[The MDK Reform Act and its effect on outpatient potential : Risk or opportunity for urology?] / Das MDK-Reformgesetz und seine Auswirkungen auf das ambulante Potenzial : Risiko oder Chance für die Urologie?

BACKGROUND: With the introduction of the MDK (Medizinischer Dienst der Krankenversicherung) Reform Act, there have been multiple new regulations for hospitals, some of which are confusing and interact with one another. A major focus of the legal changes is directly or indirectly on expanding the provision of outpatient services. OBJECTIVES: It can be assumed that-as a result of the new version of the framework conditions and the AOP catalog-the relevant OPS list will be expanded in the future. With the revision of the AOP catalog and the effects of the MDK Reform Act, the number of cases with outpatient potential will increase. Can the effects and challenges for hospitals and especially urology be identified? METHODS: Evaluation of official statistics of inpatient and outpatient treatments. Focusing on the problem based on a fictitious practical example from urology. RESULTS: A strategy is developed for dealing with cases with outpatient potential and identification of different solutions to compensate for this shift in services and enabling an increase in performance or a deliberate reduction in the provision of services. CONCLUSIONS: The choice of the type of service provision is increasingly no longer an issue, and the short-term inpatient treatment of many urological cases is coming under considerable pressure due to political measures such as the MDK Reform Act and the demands of health insurance companies. The reduction of different parts of the inpatient reimbursement for special patient groups must be anticipated. Individual strategies will range from simply not providing outpatient services to complex models of cooperation. This change also means opportunities for hospitals!

Interventional left atrial appendage closure may affect metabolism of essential amino acids and bioenergetic efficacy.

BACKGROUND: Interventional closure of left atrial appendage (LAAC) represents an alternative for stroke prevention in patients with non-valvular atrial fibrillation. Whether LAAC may affect metabolomic pathways has not been investigated yet. This study evaluates the impact of LAAC on the metabolism of essential amino acids, kynurenine and creatinine. METHODS: Peripheral blood samples of prospectively enrolled patients undergoing successful LAAC were taken before (T0) and 6 months after (T1, mid-term follow-up). Targeted metabolomic profiling was performed using electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements focusing on metabolism of essential amino acids. RESULTS: 44 patients with non-valvular AF (mean CHA2DS2-VASc score 4, mean HAS-BLED score 4) were enrolled. Changes in metabolites of essential amino acids, myocardial contraction and bioenergetic efficacy, such as phenylalanine (percentage change 8.2%, p = 0.006), tryptophan (percentage change 20.3%, p = 0.0006), tyrosine (percentage change 20.2%, p = 0.0001), creatinine (percentage change 7.2%, p > 0.05) and kynurenine (percentage change 8.3%, p = 0.0239) were found at mid-term follow-up. CONCLUSIONS: LAAC may affect the metabolism of essential amino acids and bioenergetic efficacy. ClinicalTrials.gov Identifier: NCT02985463.

Percutaneous Closure of Left Atrial Appendage significantly affects Lipidome Metabolism.

Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects.

Correction to: Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism.

The article Occlusion of left atrial appendage aff ects metabolomic profile:focus on glycolysis, tricarboxylic acid and urea metabolism, written by K. Sattler, M. Behnes, C. Barth, A. Wenke, B. Sartorius, I. El-Battrawy, K. Mashayekhi, J. Kuschyk, U. Hoffmann, T. Papavasiliu, C. Fastner, S. Baumann, S. Lang, X. Zhou, G. Yücel, M. BorggrefeI, Akin, was originally published Online First without open access.

Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism.

