems. paO2 can be estimated by capillary blood gas analysis; arterial blood gas analysis, however, is required for exact determination of paO2 and of the arterio-cutaneous pO2 gradient (atcDO2). Intraarterial fibre optic determination of oxygen saturation or determination of paO2 with an intraarterial Clark electrode does not appear to be well suited for intraoperative conditions.

[Plasma concentration and amnesia following lormetazepam and flunitrazepam in i.v. premedication]. / Plasmakonzentration und Amnesie nach Lormetazepam und Flunitrazepam bei i.v.-Prämedikation.

The correlation between serum levels and degree of amnesia following 0.03 mg/kg lormetazepam or 0.02 mg/kg flunitrazepam was analysed in a prospective randomised single-blind study evaluating 20 patients with ASA classification I in each group. Blood specimens were drawn and amnesia tests performed 20, 40 and 60 min. after drug administration. The plasma level of lormetazepam was 1.8 to 2.0 times higher than that of flunitrazepam; however, the difference of lormetazepam concentrations was considerably large between the investigated individuals. There was no difference in the degree of amnesia, but also no correlation with plasma levels was measured. A serum level breakpoint for the occurrence of amnesia could not be defined.

[Rehabilitation of the physically handicapped--rehabilitation of the gainfully employed orthopedic patient]. / Die Rehabilitation Körperbehinderter--Rehabilitation des berufstätigen orthopädisch Kranken.

Rehabilitation of physically disabled persons and resettlement of employed orthopaedic patients into social and working life are integral components of orthopaedics. Unless the patient is reintegrated, orthopaedic care remains incomplete. It is absolutely necessary to develop, already during counselling and at the outset of in-patient therapy, a detailed treatment plan that takes into account the pertaining vocational and social integration considerations. Besides outlining some general ideas, the specific experience at the Orthopaedic Clinic of Frankfort university are described.

[Replacement of proximal end of the femur (author's transl)]. / Der Ersatz des proximalen Femurendes.

The article reports on replacement of the proximal end of the femur, including the acetabulum, by means of special endoprostheses in a total of 49 hips. Besides treatment of pertrochanteral and subtrochanteral fractures of the femur in individual cases, and an increasing field of application within the framework of prosthetic exchange operations, resection and replacement of the coxal femur are mainly employed in tumour processes. Primary malignant tumours require pre-treatment and after-treatment by chemotherapy (with the exception of chondrosarcoma) in order to meet the demand of oncological radicality. Tendency to luxation, which is the most frequent component, can be reduced by employing a sophisticated surgical technique, good physiotherapy, appropriate training of the patients, and application of a Hohmann's bandage. The radiological course indicates that all the complications involved in endoprostheses, especially loosening, may be expected, even though they may occur with a certain delay of time. Besides general osseous atrophy of the prosthesis-bearing diaphysis, it is mainly the lateral "traction" side which is affected. Sintering of the prosthesis can temporarily delay breakdown of the anchoring. Prosthesis fractures are possible. Hence, the special endoprosthesis proximal to the hip joint is a recommended alternative to surgery of a crippling nature. In view of the fact that it is hardly possible to retract one's steps at a later date, indications towards special endoprosthesis must continue to be highly differentiated and closely adapted to each individual case.