[Improvement of care for diabetics using the care model from Saxony]. / Verbesserung der Versorgung von Diabetikern durch das sächsische Betreuungsmodell.

BACKGROUND AND OBJECTIVE: By promoting the networking of all those involved in caring for diabetics in Saxony, through agreement between those who provide help to them and the organizations which pay the costs, the intention is to improve the overall quality of care of diabetics. It was the aim of this study to evaluate the effectiveness of this integrated health model. PATIENTS AND METHODS: As part of the 3rd Diabetes Agreement in Saxony, a total of 275,804 diabetics were registered, treated and their management costed in the first quarter of 2000 and the fourth quarter of 2001 (56.3% females, 43.7% males; median age 68,7 years). They were patients of 2800 general practitioners and 88 specialist practices. RESULTS: Nearly 80% of all diabetics were included. Taking the level of HbA1c as the criterion of quality achieved, it had decreased from 7,1 +/- 1,3 % in the first 3 months of 2000 to 6,8 +/- 1,3 % in the last 3 months of 2001, and regional differences had been reduced. There was an obvious correlation between early referral to specialist practices and good treatment results, as measured by HbA1c and blood pressure levels. While in 1996 patients were referred when the HbA1c level was 8.8% (median 8.5%), referrals in the last quarter of 2001 were made when the mean was 8,0% (median 7.7%). After two years the risk of inadequate treatment (HbA1c > 7.5% and blood pressure > 140/90 mmHg) had been clearly reduced in about half the cases. CONCLUSIONS: Diabetes agreements, as promulgated in Saxony, have provided effective disease management programs (DMP) for efficacious and efficient integrated diabetic care, so that with continuing effectiveness and further development the St. Vincent targets can be reached. Successful regional diabetes agreements must therefore be maintained within the new, politically centralized, DMPs.

Primary breast cancer therapy in six regions of Germany.

Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.

Manifest diabetes and keratoconus: a retrospective case-control study.

PURPOSE: To assess the influence of diabetes on the development of keratoconus to show whether biomechanical effects are also reflected in epidemiology. The two diseases have opposite impact on the biomechanics of the corneal stroma: manifest diabetes stiffens the cornea, whereas keratectasia weakens the tensile strength of the stroma. METHODS: The retrospective case-control study included files of 1,142 patients, with 571 patients in the case group (keratoconus patients) and 571 in the control group (clinical population). The groups were well matched with respect to sex and age. We established the number of diabetics in both groups and compared it statistically by means of the odds ratio to determine whether diabetes can be interpreted as having a "protective effect" whether it is a "risk factor" for the development of keratoconus. RESULTS: Two patients of the keratoconus group had manifest diabetes that developed many years after the diagnosis of keratoconus, while nine cases of diabetes were found in the control group. Statistical analysis revealed a strong protective effect of manifest diabetes regarding keratoconus (odds ratio = 0.2195, P = 0.034). This effect was evident only in type II diabetes patients. CONCLUSIONS: The protective effect of manifest diabetes may be explained by the induction of cross-links in the stroma, preventing biomechanical weakening of the cornea. This study shows that different biomechanical changes can be superimposed and assume epidemiological relevance.

Development of an oncology data network in Germany.

In the 1990ies, an oncology data network has been set up mainly in the New States of Germany. Although not formally planned and established as a whole, it consists of a number of initiatives, that co-operate well and gain added value from this co-operation. From the technological view, the centre of the network is the Giessener Tumordokumentationssystem (GTDS), that was developed at Giessen University. We present important basic conditions in which this development took place, show some results and describe future directions of the development.

[Medical guidelines for diabetes mellitus in Saxony. An instrument for interdisciplinary quality management for optimizing patient care]. / Arztliche Leitlinien Diabetes mellitus in Sachsen. Instrument interdisziplinären Qualitätsmanagements zur Optimierung der Patientenversorgung.

Patients with diabetes still have a life expectancy of 5-10 years less and a markedly reduced quality of life than non-diabetic persons. Concepts, models, and contracts aiming at an efficient co-operative care for chronically ill patients have been developed in the new German states to overcome shortage of care. The dual care of motivated diabetic patients by family physicians and experts for metabolic diseases has proven to be efficient both in pilot studies as well as in country-wide investigations. A representative commission for diabetes has developed guidelines for such a structure of dual care. Design and content of these regional developed guidelines about an cooperative evidence based care for diabetic patients fulfills the criteria suggested by international bodies of experts and the medical society for quality assurance. The Saxonian guidelines for diabetes have been successfully implemented step by step in medical offices and hospitals. We are sure that the further implementation of the shared care system diabetes will further improve quality of care.

[Quality of diabetes management in the free Saxony state--scientific evaluation of the Saxony model for managing diabetes. EVA group]. / Untersuchungen zur Qualität der Diabetikerbetreuung im Freistaat Sachsen--die wissenschaftliche Begleitung des Sächsischen Modells zur Diabetikerversorgung. EVA-Gruppe.