BACKGROUND: Left atrial appendage (LAA) closure (LAAC) by implantation of an occlusion device is an established cardiac intervention to reduce risk of stroke while avoiding intake of oral anticoagulation medication during atrial fibrillation. Cardiac interventions can alter local or systemic gene and protein expression. Effects of LAAC on systemic metabolism have not been studied yet. OBJECTIVES: We aimed to study the effects of interventional LAAC on systemic metabolism. METHODS: Products of glycolysis, tricarboxylic acid and urea metabolism were analyzed by ESI-LC-MS/MS and MS/MS using the AbsoluteIDQ™ p180 Kit in plasma of 44 patients undergoing successful interventional LAAC at baseline (T0) and after 6 months (T1). RESULTS: During follow up, plasma concentrations of several parameters of glycolysis and tricarboxylic acid cycle (TCA) and urea metabolism increased (alanine, hexose, proline, sarcosine), while others decreased (aspartate, glycine, SDMA, serine). Multivariate linear regression analysis showed that time after interventional LAAC was an independent predictor for metabolite changes, including the decrease of SDMA (beta -0.19, p < 0.01) and the increase of sarcosine (beta 0.16, p < 0.01). CONCLUSIONS: Successful interventional LAAC affects different pathways of the metabolome, which are probably related to cardiac remodeling. The underlying mechanisms as well as the long term effects have to be studied in the future.

[Geocoding of routine data. Where are my referring physicians and what are my competitors doing?]. / Geocoding von Routinedaten. Wo sind meine Zuweiser und was machen meine Mitbewerber?

Modern methods of reporting include the visualization of data concerning patients and referring doctor's residence and other clinical data with geographical reference. Thus, static and dynamic information about catchment areas and their changes can be visualized as well as answers to the important question for your main referring practicing physicians and possible changes in their behavior. Apart from the purely operational significance for the hospital, we also find important strategic aspects that include issues concerning hospital perspectives and possibilities, e.g., for the planning of collaborations. Overall, the method represents a useful addition to conservative forms of controlling reports in the hospital.

[Complexity level simulation in the German diagnosis-related groups system: the financial effect of coding of comorbidity diagnostics in urology]. / Schweregradsimulation im G-DRG-System : Die finanziellen Auswirkungen der Nebendiagnosenkodierung in der Urologie.

BACKGROUND: Precise and complete coding of diagnoses and procedures is of value for optimizing revenues within the German diagnosis-related groups (G-DRG) system. The implementation of effective structures for coding is cost-intensive. The aim of this study was to prove whether higher costs can be refunded by complete acquisition of comorbidities and complications. METHODS: Calculations were based on DRG data of the Department of Urology, University Hospital of Münster, Germany, covering all patients treated in 2009. The data were regrouped and subjected to a process of simulation (increase and decrease of patient clinical complexity levels, PCCL) with the help of recently developed software. RESULTS: In urology a strong dependency of quantity and quality of coding of secondary diagnoses on PCCL and subsequent profits was found. Departmental budgetary procedures can be optimized when coding is effective. The new simulation tool can be a valuable aid to improve profits available for distribution. Nevertheless, calculation of time use and financial needs by this procedure are subject to specific departmental terms and conditions. CONCLUSIONS: Completeness of coding of (secondary) diagnoses must be the ultimate administrative goal of patient case documentation in urology.

[Reimbursement of new medical therapy]. / Erstattungsfähigkeit neuartiger Arzneimitteltherapien.

Medical progress poses a new financial challenge for the German statutory health insurance. In order to assure the stability of the German statutory health insurance all services have to be economical, but on the other hand the health care system allows access to new therapy in the ambulant and in-patient sector. This article describes in detail how new therapies are reimbursed.

The transcription factor AP-2ɛ regulates CXCL1 during cartilage development and in osteoarthritis.

OBJECTIVE: Recently, the transcription factor AP-2ɛ was shown to be a regulator of hypertrophy in cartilage and to be differentially expressed in osteoarthritis (OA). However, the only known target gene of AP-2ɛ up to date is integrin alpha10. To better characterize the function of AP-2ɛ in cartilage we screened for additional target genes. DESIGN: Promoter analysis, ChIP-assays and electrophoretic mobility shift assay were used to characterize the regulation of a new AP-2ɛ target gene in detail. RESULTS: In this study, we determined the chemokine CXCL1, already known to be important in osteoarthritis (OA), as a new target gene of AP-2ɛ. We could confirm that CXCL1 is expressed in chondrocytes and significantly over-expressed in OA-chondrocytes. Transient transfection of chondrocytes with an AP-2ɛ expression construct led to a significant increase of the CXCL1 mRNA level in these cells. We identified three potential AP-2 binding sites within the CXCL1 promoter and performed luciferase assays, indicating that an AP-2 binding motif (AP-2.2) ranging from position -135 to -144 bp relative to the translation start is responsive to AP-2ɛ. This result was further addressed by site-directed mutagenesis demonstrating that activation of the CXCL1 promoter by AP-2ɛ is exclusively dependent on AP-2.2. Chromatin immunoprecipitation and electromobility shift assays confirmed the direct binding of AP-2ɛ to the CXCL1 promoter in OA-chondrocytes at this site. CONCLUSION: These findings revealed CXCL1 as a novel target gene of AP-2ɛ in chondrocytes and support the important role of AP-2ɛ in cartilage.

