Zytokine in der Medizin

Cytokines coordinate the human immune system.Recombinant cytokines are already used to modulate the activity of the immune system.Based on our knowledge of the cytokine network, variants of cytokines and cytokine receptors were generated, which are also currently used in the clinic.Moreover, structural and genetic methods were used to design novel cytokine variants, which enable an even more sophisticated manipulation of the human immune system.These novel therapeutic strategies are described and discussed.     

Klassifikation in der Medizin

Human beings are born with the ability to recognize Gestalt and to classify. However, all classifications depend on their circumstances and intentions. There is no ultimate classification, and there is no one correct classification in medicine either. Examples for classifications of diagnoses, symptoms and procedures are discussed. The path to gaining knowledge and the basic difference between collecting data (patient file) and sorting data (register) will be illustrated using the BAIK information model. Additionally the model shows how the doctor can profit from the active electronic patient file which automatically offers him other relevant information for his current decision and saves time. "Without classification no new knowledge, no new knowledge through classification". This paradox will be solved eventually: a change of paradigms requires the overcoming of the currently valid classification system in medicine as well. Finally more precise recommendations will be given on how doctors can be freed from the burden of the need to classify and how the whole health system can gain much more valid data without limiting the doctors' freedom and creativity through co-ordinated use of IT, all while saving money at the same time.     

Autonomie in der Medizin

Autonomy is a central and multifaceted concept of ethical reflection with many nuances of meaning. Central to the concept are the ability and opportunity to self-determine and self-design, as well as the potential to shape the course of one's own life significantly. However, there is generally a narrow understanding of the concept in the debate on patient autonomy and informed consent in a medico-therapeutic context, to which the possibility to a free decision-making process based on concrete treatment scenarios is central. In contrast, the present article discusses the diversity of autonomy-related aspects in non-therapeutic areas of medicine, while underlining the need to further develop and differentiate the concept of autonomy.     

Genetische Diagnostik in der Medizin

Currently, more than half of all known monogenic diseases are characterized at the molecular (DNA) level. This opens the possibility to verify clinically suspected disease at the molecular level, to predict future (late-onset) disorders, to diagnose many diseases prenatally, and to screen the population for genetic traits. Genetic tests that can be performed in Germany, Austria and Switzerland are listed in a database maintained by the German Board of Human Genetics. As of May 2006, 678 different diseases were amenable to DNA-based testing, and 147 institutions offered such tests. The actual genetic test utilisation cannot be determined accurately, but can be deduced from the database of the "Zentralinstitut der Kassen?rztlichen Bundesvereinigung". Data have been calculated for the years 1996- 2002. In this time interval, the number of individuals undergoing genetic testing doubled approximately every three years. The total number in 2002 can be estimated at 220,000.     

Der Placeboeffekt in der Medizin

Placebos are medication surrogates that are able to improve symptoms in patients when prescribed by a doctor and for a patient, and that cannot be explained by a drug. In clinical testing and presumably also in clinical routine, placebo effects contribute substantially to the efficacy of medicines, at least with every-day diseases and complaints. Placebos on the one hand, and the mechanisms the response on the other, have not interfered with the development on novel drugs in past years, but have also brought about research that investigates its mechanisms and public interest in its clinical use in everyday medicine. Current knowledge grows by about 10.000 publications per year on placebo-controlled studies, and by nearly 100 papers on the placebo effect itself. This review will focus on the history of placebo use in medicine, on ethical issues related to the use of placebos, on methodological problems in placebo-controlled trials and their alternatives, and on mechanisms of the placebo response in clinical and experimental research, e.g. on type, size, dynamics, determinants, and predictors of the placebo response in the literature.     

Prävention in der Medizin

With the revival of “prevention” in Germany well-known problems from discussions in the 70s have gained new importance: prevention of behaviour vs prevention of conditions and orientation towards the individual vs society. On the one hand “curative” medicine in Germany never has allowed prevention to develop a role for itself, but on the other hand a preventive orientation has—unnoticed by medicine—revolutionized “curative medicine”. Not reflecting the structural differences between prevention and “curative medicine” has resulted in a number of serious misunderstandings of practical importance.     

