Schnittstellen in der ambulanten und stationären rheumatologischen Versorgung

In healthcare the term interface describes the communication and the sharing of responsibilities between different aspects of medical care und the different professional groups in medicine. It enables cooperation without conflicts and can contribute to an improvement of healthcare and reduce healthcare costs. The postgraduate professional education, medical guidelines and therapy recommendations are an important basis for the definition of interfaces. The definition of such an interface between different healthcare groups is essential for the implementation of selective contracts with health insurance companies. An appropriate health care interface between general practitioners and rheumatologists has been defined as well as between hospital and ambulant rheumatology treatment. The division of responsibilities between orthopedists and rheumatologists is still under discussion. A proposal for such an interface from the point of view of rheumatology is presented.     

Translationale Forschung in der Geriatrie?

Contemporary geriatric research focuses mainly on observational clinical studies and epidemiological surveys and the translation of basic scientific results from biogerontology into a clinical context is often neglected. Following a definition of translational research the article gives an overview of recent key publications in experimental biogerontology with a special emphasis on their relevance for clinical geriatrics. The topics dealt with include age-induced loss of skeletal muscle (sarcopenia), the aging immune system (immunosenescence) and neurodegenerative disorders (Alzheimer’s and Parkinson’s disease).     

An?mie und Eisenmangel in der Geriatrie

The prevalence of anemia in geriatric patients is high. With some variation in different patient cohorts, prevalence of anemia can reach 40%. Anemia is not an age-related disease on its own, but is a symptom with multifactorial genesis and high risk potential. It directly influences mortality, morbidity, and the rate of hospitalization, particularly in older patients suffering from chronic heart failure or chronic kidney disease. The high prevalence of anemia in chronic kidney disease is explained by a combination of erythropoietin and iron deficiency. This review summarizes the recommendations of the iron symposium at the 2010 German Geriatric Society Meeting in Potsdam, Germany. It intends to provide current information on prevalence, diagnostic work-up, and therapeutic options for anemia in the rapidly growing group of elderly patients.     

St��rze in der Geriatrie

Falls are among the most frequent adverse events in the life of an older person. Accident and emergency units, outpatient services and internal medicine wards should have a diagnostic concept for falls and fall-related injuries and implement an evidence-based risk management for fall prevention. The recently published Reviews of the Cochrane Collaboration and the revised guidelines of the Anglo-American medical societies are a proper basis to plan these steps. This, of course, has to be adapted for the needs of each institution. Currently, it is probable that at least 30% of all falls are preventable. A structured fall history and multifactorial assessment is not part of the routine of outpatient and inpatient services in Germany. The planned revision of the German nursing guideline on fall prevention and the current activities of the Aktionsbündnis Patientensicherheit will also lead to a legal dilemma for those institutions that have not implemented an adequate workup.     

Ärztliche Weiterbildung in der Geriatrie

Zum Thema Bei derzeit 1,6 Mio. pflegebedürftigen alten Menschen, wovon ein Drittel über 80 Jahre alt ist und rund 660.000 Menschen in Pflegeheimen leben, ist der bereits bestehende und in der Zukunft zu erwartende medizinische Versorgungsbedarf enorm. Mit der Etablierung des ohne Frage sehr anspruchsvollen fakultativen Weiterbildungsganges Klinische Geriatrie in die (Muster-)Weiterbildungsordnung 1992 ist es gelungen, einen Beitrag zur Verbesserung der station?ren Versorgung ?lterer Menschen zu leisten.     

Leitlinien und Standards zur Ern?hrung in der Geriatrie

Nutritional problems and deficiencies are widespread in geriatric institutions. On the other hand, benefits of different interventions to improve the nutritional situation of elderly people ?C from amelioration of mealtime ambience to the use of artificial nutrition ?C have been shown in many studies. In recent years, several guidelines and standards have been developed to facilitate the transfer of this scientific knowledge into practice. These are in particular the medical Guidelines for Enteral and Parenteral Nutrition in Geriatrics (DGEM/DGG and ESPEN), the DNQP Expert Standard for qualified nurses, the DGE Quality Standards for dietetic personnel, and the interdisciplinary BUKO-QS Standard. These guidelines and standards provide recommendations for adequate nutritional care and assistance for the institutionalized elderly person based on the scientific state of the art. They should be used as the basis for the development of local instructions for the management of nutritional problems and malnutrition. Elderly people will only profit, if these guidelines are used in daily routine.     

Was erwartet der Geburtshelfer bei der Schwangerenbetreuung vom Internisten?