[Adjustment of the German DRG system in 2009]. / G-DRG-Systemanpassung 2009.

BACKGROUND: The 2009 version of the German DRG system brought significant changes for urology concerning coding of diagnoses, medical procedures and the DRG structure. In view of the political situation and considerable economic pressure, a critical analysis of the 2009 German DRG system is warranted. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The relevant diagnoses, medical procedures and German DRGs in the versions 2008 and 2009 were analysed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focus on the development of the DRG structure, DRG validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. CONCLUSION: The German DRG system again gained complexity. High demands are made on correct and complete coding of complex urology cases. The quality of case allocation in the German DRG system was improved. On the one hand some of the old problems (e.g. enterostomata) still persist, while on the other hand new problems evolved out of the attempt to improve the case allocation of highly complex and expensive cases. Time will tell whether the increase in highly specialized DRG with low case numbers will continue to endure and reach acceptable rates of annual fluctuations.

[Changes to diagnosis-related groups in urology in 2007. Urology in the G-DRG-System 2007]. / DRG-Veränderungen 2007 im Fachgebiet Urologie. Urologie G-DRGs 2007.

BACKGROUND: The German DRG (dose-related groups) system is updated each year by the institution dealing with the remuneration in hospitals (InEK). Once again, the German Spcoety for Urology has supported the adjustment process in a constructive manner. Analysis of the changes and their implications is highly significant for urology. This article describes and discusses the main changes in the system for the specialty of urology insofar as they concern the structure of the DRG system and the catalogues of diagnoses (ICD) and of procedures (OPS). RESULTS: The 2007 edition of the DRG system leads to numerous changes for urology. There are new OPS codes for partial resection of the kidney, treatment of urinary incontinence and radical resection in the pelvis minor. Additional payment for implantation of a prosthetic penis is divided with reference to the type of prosthesis. At DRG level, new DRG splits are found depending on the PCCL and patient age. Combination operations on the bladder and bowel and on the male genitalia are assigned to newly established DRGs. CONCLUSIONS: The changes described enhance the professional accuracy of the representations of urological care provision. New strategies designed to solve problems in representation have been established (e.g. multi-step interventions). Various problems persist, e.g. those of operations on the penis (DRG M03Z) and the need for more finely defined representation of laser treatment in urology. In the short term practicable solutions to the problem of improving the quality of representation are needed.

Mercury speciation analyses in HgCl(2)-contaminated soils and groundwater--implications for risk assessment and remediation strategies.

Since the 19th century, mercury(II)chloride (HgCl(2)) has been used on wood impregnation sites to prevent wooden poles from decay, leaving behind a legacy of highly contaminated soil/aquifer systems. Little is known about species transformation and mobility of HgCl(2) in contaminated soils and groundwater. At such a site the behaviour of HgCl(2) in soils and groundwater was investigated to assist in risk assessment and remediation. The soil is low in organic carbon and contains up to 11,000 mg Hg/kg. Mercury (Hg) concentrations in groundwater decrease from 230 to 0.5 microg/l within a distance of 1.3 km. Hg species transformations in soil and aqueous samples were analysed by means of solid-phase Hg pyrolysis and CV-AAS. In aqueous samples, Hg species were distinguished between ionic/reactive Hg and complex-bound Hg. Potential mobility of Hg in soils was studied through batch experiments. Most Hg in the soil is matrix-bound HgCl(2), whereas in the aquifer secondary formation to Hg(0) could be observed. Aqueous Hg speciation in groundwater and soil solutions shows that an average of 84% of soluble Hg exists as easily reducible, inorganic Hg species (mostly HgCl(2)). The proportion of complex-bound Hg increases with distance due to the transformation of inorganic HgCl(2). The frequent occurrence of Hg(0) in the aquifer suggests the formation and degassing of Hg(0), which is, in addition to dilution, an important process, lowering Hg concentrations in the groundwater. High percentage of mobile Hg (3-26%) and low seepage fluxes will result in continuous Hg release over centuries requiring long-term groundwater remediation. Results of soluble Hg speciation suggest that filtering materials should be adapted to ionic Hg species, e.g. specific resins or amalgamating metal alloys.

