Quality Assurance in Rehabilitation under the German Pension Insurance Scheme

Ten years after its introduction, the German Pension Insurance's quality assurance programme is firmly established within the rehabilitation system. Regular, substantive reporting to rehabilitation centres and pension insurance organisations has contributed to improving the quality of rehabilitation. Legal codification of quality assurance stipulations has existed since 2001. The programme is in constant development, e. g. by optimization of patient interviewing and inclusion of evidence-based clinical practice guidelines. New programmes, e. g. in inpatient rehabilitation of children and youths or in outpatient rehabilitation, are being developed together with the German health care organizations. In the field of vocational rehabilitation quality assurance had started out with a conceptual study followed by projects concerning client interviewing, evaluation of documentation instruments, and analyses relative to the most important outcome factor, namely the vocational reintegration results achieved. External quality assurance is a mayor input factor for the rehabilitation centres' internal quality management. In future, rehabilitation centres will be asked to demonstrate the appropriate use of this information. It will remain the centres' decision which method of quality management system implementation they choose. Quality assurance results of every centre are planned to be made publicly accessible in the medium term, in particular to the insureds. Moreover, the results of the quality assurance programmes are intended to clearly impact the allocation of patients as well as the remuneration of the rehabilitation centres concerned. Quality assurance and quality management will continue to play a major role in the political discussion of health care.     

Evaluation of air-purifying respirators for protection against toluene diisocyanate vapors

Two brands of air-purifying organic vapor cartridges (Willson and Survivair) and a disposable respirator (3M) were evaluated for protection against toluene diisocyanate (TDI) vapors. The respirators/cartridges were tested by generating dynamic atmospheres of TDI at concentrations of 0.2 and 1.5 ppm or greater, which are substantially above the currently accepted exposure limits. The TDI atmospheres were generated by controlled and continuous evaporation and dilution techniques. The relative humidity of the final TDI atmosphere was maintained at 50%. For the testing of Survivair and Willson respirators, one cartridge was mounted on a stainless steel plate and placed inside an exposure chamber through which air was drawn unidirectionally at 32 L/min. Periodically, the air before and after the cartridge was monitored for TDI. In the case of the disposable, valveless 3M respirator, a breathing pump was used to simulate the breathing through the respirator. The TDI atmosphere was respired through the respirator at 28.8 L/min (24 cycles/min at 1.2 L/cycle). As before, the concentration of TDI was measured periodically before and after the respirator. There was no significant breakthrough (less than 0.5%) of TDI in any of the respirators tested for 40 hr at 0.2 ppm and for 20 hr at 1.5 ppm or higher concentration of TDI. The detection limits of the post-respirator TDI measurements ranged from 0.4 to 0.02% of the pre-respirator concentration. It is important to note that, at the present time, because the odor threshold for TDI is higher than the ceiling exposure limit (poor warning property), NIOSH and most of the respirator manufacturers do not recommend the use of air-purifying respirators in isocyanate containing environments.     

The "rehabilitation sciences" research funding programme: research findings -- implementation -- impact and perspectives

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This "Rehabilitation Sciences" research funding programme comprises eight regional research networks for eight years in two periods (1998-2002, 2001-2005). In our paper we review the findings of the first funding period in five of the research fields: patient education, need for and access to rehabilitation, vocational training in medical rehabilitation to enhance return to work, comorbid mental disorders in patients with somatic diseases, and gender differences. Several activities aimed at transferring research findings into practice are outlined. Finally, the impact of the funding programme is summarized and perspectives for further funding are given.     

The "rehabilitation sciences" promotional emphasis--a promotional program and its implementation

The German Federal Research Ministry and the German pension insurance have set up a special funding programme for medical rehabilitation research. Eight regional research networks with about 70 projects receive funds for a first three year period. Rehabilitation experts from several countries selected the promising networks and studies from more than 100 proposals. In these networks medical and social scientists from universities and other research units cooperate with rehabilitation centers and pension insurance institutes in order to combine forces for the development of German rehabilitation science. The programme aims at improving the research structures and at tackling the major challenges of medical rehabilitation research. The following subjects represent the main fields of the ongoing research: a) etiology, course and prognosis of chronic diseases and their consequences to rehabilitation, b) diagnostics in rehabilitation, c) evaluation and improvement of rehabilitation therapy, d) the patient's perspective in rehabilitation and e) rehabilitation system research. As yet funding is limited to the year 2001. Further support of the networks will depend on the results of a thorough evaluation of the progress of their research and their structural perspective.     