Weiterentwicklung des Promotionsverfahrens in der Medizin

The medical doctorate and the subsequent advanced research qualification in medicine have an exceptional position within the natural sciences. While, in the German system, graduation to the degree of a medical doctor is often an initiation into scientific practice, the in-depth scientific education of medical doctors may be achieved in various configurations. In recent years, structured programs for doctorates in medicine and natural sciences have found increasing acceptance, following recommendations of national scientific councils (“Deutsche Forschungsgemeinschaft” and“Hochschulrat”). Hannover Medical School has been offering such programs for a number of years. The StrucMed program increases the quality of medical doctorate studies, typically performed in the third and fourth years of university studies. The Hannover Biomedical Research School (HBRS) combines several programs for a doctorate in natural sciences, creating a platform for an internationally oriented education of post-graduates in various disciplines of life sciences. Evaluating the achievements and career paths of the trainees will contribute to the successful integration of research work in an efficiency-oriented clinical environment.     

Versorgungsforschung in der operativen Medizin am Beispiel der Mammakarzinomchirurgie

The epidemiological relevance of breast cancer in Germany has led to a number of initiatives actually changing the processes and structures of care. The ultimate aim of health services research in surgery is to evaluate the impact of these initiatives on the effectiveness and efficiency of the respective health care services. Results of international studies show for instance breast-conserving therapy to be related to the patients' socioeconomic status. In addition, breast specialists tend to operate more in adherence to practice guidelines and to implement new procedures like sentinel lymph node biopsies earlier. Preliminary results from Germany also demonstrate a considerable practice variation in breast cancer surgery. Causes and effects of such variation still have to be explored. For that purpose, newly available data sources on health care services in relation to breast cancer surgery in Germany could be used. The inherent challenge is to combine data from tumour registries, statutory comparative quality assurance activities and inpatient remuneration via DRGs for health services research in surgery.     

Personalisierte Medizin in der Psychiatrie und Psychotherapie

The main goal of psychiatric high-risk research—the personalised early recognition and intervention of schizophrenic and affective psychoses—is one of the biggest challenges of current clinical psychiatry due to the immense socioeconomic burden of these disorders. In this regard, this review discusses the prospects and caveats of new clinical, neuropsychological, neurophysiological and imaging-based concepts aimed at optimising the current state-of-the-art of early recognition. Finally, multivariate modelling and machine learning methods are presented as a novel methodological framework facilitating the decoding of early psychosis into different intermediate phenotypes. In the future, these phenotypes could be employed for a more objective risk stratification that operates at the single-subject level. This could allow us to generate clinically applicable prognostic biomarkers for these disorders that would propel the individualised prevention of disease transition, chronification and psychopharmacological treatment resistance of psychotic disorders.     

Besonderheiten bei der Regulierung biologischer Arzneimittel in der individualisierten Medizin

The term individualised medicine, also called personalised medicine, is commonly used as an equivalent to stratified medicine. However, this is erroneous since quite often it is forgotten that especially biological medicinal products have other aspects of individualization that go beyond mere stratification. The principles of stratified medicine have been applied for biological medicinal products for many years. A historical example is diphtheria antitoxin made from horse serum, while current examples are transfusion of red blood cells and the administration of factor VIII in haemophilia A. The stratifying aspects of these medicinal products are given by the following considerations: diphtheria antitoxin is only administered after a diagnosis of diphtheria and not in other forms of tonsillitis, red blood cells should only be transfused once blood group compatibility as been established and factor VIII replacement is only administered in haemophilia A as opposed to other acquired or hereditary disease of the coagulation system. The peculiarities of biological medicinal products, in particular the inherent variability of the drug, are especially important for autologous cellular medicinal products. In addition to the expected variability of the biological source material there is interindividual variability of patients as cell donors, which make definition of specifications and determination of criteria for pharmaceutical quality and potency tests difficult. Therapy with modified autologous cells, a common and important application of advanced therapy medicinal products, is exemplary for the special considerations that must be made when evaluating pharmaceutical quality, mode of action and toxicological properties of the biological medicine. The clinical investigation of advanced therapy medicinal products with the intent of demonstrating safety and efficacy is particularly challenging because of the complexity of therapy, which often involves invasive interventions. The development of biomarkers accelerates the process towards stratified or individualised therapies. Increased requirements for companion diagnostics are a possible consequence. Progress in analytical processes and in biotechnology make a higher degree of individualization likely, possibly to the degree that medicinal products will be individually manufactured for each patient. Current principles of medicinal product testing and market authorization may be applicable only with limitations, because the individual medicinal products are not uniform and are not repeatedly manufactured. The assessment of the process, performed on several different medicinal products manufactured by the same process could potentially serve as a basis for the assessment. For the evaluation of risk for the patient in clinical trials new concepts must be considered, which can be facilitated by interaction of regulatory authorities and developers.     