Cooperation between the obstetrician and the physician for internal medicine is especially needed when a pregnant woman suffers from complex medical diseases. This contribution focuses on the special circumstances of maternal treatment also considering the fetal state with the following examples: drugs in the first trimester, cardiac diseases, pregnancy-induced hypertension, HELLP syndrome, gestational and type I diabetes, thrombosis, pulmonary diseases, infections, and treatment of cancer during pregnancy. Special obstetric requests to the physician are: keeping in close contact, avoiding recommendations for the mode of delivery, avoiding overtreatment of hypertensive disorders as well as intensifying the surveillance including the creation of preventive schedules for pregnant women with an increased risk of developing metabolic syndrome in their later life.     

Qualität der Versorgung älterer Menschen

Ohne Zusammenfassung     

��?116b SGB?V in der rheumatologischen Versorgung

Background

The choice between outpatient and inpatient care is currently undergoing major changes within the German health care system with the amendment of §?116b SGB?V. This study investigates what proportion of hitherto inpatient rheumatologic care could potentially be given on an outpatient basis.

Methods

The analysis is based on administrative inpatient data from 2004 to 2008 covering approximately 23.6 million private health insurance insurants. The selection of patients with rheumatological diseases was based on diagnosis according to ICD-10 of §?116b SGB?V.

Results

From 2004 to 2008 the number of all rheumatologic cases increased by 13.9%, while the average length of hospital stay decreased from 9.46?days to 8.08?days and the number of attending hospitals declined by 3.1%. The number of rheumatologic cases with a short inpatient stay (??2?days) increased by 32.3%. We define the ambulatory potential as the proportion of patients with a short length of stay to the total of inpatient rheumatologic cases; this increased from 25.7% to 29.9%.

Discussion

Not all patients with a short inpatient stay can be transferred problem-free to ambulatory care. No channeling of patients to specialized centres has taken place thus far in Germany. Quality of care at the hospitals studied has not been considered. Further data are needed to link administrative data with quality care data.     

Evidenz-basierte Medizin – Probleme und Anwendung in der Geriatrie

The use of evidence-based medicine (EBM) in the field of geriatrics faces some specific problems. Deficits in representation of older people in medical trials and the attitude of the majority of patients and their physicians considering disease as normal aging counteract successful implementation. EBM is also feasible in older patients after some adjustments without dropping the principles of the method or the preferences of patients, thus, resulting in improvement in diagnostic and therapeutic decisions. The methods are exemplified in the use of prophylactic antibiotics in endoscopic gastrostomy, a relevant geriatric problem with practical consequences.     

Telematik in der Geriatrie – Potentiale, Probleme und Anwendungserfahrungen

Modern telecommunication technology (telematics) has the potential to improve the quality of life for elders with physical and mental impairments as well as for their care giving relatives. Videophones, internet resources, and multimedia computers can be used for networking them together with social workers, nurse practitioners, physicians and therapeutic staff in service-centers. This can be viewed as a unique opportunity to establish and maintain instant and personalized access to various medical services in a situation where increasing needs are opposed to decreasing resources. However, it is not yet clear whether telematics is adequate, efficient, and effective in supporting care for geriatric patients. Some studies already showed its applicability and feasibility, but there are still no larger trials showing that maintenance or enhancement of autonomy can be achieved effectively by using new technologies. This article reviews the literature on telematics in geriatrics and presents data of a tele-rehabilitation project ("TeleReha", conducted at the Berlin Geriatric Center) which comprised mobility-impaired patients (N = 13, mean age 72 yrs), care giving relatives (N = 8), and geriatric professionals. Networking was established using ISDN technology with videophones or PC-based videoconferencing systems. Results showed that participants regard telecommunication devices as a valuable resource for their informational and communicational needs. Use of telecommunication systems was inversely related to physical mobility. Having access to professional service and counselling was rated highly important but also the opportunity to establish reliable contacts with non-professionals (relatives, other participants). Despite experienced technical problems, use of telecommunication systems was evaluated more positively in the post-test as compared to the pre-test. In summary, current experience suggests that telematics can be used efficiently by geriatric patients and by relatives and professionals caring for them. However, evidence for a medically and economically effective use is still scarce. A lack of structural and organizational concepts for geriatric telematics initiatives can be identified which in part may be due to the fact that the considerable potentials of telematics applications are still largely unrecognized by geriatricians.     