Metabolism of bis(2-chloroethyl)ether and bis(2-chloroisopropyl)ether in the rat

Male rats were given single peroral doses of bis(1-¹⁴C-2-chloroethyl)ether ([1-¹⁴C]BCEE) (40 mg/kg) and of bis(1-¹⁴C-2-chloroisopropyl)ether ([1-¹⁴C]BCIE) (90 mg/kg). Excretion of¹⁴CO₂ and urinary¹⁴C was followed for 48 hr. The time required to eliminate one half of the dose was 12 hr for [1-¹⁴C]BCEE and 19 hr for [1-¹⁴C]BCIE. In the case of [1-¹⁴C]BCEE, expired¹⁴CO₂ accounted for 11.5 ± 5.6(SD) % of the dose, urinary¹⁴C accounted for 64.7 ± 14.8%, and 2.4 ± 1.3% was found in the feces. The figures for [1-¹⁴C]BCIE were 20.3 ± 9.4% expired as¹⁴CO₂, 47.5 ± 8.1% as urinary¹⁴C, and 3.8 ± 0.3% as fecal¹⁴C. Thiodiglycolic acid (TDGA) accounted for roughly 75% of the total urinary¹⁴C collected after the [1-¹⁴C]BCEE dose. Lesser metabolites of BCEE were 2-chloroethoxyacetic acid (CEAA) (5%), and N-acetyl-S-[2-(2-chloroethoxy)ethyl]-L-cysteine (ACEEC) (7%). Metabolites of [1-¹⁴C]BCIE identified in rat urine were 2-(2-chloro-1-methylethoxy)propanoic acid (CMEPA), roughly 36% of the total urinary¹⁴C, and N-acetyl-S-(2-hydroxypropyl)-L-cysteine (AHPC) at 19%.     

Evaluation of organic-vapor respirator cartridge efficiency for hexamethylene diisocyanate vapor in the presence of organic solvents

Hexamethylene diisocyanate (HDI)-based polyisocyanates are widely used in formulating polyurethane coatings. These polyisocyanates contain a small amount of HDI monomer and the American Conference of Governmental Industrial Hygienists (ACGIH) recommends an eight-hour time-weighted average (TWA) threshold limit value (TLV) of 5 ppb for HDI. Some polyurethane (PU) paint applicators have used air-purifying paint spray respirators with organic vapor cartridges and particulate pre-filters. In this study, the effect of typical paint solvents on the efficiency of organic vapor cartridges (OVC) for HDI vapor was tested. A Teflon-coated polycarbonate exposure chamber was constructed. Three OVCs were simultaneously tested in an atmosphere containing HDI vapor and solvents. The test atmosphere was generated by evaporating a mixture of paint solvents containing n-butyl acetate, propylene glycol mono methyl ether acetate, toluene and methyl ethyl ketone, and neat HDI. The target challenge concentrations were 20 times the TLV for HDI and 10 times the combined TLV for the solvent mixture. The test atmosphere, with 20 or 80 percent relative humidity and at room temperature, was drawn through each cartridge at 32 L/min for 40 hours. However, in the last 8 hours of the test, the atmosphere had only HDI vapor. The pre- and the post-cartridge atmospheres were periodically sampled for HDI and the solvents. The study concluded that under the test conditions there was no detectable breakthrough of HDI from the OVCs. The average calculated efficiency of the OVCs, based on the HDI analytical limit of quantitation, was >99.4 percent for the 40 hours tested. The overall average challenge concentration of HDI was 105 ppb and the average combined solvent concentration was 3,176 mg/m3. The cartridges were saturated with solvents within the first 10 hours of testing; nevertheless, continued challenging with HDI vapor and solvents did not show any HDI breakthrough. Solvent breakthrough and breathing resistance, rather than HDI breakthrough, would be the key parameters in life expectancy calculations for cartridge change out schedules.     

Pr?valenz auff?lliger Schleimhautbefunde bei Patienten in HNO-Praxen

Objective

To date, no secondary prevention program is in place for patients carrying an increased risk for developing head and neck cancer (HNSCC). In terms of successful, long-term curative therapy and increased quality of life, it would be useful to detect such diseases at an early stage.

Patients and Methods

A total of 370?patients with at least one risk factor such as ??smoking??, ??alcohol??, or ??reflux disease?? and without any symptoms were examined during a 1-year period using standard HNO methods (e.?g. endoscopy) for suspicious alterations of the mucosa of the upper aerodigestive tract.

Results

In 13 (3.5%) of all 370 cases a biopsy was taken for further diagnosis. Squamous cell carcinoma was found in eight cases, while one further patient was suffering from non-Hodgkin lymphoma.

Conclusions

It is simple and safe to examine patients at risk of developing HNSCC by standard HNO methods. The rate of detected carcinomas is much higher than in former investigations, likely because our survey focused only on patients with specific risk factors.     

Heart rate variability and nonlinear dynamics

Summary In this review the importance of nonlinear analysis of heart rate variability is discussed. In the introduction the complexity of the heart rate signal is highlighted which reflects an abundance of external and internal control mechanisms. It is shown that one way to improve analysis of heart rate variability in terms of risk prediction is “perturbation” analysis. In this system analysis approach, the response of heart rate to a specific perturbation rather than the global dynamics of a 24 hour recording are analyzed. Prominent examples of this approach are “heart rate turbulence” and “heart rate recovery”. After mentioning 1/f-fluctuations as the dominant but still linear phenomenon in spectral analysis of heart rate variability, the remainder of the review is focused on the return map. Fundamental properties of the return map of heart rate are delineated which clearly demonstrate nonlinear properties of the heart rate signal. In addition, practical aspects of return map analysis are reviewed which prove to be very fruitful in the handling of heart rate data. Received: 13 July 2000/Accepted: 9 August 2000