Deutsche Leitlinie zur Rehabilitation von Patienten mit Herz-Kreislauferkrankungen (DLL-KardReha)

Ohne Zusammenfassung Deutsche Gesellschaft für Pr?vention und Rehabilitation von Herz-Kreislauferkrankungen e.V. (DGPR) in Zusammenarbeit mit der Deutschen Gesellschaft für Rehabilitationswissenschaften e.V. (DGRW) und der Deutschen Gesellschaft für Sportmedizin und Pr?vention e.V. (DGSP) Unter Mitarbeit von: Stephan B?hmen Kardiologische Abteilung, Reha-Zentrum Oldenburg, Oldenburg Gerd B?nner · Christian Holubarsch MEDIAN Kliniken Bad Krozingen, Klinik Lazariterhof/Klinik Baden – Privatklinik, Bad Krozingen Curt Diehm Innere Medizin, Klinikum Karlsbad-Langensteinbach, Karlsbad Hermann Faller Institut für Psychotherapie und medizinische Psychologie, Universit?t Würzburg Helmut Gohlke · Christa Gohlke-B?rwolf Wolfgang Langosch Herzzentrum Bad Krozingen, Bad Krozingen Gesine Grande Hochschule für Technik, Wirtschaft und Kultur (HTWK), Leipzig Klaus G?tzmann Postfach 468, Waldkirch bei Freiburg Harry Hahmann Klinik Schwabenland, Isny-Neutrauchburg Rainer Hambrecht Klinik für Kardiologie, Klinikum Links der Weser, Bremen Christoph Herrmann-Lingen Klinik für Psychosomatische Medizin und Psychotherapie, Universit?t Marburg Stephan Jacob Forum für Vaskul?re Medizin, Brombeerweg 6, Villingen-Schwenningen Ulrich Keil Institut für Epidemiologie und Sozialmedizin, Universit?tsklinikum Münster Ellen Kuhlmann Zentrum für Sozialpolitik, Abt. Geschlechterpolitik im Wohlfahrtsstaat, Uni Bremen Wolfgang Mayer-Berger Klinik Roderbirken der Deutschen Rentenversicherung Rheinland, Leichlingen Olaf Schulz Kardiologische Praxisgemeinschaft am Klinikum Spandau, Berlin Joachim Thiery Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universit?tsklinikum Leipzig, Leipzig Diethelm Tsch?pe Herz- und Diabeteszentrum NRW, Bad Oeynhausen Helmut Teschler Abt. Pneumologie, Ruhrlandklinik – Universit?tsklinik, Essen Claudia Wilhelm Klinik Falkenburg, Bad Herrenalb Alfred Wirth Teutoburger-Wald-Klinik, Bad Rothenfelde Horst Zebe Am Unterscheid 2, Bad Wildungen Redaktionelle Assistenz: Kristina Korinth · Erika Winterhalter Deutsche Gesellschaft für Pr?vention und Rehabilitation von Herz-Kreislauferkrankungen e.V., DGPR     

Herzgruppen in Deutschland—Status quo und Perspektiven

Currently, more than 6,600 heart groups (AHGs) have been established in Germany, in which more than 110,000 patients are physically active. Following cardiac rehabilitation (CR) after an acute event, in the AHG patients aim to meet the set rehabilitation goals in groups of about 15-20 patients, instructed by a competent exercise therapist and attended by a physician. While physical activity has been the dominant aspect thus far, psychosocial and educative elements are now more strongly integrated to stabilize secondary prevention. According to the German rehabilitation law, the patient is legally entitled to participate in AHGs. The insurance companies pay 6.00 Euros for 90 therapeutic units at 60-90 min each. Thereafter, the patient should be encouraged to continue participation at his/her own cost. The opportunity to participate in AHG is not yet sufficiently responded to by the patients. According to different studies, only 13-40% of all patients attend an AHG after phase II CR. In future, special emphasis has to be placed on the recruitment of more patients into AHGs, especially those groups which are known to be underrepresented (e. g., women, old patients, patients with low socioeconomic status). Furthermore, AHGs have to be established for patients with special needs, e. g., heart failure patients or young grown-ups with congenital heart diseases. Until now, the efficiency of AHG participation has not been sufficiently investigated. In a case-control study analyzing the long-term results of AHG participation, an improvement in physical performance as well as a reduction of cardiovascular morbidity (54%) and medical costs (approximately 47%) were observed. In future, more high-class investigations on this field are needed.     

REDIA--impacts of DRG introduction in the acute sector on medical rehabilitation

The REDIA study is the only long-term (2003-2009), prospective, multicentre study analyzing the impact of the DRG system on quality and costs in rehabilitation facilities. In 2004, Diagnosis Related Groups (DRG) were implemented on a mandatory basis in the German healthcare system as a reimbursement scheme for hospitals based on administered prices for procedures. Experiences from other countries revealed that introduction of DRG does not only have a significant impact on hospitals but also on rehabilitation facilities. The study approach ensures a comprehensive analysis as it considers major clinical, therapeutic, psychological and economic aspects. The REDIA study is the only nationwide empirical study that includes all stages of the implementation process: before DRG implementation, during the convergence phase and following implementation. An indication-specific comparison of the phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in admission of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversions of treatment efforts from the acute sector to the rehabilitative sector have been proven in terms of increased nursing efforts and potential changes in the therapeutic and medical treatments to be provided.     

