[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']. / Memorandum "Weiterentwicklung der Gesundheitsversorgungsforschung in Bayern aus Sicht der Landesarbeitsgemeinschaft Gesundheitsversorgungsforschung: Status quo - Entwicklungspotenziale - Strategien".

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

[Coxarthrosis--an update]. / Koxarthrose--ein Update.

Degenerative osteoarthritis of the hip joint (coxarthrosis) is the most common disease of the hip joint in adults. The diagnosis is based on a combination of radiographic findings and characteristic clinical symptoms. The lack of a radiographic consensus definition has seemingly resulted in a variation of the published incidences and prevalence of degenerative osteoarthritis of the hip joint. The chronological sequence of degeneration includes the following basic symptoms on conventional radiographs and CT: joint space narrowing, development of osteophytes, subchondral demineralisation/sclerosis and cyst formation, as well as loose bodies, joint malalignment and deformity. MR imaging allows additional visualization of early symptoms and/or activity signs such as cartilage edema, cartilage tears and defects, subchondral bone marrow edema, synovial edema and thickening, joint effusion and muscle atrophy.The scientific dispute concerns the significance of (minimal) joint malalignment (e.g. impingement, dysplasia etc.) and forms of malpositioning which as possible prearthrosis have a high probability of leading to degenerative osteoarthritis. Moreover, without any question, the preservation of joint containment and gender differences are important additional basic diagnostic principles, which have gained great interest in recent years.In research different MR procedures such as Na and H spectroscopy, T2*-mapping etc. with ultrahigh field MR allow cartilage metabolism and its changes in early degenerative osteoarthritis ("biochemical imaging") to be studied. There is no doubt that even in a few years new profound knowledge is to be expected in this field.

Structure of biodiesel based bicontinuous microemulsions for environmentally compatible decontamination: A small angle neutron scattering and freeze fracture electron microscopy study.

Most toxic industrial chemicals and chemical warfare agents are hydrophobic and can only be solubilized in organic solvents. However, most reagents employed for the degradation of these toxic compounds can only be dissolved in water. Hence, microemulsions are auspicious media for the decontamination of a variety of chemical warfare agents and pesticides. They allow for the solubilization of both the lipophilic toxics and the hydrophilic reagent. Alkyl oligoglucosides and plant derived solvents like rapeseed methyl ester enable the formulation of environmentally compatible bicontinuous microemulsions. In the present article the phase behavior of such a microemulsion is studied and the bicontinuous phase is identified. Small angle neutron scattering (SANS) and freeze fracture electron microscopy (FFEM) measurements are used to characterize the structure of the bicontinuous phase and allow for an estimation of the total internal interface. Moreover, also the influence of the co-surfactant (1-pentanol) on the structural parameters of the bicontinuous phase is studied with SANS.

Peripheral large or giant fusiform middle cerebral artery aneurysms: report of our experience and review of literature.

Peripheral large and giant middle cerebral artery (MCA) aneurysms are rare and difficult to treat. We report our and others' experience with different possible modalities used to treat such lesions. Three patients were treated differently at our institution. One harboured a giant fusiform aneurysm on a peripheral branch of the superior trunk of the left MCA, and was treated by extracranial-intracranial (EC-IC) bypass and trapping of the aneurysm. The second patient was harbouring a large fusiform aneurysm on a peripheral branch of the inferior trunk of the right MCA, which was treated by trapping and excision without the need of an EC-IC bypass as assessed pre- and intraoperatively, while the last case was harbouring a giant fusiform aneurysm at the junction of M2-M3 and was treated by EC-IC bypass and end-to-end anastomosis after resection of the aneurysm. The aneurysms proved to be neither mycotic nor dissecting. The patients were clinically intact during their perioperative course without any postoperative complications and required no further treatment. Follow-up angiography demonstrated a functioning EC-IC bypass. Based on the surgical experience in these 3 cases and a review of the reported literature, the authors propose that when considering surgical treatment for such rarely encountered aneurysms, careful pre- and intraoperative evaluation including aneurysm trapping with or without EC-IC bypass when possible should be performed to obtain a satisfactory result without complication.

Hemorrhagic cerebral dissecting aneurysms: surgical treatments and results.

INTRODUCTION: Cerebral dissecting aneurysms are an increasingly recognized etiology of subarachnoid hemorrhage SAH and cerebral stroke. Hemorrhagic dissecting aneurysms of the anterior circulation have been considered to be somewhat different to those of the posterior circulation not only in terms of their pathophysiology, but also in terms of their management. Herewith our series of hemorrhagic dissecting aneurysms of the internal carotid artery ICA, vertebral artery VA, basilar artery BA and some of those of distal cerebral arteries is presented and compared to the series reported in the literature. Therapeutic consideration in the light of our experiences emphasizing the significance of aneurysm entrapment in combination with bypass surgery is presented. MATERIAL AND METHODS: During the last 13 years over 1000 patients with cerebral aneurysms were treated surgically in our department. Hemorrhagic dissecting aneurysms were diagnosed in 26 patients. Diagnosis was based on neuroradiological findings as well as intraoperative findings. All patients underwent surgical intervention. Clinical findings of these patients were analysed retrospectively. Follow-up outcomes were evaluated according to the Glasgow Outcome Scale GOS at 3 months after treatments. RESULTS: Location of 26 dissecting aneurysms was: ICA 11 cases (42%), VA 9 cases (35%), BA 3 cases, MCA 2 cases and PCA (P1 segment) one case. Primary surgical treatments were performed on day 3.7 of SAH on average. Clinical manifestation of dissecting aneurysms of the ICA and their outcome was more severe compared with those of the VA (p < 0.01): WNFS grade 3.1 vs 2.4 and GOS score 3.4 vs 4.3. As a conventional neck clipping procedure was problematic or impossible (aneurysm recurrence after clipping, premature rupture at the time of exposure or clipping), entrapment (or proximal ligation) plus EC-IC bypass procedure was the most frequent final definitive method of surgical treatment (9/26 35%: ICA 6/11, VA 1/9 and MCA 2/2) followed by proximal ligation or trapping only 7/26, neck clipping 7/26 and coating 4/26. CONCLUSIONS: Hemorrhagic dissecting aneurysms still remain problematic in their diagnosis and treatment. One has to be aware of the diagnostic possibility of dissecting aneurysms as an etiology of SAH. Neurosurgeons have to be prepared to be able to manage complex surgical situations also by the use of EC-IC bypass, as its combination with entrapment procedure can be the final treatment of choice. Less invasive endovascular technique is in evolution but its availability and superiority are still to be settled.