Der Schmerz — Stiefkind der Medizin

Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz -     

Mind-Body Medicine als Bestandteil der Integrativen Medizin

Mind-body medicine (MBM) as a holistic approach to health and healing has been shaped by research into stress physiology and stress psychology, by psychoneuro(endocrino)immunology and by Antonovsky's salutogenetic paradigm. MBM seeks to acknowledge physical, psychological as well as social and spiritual aspects of human beings. MBM constitutes one of the traditions, which the emerging field of integrative medicine in Germany draws upon, others being mainstream medicine, traditional European naturopathy and non-European methods like traditional Chinese medicine. The article outlines historical aspects of MBM, gives a brief review of research evidence, and introduces clinical MBM institutes in Germany. Especially the Clinic and Chair of Complementary and Integrative Medicine, Alfried Krupp von Bohlen und Halbach Foundation at the University Duisburg-Essen has been integrating MBM into the concept of integrative medicine. Considering that a growing number of health issues arises due to maladaptive lifestyles, MBM is being identified as a development that supports a shift from increasingly expensive treatments to more cost-effective preventive approaches.     

Erfahrungen mit Methoden der systematischen Kompetenzdarlegung und Rezertifizierung in der Medizin in Kanada

Recertification and systematic assessment of performance are components of well-developed medical quality culture. Canada has accumulated a wealth of experience in the development and application of methods of assessment. Germany can learn from the Canadian experience. In this article the Canadian three-step approach to assessment is introduced as well as the experience of its implementation in the provinces of Ontario and Alberta.     

Zentrum für Qualität in der Medizin

Zusammenfassung Grundlage der Modernisierung des Gesundheitswesens ist eine systematische, auf den Patienten bezogene Qualitätsentwicklung. Bereits 1999 wurde in den Zielen für eine einheitliche Qualitätsstrategie im Gesundheitswesen der Gesundheitsministerkonferenz festgestellt, dass der Aufbau eines nationalen Kompetenzzentrums für Qualität in der Medizin eine Chance sei, die vielfältigen Bemühungen um wissenschaftlich orientierte, praktikable Qualitätsförderung zu vereinheitlichen und zu stützen. In diesem Zusammenhang wurden seit Ende 2002 neue Planungen der Regierungskoalition zur Gründung eines Instituts für Qualität im Gesundheitswesen als Bundeseinrichtung kontrovers diskutiert. Aufgrund des Widerstandes—insbesondere seitens der Selbstverwaltungskörperschaften—wurden diese Vorstellungen fallen gelassen. Statt dessen wurde die Einrichtung eines nationalen Kompetenzzentrums für Qualität in der Trägerschaft der Selbstverwaltung vorgeschlagen. Es hat den Anschein, dass in den konkreten Planungen die Konzepte von 1999 wieder aufgegriffen werden. Hintergründe,Ziele und Alternativen dieses Projektes werden dargelegt und kommentiert.     