[Volume outcome relationship. Consequences of reallocation of minimum volume based on current German surgical regulations]. / Mindestmengen. Konsequenzen der Festlegung von Schwellenwerten für chirurgische Leistungen.

BACKGROUND: Consequences of the volume outcome relationship are controversial. Objectification based on data analysis is strongly needed. The aim of this publication was to analyse the effects of volume outcome reallocations based on German inpatient data. METHOD: The analysis based on inpatient data of the Krankenhauszweckverband Koeln, Bonn und Region (Hospital Association of the Cologne and Bonn Region) of 2002 and 2005. Relevant data sets were identified according to the effects of current German regulations on volume outcome on the special fields liver transplant, kidney transplant, complex pancreatic surgery, and complex oesophageal surgery. RESULTS: The effects of current German regulations on volume outcome results differed greatly between the four surgical specialities. There were fewer effects on kidney transplant, but due to an already very high level of centralisation 34% (oesophagus) and 8% (pancreas) of the hospitals stopped related surgery. This affected 8.9% (oesophagus) and 2.2% (pancreas) of related cases. CONCLUSION: Concentration and the formation of specialised medical centres are results of the implementation of volume outcome relationships. The quality of medical treatment does not automatically improve from this development. It is necessary to analyse any correlation between quality and frequency of treatment or other criteria such as know-how, structure and process management, and multidisciplinarity.

[Changes for the field of rheumatology in the G-DRG-System 2007]. / Was gibt es Neues für die Rheumatologie im G-DRG-System 2007?

After extensive revision the partners of the self-administration"Selbstverwaltung" reached an amicable agreement on the new version 2007 of the G-DRG system. Like in the years before, version 2007 brings about large-scale changes for its users. A better representation of inpatient services in Germany combined with an improved economic homogeneity and appropriateness can be assumed. This is based on various factors, e. g. considerably increased data-quality and the optimization of technical influences on the system. Due to the rising level of complexity it is hardly possible to maintain a clinically homogeneous classification on the basis of G-DRGs. There is need [This calls] for a new approach in strategic matters. Various initiatives succeeded in a continuous improvement how the services provided by specialised rheumatologic clinics and departments are represented in the G-DRG system. Meanwhile, even under the pressure caused by the period of convergence, quality standards were focused on as well. The systematic changes of version 2007 as well as modifications concerning co-payments, coding and accounting rules relevant for rheumatologic clinics are presented and the consequences for users are discussed.

[Changes for rheumatology in the G-DRG system 2005]. / Veränderungen für die Rheumatologie im G-DRG-System 2005.

The German prospective payment system G-DRG has been recently adapted and recalculated. Apart from the adjustments of the G-DRG classification system itself changes in the legal framework like the extension of the "convergence period" or the limitation of budget loss due to DRG introduction have to be considered. Especially the introduction of new procedure codes (OPS) describing the specialized and complex rheumatologic treatment of inpatients might be of significant importance. Even though these procedures will not yet develop influence on the grouping process in 2005, it will enable a more accurate description of the efforts of acute-rheumatologic treatment which can be used for further adaptations of the DRG algorithm. Numerous newly introduced additive payment components (ZE) result in a more adequate description of the "DRG-products". Although not increasing the individual hospital budget, these additive payments contribute to more transparency of high cost services and can be addressed separately from the DRG-budget. Furthermore a lot of other relevant changes to the G-DRG catalogue, the classification systems ICD-10-GM and OPS-301 and the German Coding Standards (DKR) are presented.