Emergency extra-intracranial bypass surgery in the treatment of cerebral aneurysms.

The need of an emergency bypass in hazardous situations during treatment of intracranial aneurysms has rarely been addressed in the literature. We report our 10 year experience with emergency bypass for aneurysm treatment. We retrospectively analyzed the data of patients who underwent emergency bypass surgery for the treatment of an intracranial aneurysm and compared the results with patients treated with bypass as a planned procedure during the same time period. Three groups were formed: group I, emergency bypass during clipping procedure; group II, emergency bypass for therapy refractory vasospasm; group III, planned bypass surgery. Sixteen patients (35%) out of 46 were treated with emergency bypass. In group I (11 patients) mortality was 37% and a good outcome (GOS 4 & 5) was achieved in 36%. In group II (5 patients) mortality was 20% and good outcome was reached in 60%. In group III (30 patients) mortality was 10% and good outcome was achieved in 86.6%. Outcome was worse in patients with additional SAH. An emergency bypass procedure as part of the aneurysm treatment should be considered in risky situations. Accurate timely decision-making is crucial combined with a fast and secure bypass technique. Treatment of refractory vasospasm with emergency bypasses may help to improve outcome in selected patients.

Conventional microsurgical treatment of paraclinoid aneurysms: state of the art with the use of the selective extradural anterior clinoidectomy SEAC.

Surgical treatment of paraclinoid aneurysms is considered to be difficult due to their complicated anatomical location in the vicinity of important neural, vascular and bony structures. We present our clinical experience of the past 10 years of conventional microsurgical treatment of 81 paraclinoid aneurysms in 75 patients with the use of selective extradural anterior clinoidectomy SEAC and discuss the method of therapy option by reviewing recent reports on results of endovascular coiling method and the combination of these with conventional microsurgical therapy. The favorable surgical results with the use of SEAC and no recurrence of the treated aneurysm after clipping procedure in our series indicate that direct surgery can still be a standard technique for paraclinoid aneurysms in view of the fact that the endovascular aneurysm coiling methods are still associated with a considerable percentage of incomplete occlusion and present the problem of coil packing.

Basilar bifurcation aneurysms. Lessons learnt from 40 consecutive cases.

Basilar bifurcation aneurysms are lately treated frequently with endovascular technique. Microsurgical clipping occlusion technique has, however, still its solid position because of its completeness. This standard technique is required often due to unfeasibility and/or incompleteness at the time of application of the endovascular technique for aneurysms of this location. The authors suggest following strategies and tactics for safe and secure occlusion of aneurysms of this location: pterional approach, selective extradural anterior clinoidectomy SEAC, no transection of the posterior communicating artery, isolation of perforating arteries at the time of neck clipping with oxycellulose and combination of the use of fenestrated clip and conventional clip (especially for aneurysms projected posteriorly), controlled hypotension (systolic pressure of around 100 mmHg), temporary clipping (trapping) procedures of usually less than 15 min. All these are aimed for prevention of intraoperative premature rupture, and of injury of perforating arteries and for complete occlusion of aneurysms in the narrow depth of the operative field.

Management of ruptured aneurysms combined with coexisting aneurysms.

In patients suffering from subarachnoid haemorrhage (SAH) and presenting with multiple intracranial aneurysms (MIA) two questions have to be decided on: 1st when is the ideal moment to eliminate the ruptured aneurysm and 2nd when to treat the coexisting aneurysms. In our series we retrospectively analysed 124 SAH-patients presenting with a total of 323 aneurysms. In 57 patients the ruptured aneurysm and all coexisting aneurysms were clipped during the first operation, whereas in 9 patients only some of the coexisting aneurysms (group-A; age in median 55 years) were clipped besides the ruptured one. In 55 patients (group-B; age in median 55 years) the first operation was restricted to clipping the ruptured aneurysm, dealing with the coexisting aneurysm subsequently. Immediately after admission 3 patients passed away. One of the 64 patients waiting (average 60 days, median 14 days) for the subsequent clipping of the not yet secured aneurysms suffered a SAH. Six to 12 months after the initial SAH, 78% of the cases in both groups reached a Glasgow Outcome Score of 4 or 5. Even if in patients with coexisting unruptured intracranial aneurysms the elimination of each and every aneurysm is recommended, the advantages of an unstaged procedure versus the additional strain caused by the prolongation of the procedure, e.g. approach over the midline, 2 or more craniotomies, and the risk of additional ischemic damage to the brain, caused by increased manipulation of cerebral arteries and brain tissue, have to be carefully considered. This is of special importance in dealing with patients in higher Hunt and Hess grades.