Telematik in der Geriatrie – Potentiale, Probleme und Anwendungserfahrungen

Die Darstellung der modernen Kommunikations- und Informationstechnologie in den Medien verspricht auch ?lteren Menschen eine Chance zur Verbesserung der Lebensqualit?t. Mit „Neuen Medien” wie Bildtelefon oder PC, dem Internet und der elektronischen Post k?nnen geriatrische Patienten mit Beratungseinrichtungen, ?rzten, Therapeuten oder Pflegekr?ften, aber auch ihren eigenen Angeh?rigen oder Selbsthilfeeinrichtungen so vernetzt werden, dass sie bildgestützt kommunizieren und Informationen elektronisch erhalten oder übermitteln k?nnen. In der vorliegenden Arbeit wird untersucht, ob Versorgungsstrukturen in der Altersmedizin und Altenhilfe durch moderne Informations- und Kommunikationstechnologie („Telematik”) sinnvoll erg?nzt oder sogar substituiert werden k?nnen. Trotz einer Vielzahl von Untersuchungen zur Telemedizin und zu Telematikanwendungen existieren nur wenige Studien, die eine Eignung für geriatrisch-rehabilitative Belange belegen. Eigene Anwendungserfahrungen aus einem geriatrischen Telematik-Projekt („TeleReha”) am Evangelischen Geriatriezentrum Berlin, in dem geriatrische Patienten und deren Angeh?rige mit professionellen Kr?ften aus dem Geriatriezentrum unter der Ma?gabe des Erhalts eines Rehabilitationserfolges vernetzt wurden, zeigen aber, dass Telematik-gestützte Dienste von geriatrischen Patienten und deren Angeh?rigen als eine wertvolle zus?tzliche Ressource angesehen werden, wenn sie mit einem qualifizierten Dienstleistungskonzept einhergehen. Abschlie?end werden die Potentiale, aber auch die Probleme von Telematikanwendungen in der Geriatrie diskutiert. Obwohl sich ein Bedarf beim geriatrischen Klientel identifizieren l?sst, fehlt es in der Geriatrie noch an Initiativen, die notwendigen Konzepte und tragf?hige Strukturen zu entwickeln. Das beachtliche Potential der telematischen Anwendungen für Geriatrie und Altenhilfe wird noch zu wenig beachtet. Gerade die Geriatrie kann und muss hier ihre spezifische Expertise einbringen, über die andere Disziplinen nicht gleicherma?en verfügen.     

Die Erfassung alltagsrelevanter Mobilität in der Geriatrie mittels statischer Posturographie – Eine bevölkerungsbezogene Studie

In a population-based study of 110 women between 53 and 82 years of age (mean age 64.5 +/- 7.9 years) static posturography data were compared to functional items of gait and balance in common geriatric mobility scales. Posturographic data of double-stance with eyes open and eyes closed (DSEO; DSEC) did not differ from those of a group of healthy women previously tested for intact nervous system function. The total neuromuscular score--roughly corresponding to the well-known Tinetti score--did not correlate to the posturographic measures. DSEC correlated with the items "rapid walking" and "single-stance left leg". Age, vision, and neuropsychologic test results correlated with DSEO, "rapid walking", "single-stance right leg", "single-stance left leg", and "walking a figure eight". Multiple linear regression confirmed the impact of age, vision, DSEO, and DSEC on "rapid walking" with a 34% variance explanation. Posturographic parameters did predict other selected gait and balance items. When used in older women living independently in the community, parameters of static posturography reflect to some extent the functional disabilities of gait and balance.     

Morbidit?t und Mortalit?t der HIV-Infektion

Combination antiretroviral therapy (cART) has dramatically improved the prognosis of HIV-infected individuals, with a close to a normal life expectancy in a significant proportion of treated individuals. Upon start of cART, HIV-induced immune deficiency can be prevented or, if already present, reconstituted. Remaining morbidity and mortality is partly due to the late diagnosis of HIV infection or late presentation of patients, when CD4-T-cells have already fallen below 200 cells/μl and/or AIDS-defining conditions have manifested. Further reasons for remaining morbidity and mortality are related to co-morbidities such as viral hepatitis and tumors, particularly in older patients. As HIV-infected patients become older, increasing co-morbidities and socio-economic costs may become a challenge in the future.     

Entwicklung eines neuen Depressionsscreenings für den Einsatz in der Geriatrie

Purpose

The purpose of the study was to develop and validate the depression in old age scale (DIA-S). The DIA-S is a new screening scale for depression, which is comparable to the GDS-15 in terms of practicality but which is more appropriate for the use in geriatric patients.