After the societal change in the "New Federal States" of Germany Saxon diabetologists developed an integrated concept for care of diabetic patients: the Saxon Care Model (SCM). It aims at quality assurance in diabetes care and is based on services by cooperating general practitioners and specialists. This model was evaluated. First results were obtained describing the quality of care for 510 patients at baseline. This sample was collected at two specialized diabetologists (level 2), two specialized out-patient units at universities (level 2) and two general practitioners (level 1). The design of the study is a descriptive evaluation. Process and outcome quality at specialized and primary care units working according to the SCM is relatively high. HbA1c measurements were taken in order to quantify outcome quality. The results for primary as well as specialized care units ranged from acceptable to very good. They unfortunately cannot be generalized. The patients expressed that their quality of life was limited only scarcely. The presented preliminary results indicate a high effectiveness of the SCM with regard to relevant process-related outcome-variables. The large variance between single practices of both levels demonstrates that deficits in early diagnosis of diabetes-related complications still exist. On the other hand this points towards resources of quality improvement. The influence of quality assuring measures, e.g. quality circles, will be assessed in a three-year follow up.

Recommendations of the German Association for Medical Informatics, Biometry and Epidemiology for education and training in medical informatics.

In the fields of health care and medicine there is an immense demand for a systematic application of methods of information processing and for the use of computers. Obviously, to that end well-trained scientists and qualified personnel must be available. With the present recommendations on education and training in medical informatics the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) proposes structure and contents of medical informatics curricula and courses. The recommendations describe a 2-dimensional educational framework with different education levels in one dimension and various types of educational needs and orientation in the other one. The recommendations comprise at the university level education as well specialized curricula covering the total spectrum of medical informatics as well as informatics curricula with medical informatics as integrated applied subject or subsidiary subject, respectively. Besides these informatics-oriented approaches medical-oriented programs of education in medical informatics are recommended, e.g., post-graduate education in medical informatics for physicians based on foundations in medical informatics as part of their initial training in medicine. At the level of polytechnical schools curricula of medical documentation and informatics and at the level of professional schools training in medical documentation are recommended. This report is a translation of its German original. Although considered by the GMDS as recommendations for the Federal Republic of Germany, the text may also contribute to the development of an international, especially European framework of training in medical informatics.

[Jena longitudinal study of growth of 0-3 year old children. 1: Average values of body height and body weight, somatograms and percentile values]. / Jenaer Längsschnittstudie über das Wachstum 0-3jähriger Kinder. Teil 1: Mittelwerte der Körpergrösse und des Körpergewichtes, Somatogramme und Perzentilwerte.

Normal values (means +/- s and percentiles) for body height and weight and a somatogram for children from the newborn period up to 3 years determined in 306 children (164 boys and 142 girls) are presented. Beyond the first year of life the children are slightly taller and have a reduced height related body weight in comparison to older standards.

[Jena longitudinal study of the growth of 0-3 year old children. 2: Percentile curves for body height, body weight, height related weight and growth rate]. / Jenaer Längsschnittstudie über das Wachstum 0-3jähriger Kinder. Teil 2: Perzentilkurven für die Körpergrösse, das Körpergewicht, das grössenbezogene Gewicht und die Wachstumsgeschwindigkeit.

Charts for body length and height, body weight, and height- and weight velocity basing on a longitudinal study with 306 children from the newborn age to 3 years of age, are presented. Length and weight velocity are strongest in the time between the 4th and 8th week of life. From the first to the fourth trimester velocities decrease continuously.

Investigations on biochemical properties of milk-clotting enzymes.

The properties of proteolytic enzymes produces from calf maws and from an Ascomycete were studied. Both milk-clotting proteases have their optimum activity at pH 5.2 and 45 degrees C. The microbiological rennin has a second maximum activity at pH 3.5 and 55 degrees C. Temperatures above 55 degrees C cause a rapid decrease of activity. The behaviour of enzyme activity is similar with varying substrate and enzyme concentrations. However, increasing amounts of enzyme in ratio to the substrate lead to reaction rates of the calf rennin differing clearly from that of the microbiological rennet complex.

[Epidemiologic aspects of disability caused by rheumatic diseases in the Gera district, East Germany]. / Epidemiologische Aspekte der Invalidität infolge rheumatischer Erkrankungen im Bezirk Gera, DDR.

In the period 1968-1977, the mean annual invalidization rates due to rheumatic diseases in the district of Gera are 36.6 for the female insured population, 19.3 for the male one, per 10(5) persons. After the age of 40, invalidization rates are rising steeply. Degenerative arthropathies (osteoarthroses and displacements of the intervertebral disk or vertebrogenic pain syndromes) constitute more than four fifths of all first-time invalidizations. First-time invalidization was done, on average, 7 years before reaching the age-limit provided by law for old-age pension, in one third temporally limited. The longitudinal monitoring of the invalidzation rates supports the hypothesis that clinical manifestations of degenerative arthropathies are increasing.

Virulence properties of Escherichia coli strains in patients with chronic pyelonephritis.