[Current aspects of stone therapy]. / Aktuelle Aspekte der Steintherapie.

More than 30 % of all admissions to an urologic clinic are for the treatment of urinary stones. In almost all cases, the treatment is minimally invasive employing extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS) or percutaneous nephrolithotomy (PCNL). Technical advances in endourology and a growing expertise in ESWL led to a decline in ESWL and an increase in endoscopic techniques. In comparison with ESWL, the endoscopic techniques are more invasive but in most cases achieve a stone free state faster. With the introduction of diagnosis related groups (DRG), the economic aspect of stone therapy is gaining in importance. Stone prevention leads to a cost reduction in the health care system, justifying the use of an appropriate stone metaphylaxis. This review article presents the current recommendations for interventional urinary stone therapy and lists the options of conducting both medical and economically rational therapy.

Risk of gastrointestinal bleeding associated with Helicobacter pylori infection in patients with hemophilia or von Willebrand's syndrome.

BACKGROUND: Many episodes of bleeding in the upper gastrointestinal tract are caused by Helicobacter pylori infection. Because these episodes present a life-threatening complication in patients with bleeding disorders, we prospectively investigated the prevalence of H. pylori infection in patients with hemophilia A or B and with the von Willebrand syndrome. METHODS: Seventy patients (54 men, 16 women, ages 40 +/- 11 years) and 100 age-related volunteers (63 men, 37 women, ages 39 +/- 9 years) were tested for H. pylori infection using the 13C urea breath test. Fifty-four patients with hemophilia and 16 patients with von Willebrand syndrome participated. RESULTS: Thirty-three (33%) of the controls and 24 (34.3%) of the patients showed positive 13C urea breath tests (p = .97). Nineteen (35.2%) patients with hemophilia and 5 (31.3%) patients with von Willebrand syndrome were positive for H. pylori. History of dyspeptic symptoms (28% vs. 26%) were not different in patients and controls (p = .91). Gastric ulcers (20% vs. 5%) and duodenal ulcers (7% vs. 5%) were diagnosed more often in patients with bleeding disorders. Fourteen of the patients (20%), but none of the controls had a history of gastrointestinal bleeding (p < .001). CONCLUSIONS: The rate of H. pylori infection and dyspepsia in patients with bleeding disorders is similar to the prevalence in the normal population. Due to increased bleeding complications, H. pylori screening and therapy appears mandatory in patients with bleeding disorders.

Leg ulcers in Klinefelter's syndrome--further evidence for an involvement of plasminogen activator inhibitor-1.

An abnormality in platelet aggregability or fibrinolysis, namely elevated activity of plasminogen activator inhibitor-1 (PAI-1), has been recently documented in patients suffering from Klinefelter's syndrome associated with leg ulceration without underlying venous insufficiency. To determine whether increased PAI-1 activity is a general feature of Klinefelter's syndrome, or more specifically associated with leg ulceration, we investigated PAI-1 influencing parameters and PAI-1 activity in two groups of patients: (i) Klinefelter patients suffering from leg ulceration (n = 7); and (ii) Klinefelter patients without leg ulceration (n = 6). On analysing PAI-1 influencing parameters such as age, body mass index, triglycerides, C-reactive protein, testosterone, smoking behaviour, the presence of diabetes mellitus, and arterial hypertension, respectively, we found no statistically significant differences between the two groups. However, PAI-1 activity in group 1 was highly significantly elevated compared with that in group two patients (P < 0.005). We conclude that (i) PAI-1 activity is not elevated in Klinefelter's syndrome in general; (ii) elevation of PAI-1 activity in patients suffering from Klinefelter's syndrome does not appear to be secondary to PAI-1 influencing parameters; and (iii) elevation of PAI-1 activity may play a crucial role in the pathogenesis of leg ulceration in Klinefelter's syndrome. Therefore, a therapy for leg ulceration in Klinefelter's syndrome that aims to return the elevated PAI-1 activity to normal should be explored.