Methods

The DIA-S and the GDS-15 were validated among a sample of n=331 geriatric inpatients (n=151 depressed subjects and n=180 not depressed subjects), using the Montgomery and Asperg Depression Rating Scale as gold standard criterion for depression. For the comparison of the two scales, item analysis (missing values, difficulty, discriminatory power) was considered as well as test performance (internal consistency, correlation with the MADRS, ROC curves, sensitivity, specificity).

Results

All outcomes indicate a good psychometrical quality of the DIA-S. The new instrument showed a considerably higher discriminatory power for the items internal consistency and test specificity than the GDS-15.     

Das hepatozellul?re Karzinom aus der Sicht des Internisten und des Chirurgen

Hepatocellular carcinoma (HCC) is the 5th most common cancer in the world and the 3rd cause of cancer-related death. Despite therapeutic advances, the overall survival of patients with HCC has not significantly improved in the last decades. Because in the majority of patients HCCs develop in a cirrhotic liver, the patient’s prognosis depends not only on the tumor stage but also on the liver function. Patients at an early stage with an asymptomatic single HCC with a maximum diameter of 5 cm or up to three nodules each less than 3 cm may benefit from curative therapies, including resection, liver transplantation, and percutaneous ablation. Patients exceeding these limits, but who are free of cancer-related symptoms and vascular invasion or extrahepatic spread, may benefit from palliation with chemoembolization. The advanced stage is characterized by mild cancer-related symptoms and/or vascular invasion or extrahepatic spread. Patients at this stage are eligible for treatment with sorafenib; however, a variety of other new drugs, including small molecules and antibodies, are being tested in randomized controlled trials. The development and evaluation of novel HCC treatment strategies as well as the implementation of existing measures and the development of new ones to prevent HCCs are of utmost importance. A better understanding of the clinical and molecular pathogenesis of HCCs should lead to improved diagnostic, therapeutic, and preventive strategies, with the aim to reduce the incidence of HCC, one of the most devastating malignancies worldwide.     

Niedermolekulare Heparine nach orthopädischen und traumatologischen Operationen in der Geriatrie

Deep vein thrombosis and pulmonary embolism are common complications after orthopedic and trauma surgery. To prevent these complications, the use of low-molecular-weight heparins (LMWH) as prophylaxis is well proved and accepted. We reviewed 203 patients undergoing geriatric rehabilitation in our hospital after orthopedic and trauma surgery. Despite a prophylaxis with LMWH, 23 (11.3%) of these patients were diagnosed with having a clinically apparent and sonographically confirmed thromboembolic event. The average age of all patients was 81.8 years; the time between surgical or orthopedic intervention and thrombembolic event was on average 29.4 days. Using evidence-based medicine, a search of the literature showed 34 clinical trials concerning the prophylaxis of thrombembolic events with LMWH after orthopedic or trauma surgery. All studies have been reviewed for age of patients and for duration of prophylaxis with LMWH. The average age of all patients involved is 65.8 years. There are only 4 trials with an average age of 75 years or more, with a total number of less than 250 patients. The mean duration of prophylaxis with LMWH is 12.5 days. Only 6 trials concern thromboprophylaxis given longer than 3 weeks after surgical intervention. We conclude that there are no clear data about safety, efficiency and optimal duration of prophylaxis with LMWH in geriatric patients undergoing orthopedic or trauma surgery.     

Nutzen der stationären Therapie in der Versorgung von Patienten mit Rheumatoider Arthritis

Our aim was to analyze the existing body of evidence about inpatient care of patients suffering from rheumatoid arthritis (RA). The report was induced by the executive board of the German Society of Rheumatology which assigned the "Oliver-Sangha committee" to dissect and point out the tasks of inpatient care during the next few years. A systemic search of the literature was performed covering the years 1966 to 2001. A total of 16 studies were selected and thoroughly appraised in a systematic way. Four randomized controlled trials addressing the question could be identified. All of them included only patients in a clinical condition allowing outpatient care as well. Two studies indicate some advantage of inpatient care in comparison to outpatient treatment. Two studies, both equivalence studies from design, reveal that RA patients do not generally experience additional benefit from hospitalization. Consideration of two additional cohort studies demonstrates the increased need of inpatient care in RA patients. None of the studies was derived from the German health care system. Emergency cases were not the subject of any of these trials. General statements about the value of inpatient care of RA patients can not be drawn from the analyzed studies. The committee makes suggestions for future investigations that may help to answer this important question considering the special circumstances of the German health care system.