In 50 Escherichia coli strains obtained from the bladder puncture urine of patients with chronic pyelonephritis, determinations of virulence properties were performed. All of the E. coli strains isolated from 26 acute episodes of pyelonephritis were found in the smooth form. 30% possessed K 1 antigen, 77% showed the ability to form hemolysin and 30% produced colicin V (aerobactin). Fimbriae (detected by mannose-resistant hemagglutination) were registered in 81%, and plasmids ranging between 50 and 70 Md were demonstrated in 70% of the bacteria. In contrast to this, only 70% of the E. coli strains isolated from 24 patients at an inactive stage of pyelonephritis were found in the smooth form; 10% of these encoded K 1 antigen, 20% hemolysin and 10% colicin V. Plasmids in the range 50 to 70 Md could be found in 30%. On the basis of multivariate analysis of variance and discriminant analysis, it was confirmed that uropathogenic strains possess several virulence properties, mannose-resistant hemagglutination being of particular importance.

[Personal experiences with conservative drug therapy of urgency symptoms in the female]. / Unsere Erfahrungen mit der konservativ-medikamentösen Therapie der Drang-Symptomatik der Frau.

On the basis of clinical and urodynamic results the authors adopt a definite attitude to the treatment of the urgency syndrome in the woman with the anticholinergic drug propiverin hydrochloride (Mictonorm). The results show a satisfactory improvement in 42 of 68 women (= 62%), whereas 24 of 68 women (= 35%) reported a subjective improvement of the clinical symptoms. These results correspond with the data from literature. In 15 women with no satisfactory effect the beta 2-sympathicomimetic drug clenbuterol (Contraspasmin) was additionally applied. There was a satisfactory success under this medication in 11 of the 15 women (= 72%). The results are discussed with the references of the literature to the conservative therapy of the urgency syndrome.

[Colchicine therapy of fibrosing liver diseases--report of a randomized double-blind study]. / Die Colchizintherapie fibrosierender Lebererkrankungen--Bericht über eine randomisierte Doppelblindstudie.

It is reported on results of a double blind study of colchicine therapy in fibrotic liver diseases over a period of three years. The study includes 74 probands; 37 of them had been treated after randomization for five days a week with 4 X 0,25 mg/d colchicine, 37 with placebo. 53 probands attained the 12th month of treatment, 43 of them 24th, 24 probands were in the study for 36 months. 3 diagnoses groups had been formed with regard to the histological grades of fibrosis: chronic hepatitis (without structural transformation); structural liver transformation/moderate liver cirrhosis; severe liver cirrhosis. In 38 cases the disease was caused by alcohol. 45 data had been studied (clinical results, paraclinical data concerning hepatological diagnostic and connective tissue metabolism and morphologic data). The biometric evaluation was carried out with the stage variant analysis by Friedman. Rebiopsies have been carried out in 40 probands after 1 year, in 4 probands after 2 years. 4 data (Serumalbumine, Gamma-GT, ALAT, KP) showed significant changes in the colchicine-group as well as in the placebo-group. In both therapy groups the morphologic supervisions of the fibrosis grades (rebiopsies) showed improvements, no changes, and deterioration about in the same frequency. In this study there was no effectiveness of colchicine on the course of fibrotic liver diseases to be stated. Concerning the contradictions in the recent literature and probable the insufficient colchicine dose, the authors recommend further studies on colchicine therapy in liver diseases with incipient i.e. reversible fibrosis.

[Exploratory studies of the common incidence of cholelithiasis, status following cholecystectomy and colonic cancer]. / Explorative Untersuchungen zum gemeinsamen Vorkommen von Cholelithiasis, Zustand nach Cholezystektomie und Kolonkarzinom.

For studying the postulated relationship between prior cholecystectomy, cholelithiasis, and occurrence of subsequent colorectal cancer, we examined in a retrospective study autopsy cases to get information about the frequency of them. The material consisted of 10,000 cases (female:male = 1,08:1) with an age maximum in the 8. decennium. Among them were 2457 (902 male and 1555 female) cases of cholelithiasis and 646 (211 male and 435 female) cases of cholecystectomy. 449 colorectal cancer were found, altogether. The incidence of cancer in cases without gallbladder disease amounts to 4.13%, in cases with cholelithiasis 5.37%, and after cholecystectomy 4.95%, respectively. The results must be discussed with care because Berkon's Fallacy. Further exploratory investigations are necessary.

[Changes in the parameters of the urethral pressure profile by measuring the patient in supine and sitting position]. / Veränderungen der Parameter des Urethradruckprofils bei Messwertaufnahme in liegender oder sitzender Position der Patientin.

For testing the influence of the examination position on the parameters of the urethrocystometry 124 findings of urethrocystometry of 103 female patients were evaluated in 3 groups. In these cases slight alterations develop when changing between lying and sitting position, whereby in sitting position a greater differentiation of an existing component of stress incontinence becomes possible. On the basis of our examination findings and the references in literature it seems to be advisable to perform the urethrocystometry in the same session both in lying and in sitting position for further improvement of the indication for therapy.