B7-H3 silencing increases paclitaxel sensitivity by abrogating Jak2/Stat3 phosphorylation

In many types of cancer, the expression of the immunoregulatory protein B7-H3 has been associated with poor prognosis. Previously, we observed a link between B7-H3 and tumor cell migration and invasion, and in present study, we have investigated the role of B7-H3 in chemoresistance in breast cancer. We observed that silencing of B7-H3, via stable short hairpin RNA or transient short interfering RNA transfection, increased the sensitivity of multiple human breast cancer cell lines to paclitaxel as a result of enhanced drug-induced apoptosis. Overexpression of B7-H3 made the cancer cells more resistant to the drug. Next, we investigated the mechanisms behind B7-H3-mediated paclitaxel resistance and found that the level of Stat3 Tyr705 phosphorylation was decreased in B7-H3 knockdown cells along with the expression of its direct downstream targets Mcl-1 and survivin. The phosphorylation of Janus kinase 2 (Jak2), an upstream molecule of Stat3, was also significantly decreased. In contrast, reexpression of B7-H3 in B7-H3 knockdown and low B7-H3 expressing cells increased the phosphorylation of Jak2 and Stat3. In vivo animal experiments showed that B7-H3 knockdown tumors displayed a slower growth rate than the control xenografts. Importantly, paclitaxel treatment showed a strong antitumor activity in the mice with B7-H3 knockdown tumors, but only a marginal effect in the control group. Taken together, our data show that in breast cancer cells, B7-H3 induces paclitaxel resistance, at least partially by interfering with Jak2/Stat3 pathway. These results provide novel insight into the function of B7-H3 and encourage the design and testing of approaches targeting this protein and its partners.     

TP53 alterations in atypical ductal hyperplasia and ductal carcinomain situ of the breast

Summary Abnormalities in theTP53 tumour suppressor gene in 75 atypical ductal hyperplasias and 62 ductalcarcinomasin situ (DCIS) of the breast were studied using immunohistochemistry and mutation analysis. Accumulation of p53 protein was detected in 10 out of 62 (16%) DCIS, whereas no cases of positive staining was observed in the atypical lesions.TP53 mutations were identified in four out of 30 (13%) DCIS by constant denaturant gel electrophoresis (CDGE). Two of these cases were positive and two negative for p53 protein. A total of 12 out of 62 DCIS (19%) carriedTP53 mutation and/or p53 protein overexpression. The present results suggest thatTP53 alterations may be important in the development of a subset of DCIS.     

Mitteilungen der Deutschen Gesellschaft für Pr?vention und Rehabilitation von Herz-Kreislauferkrankungen e. V. (DGPR)

MITTEILUNGEN

Mitteilungen der Deutschen Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen e. V. (DGPR)     

Intensified after-care--a method for improving occupational reintegration after myocardial infarct and/or bypass operation

Occupational reintegration after coronary heart disease of patients who are insured by the German workers pension (Arbeiterrentenversicherung) succeeds in 40-60% of the recorded cases. Patients who were not able to return to work after finishing their regular cardiac rehabilitation took part in a program called "Intensivierte Nachsorge (INA)". INA is an interdisciplinary support program, taking place twice a week for a whole day over a period of six weeks. On the remaining three days patients were either progressively reintegrated into their working place or stayed at home. The results of the INA group were compared to those of a control group. Two years after patients had terminated the cardiac rehabilitation, statistically significant effects could still be found: 70.2% of the INA group had returned to work compared to 52.6% of the control group. This is a difference of 17.6%. After the results had been corrected by considering age differences between the two groups, the control group had a recalculated return to work rate of 57.4%. A significant difference of 12.8% could still be identified with respect to the INA group. Support programs which follow regular cardiac rehabilitation seem to be specially suitable for older patients with highly perceived job strain, because our results showed that these patients had lower return to work rates. 44.2% of the INA group and 21.9% of the control group were progressively reintegrated into their work place. Two years after their regular rehabilitation 36.3% of the INA group patients took part in ambulatory heart groups compared with 10.4% of the control group. It was also found that patients of the INA group showed improvements in activities of daily life. The INA program however does not seem to have an influence on behavioral components such as eating habits, relaxation, and smoking as well as on the psychological status. The physical fitness measured in watt x min at the beginning of the INA program (T1) was 589.46 +/- 255.03 in the control group. This number increased to 598.32 +/- 276.01 six months after regular rehabilitation (T3) and continued to rise to 661.15 +/- 362.01 after two years (T4). In the INA group the numbers were as follows: 658.13 +/- 263.63 at T1, 751.83 +/- 318.15 at T3, and 717.93 +/- 336.76 at T4. The differences between the groups are significant at T1 and T3, whereas at T4 there is no significant difference. It should also be stated that the lipid parameters indicated no differences between the groups except for the triglyceride values which were significantly lower statistically in the INA group than in the control group.     

Depression in cardiac patients undergoing rehabilitation--a study for investigating the correlations between depression and occupational groups

The results of many studies show that physical recovery and social integration of cardiac patients are negatively influenced by a persistent depressive disorder. For this reason issues of occupational integration should be considered from this point of view, too. Correlations between various occupational groups and depression were investigated with 907 cardiac patients at the beginning and at the end of a follow-up treatment. The results were compared to those for 756 persons in corresponding age groups from the general population. We found that at the beginning of rehabilitation the depression values of the HADS did not show any significant differences between the various occupational groups, however, their values were significantly higher than those found in the general population. During rehabilitation the HADS values decreased significantly. At the end of rehabilitation, unskilled and semi-skilled workers had significantly higher depression values than skilled workers and persons in higher positions. Consequences for medical rehabilitation are discussed.