Stellenwert der Bioinformatik für die personalisierte Medizin

Medicine is experiencing a period of change: Extensive molecular biological data on the patient are increasingly included in diagnosis and treatment. This trend is based on the development of targeted drugs and accompanying diagnostics, which serve the purpose of providing advance evidence that the medication promises therapy success for the patient. According to this concept drugs are often given in combination. The sizes of patient groups for which a given therapy out of many possible alternatives can be expected to be successful are quite limited. The relationship between the molecular data pertaining to a patient and their disease phenotype are complex and cannot be determined manually. Thus, computer-based bioinformatics methods play a central role in interpreting the molecular data and as an instrument for providing recommendations for the practicing physician. Bioinformatics is an essential component in basic research, in the development of new concepts for diagnosis and therapy as well as in clinical practice, in which these concepts are applied to treating patients. This article discusses the role of bioinformatics in both basic research and clinical practice. We present the example of treatment of HIV patients, for which bioinformatics-assisted therapy selection has already entered clinical practice. Such a therapy concept is also predestined for other diseases (e.g., cancer). The article concludes with remarks on the prerequisites for society as a whole for ensuring success of this concept of personalised medicine as a factor of medical progress.     

Gesundheitsinformationen als Beitrag zur Qualitätssicherung in der Medizin

Ohne Zusammenfassung Dr.Werner St?ber Deutsches Institut für Medizinische Dokumentation und Information, Waisenhausgasse 36–38a, 50676 K?ln, E-Mail: stoeber@dimdi.de Prof.Dr. Rüdiger Klar Abteilung Medizinische Informatik, Universit?tsklinikum Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, E-Mail: klar@mi.ukl.uni-freiburg.de     

Aktuelle Therapie der Osteoporose unter Berücksichtigung der auf Evidenz basierenden Medizin

Osteoporose ist gekennzeichnet durch Demineralisation, Strukturverlust und verminderte Belastbarkeit der Knochen. Atraumatische Frakturen k?nnen die Folge sein. Die Krankheit wird zu den zehn h?ufigsten Krankheiten in Europa gez?hlt. Drei Millionen Menschen in Deutschland leiden an osteoporosebedingten Wirbelfrakturen. Die Kosten für die Therapie der Frakturfolgen (hüftnahe und sonstige periphere Frakturen sowie die der Wirbelk?rper) werden auf 6 bis 7 Milliarden DM in Deutschland beziffert. Nur 20 % der an Osteoporose Erkrankten erhalten eine ad?quate Therapie. Ziel der Osteoporosetherapie ist die Verhinderung erster und weiterer Frakturen. Dies ist durch moderne Therapeutika, wie den Bisphosphonaten – so die Studienlage – m?glich. Durch den Zwang der Budgetierung sollten für Therapieentscheidungen die Prinzipien der “Evidence based Medicine” berücksichtigt werden.     

Der bemerkenswerte Anstieg der Lebenserwartung und sein Einfluss auf die Medizin

In den Industrienationen ist die Lebenserwartung in den vergangenen 160 Jahren stetig gestiegen. Und der Trend hält an: Die Zahl der Menschen, die ihren 100. Geburtstag feiern können, hat sich seit 1950 in jedem Jahrzehnt mindestens verdoppelt. Ausschlaggebend für die Verlängerung der Lebenserwartung war und ist ein Zusammenspiel wirtschaftlicher Entwicklungen, sozialer Errungenschaften und medizinischer Fortschritte. Eine unentrinnbare Obergrenze der Lebenserwartung ist nicht in Sicht. Vielmehr erweist sich der Alterungsprozess als plastisch und über genetische und nicht-genetische Interventionen modifizierbar. Heute ist der Anstieg der Lebenserwartung vor allem der verringerten Sterblichkeit im Alter zuzuschreiben, was durch Fortschritte in der effektiven Prävention, der Diagnose und der Therapie von Alterskrankheiten weiter unterstützt wird. Setzt sich der Trend fort, wird die Lebenserwartung in der ersten Hälfte dieses Jahrhunderts in Deutschland auf über 90 Jahre steigen. Viele offizielle Prognosen bleiben jedoch darunter, was schwerwiegende Konsequenzen für öffentliche und private Entscheidungsprozesse haben kann.