[Association of Health Insurance and Socio-economic Factors with Health Care for Malignant Melanoma]

Objective: To analyze the relationship between socio-demographic and regional factors, health insurance status and clinical features of malignant melanoma (MM). Methods: Primary data from a nationwide dermato-histopathologic laboratory on all consecutive excisions with proven diagnosis of MM over the 5-year period 2009-2013 were analyzed regarding tumor-specific and socioeconomic characteristics. The tumor depth (Breslow index) being a predictor of invasive MM progression and mortality was defined as a major indicator for early detection and intervention, thus reflecting quality of health care. Results: N=4 840 histologically verified MM samples from 4 583 patients were analyzed; of these, 2 537 (52.4%) were invasive MM. The tumor depth, which was 1.09 mm on average, increased with age from 1.00 mm in the lowest to 1.56 mm in the highest age group, p<0.001). Controlled for age and sex, the members of agricultural health insurances (LKK) and of German local public health insurances (AOK) showed significantly increased tumor depths (1.67 resp. 1.20 mm). The lowest average levels were found in members of the substitute health funds (e. g. Barmer GEK 0.93 mm) and in privately insured persons (0.99 mm). Based on a regional 4-step classification, there was a gradient in MM depth from more populated to more rural areas, ranging from 1.05 mm in nucleated cities to 1.22 in small rural communities. Distribution of MM locations varied significantly by health insurance: The highest proportion of MM in the head/neck area was seen in members of the agricultural (52.3%) and of the local public health insurances (30.2%) vs. 18.5% in patients from the substitute health funds. In contrast, MM located on the trunk and lower extremities was more prevalent in private, substitute and company health insurance funds. Conclusion: Age, gender and health insurance status are relevant determinants of MM health care and progression risk in Germany. Prevention and early detection programs by health insurances should take this into account.

[Posttraumatic disorders in patients with schizophrenia spectrum disorders]

BACKGROUND

The findings of international studies suggest high rates of interpersonal violence and posttraumatic stress disorder (PTSD) among patients with schizophrenia spectrum disorders. Only few studies, however, have so far been conducted in the German-speaking countries.

OBJECTIVES

The aim of our study was to determine the prevalence of lifetime experiences of interpersonal violence and comorbid PTSD among inpatients in a German university hospital.

METHOD

In N = 145 consecutively admitted patients with schizophrenia spectrum disorders (67 % male) the structured trauma interview (STI) was used to assess experiences of interpersonal violence and the structured clinical interview for DSM-IV (SCID) to assess comorbid PTSD.

RESULTS

Sexual violence under the age of 16 years was reported by 17 % of the patients (women 27 %, men 12 %). Approximately one third (32 %) reported physical violence by parental figures (women 38 %, men 29 %). At least one form of early violence (sexual or physical) was reported by half of the women (48 %) and one third of the men (34 %). Negative sexual experiences later in life were reported by 17 %, physical violence by 38 % and at least one of these forms by 48 % of the patients. In total two thirds of all patients (66 %) reported experiences of violence during their lifetime. The prevalence of acute PTSD was 12 %. Another 9 % of patients had a subsyndromal PTSD.

CONCLUSION

The present study confirmed the high rates of experiences of interpersonal violence and comorbid PTSD in a German sample of patients with schizophrenia spectrum disorders. Violence and it's consequences should therefore be routinely assessed and the full spectrum of trauma-specific therapies should be integrated into the treatment of this group of patients.

Health care characteristics of basal cell carcinoma in Germany: the role of insurance status and socio-demographic factors

BACKGROUND

In Germany population-based data on health care of basal cell carcinoma (BCC) are rare.

OBJECTIVE

To analyze the relationship between socio-demographic and regional factors, health insurance status and clinical features of BCC.

METHODS

Data base was from a nationwide dermatopathology laboratory. All consecutive excisions from 2010 were analyzed regarding tumor-specific and socioeconomic characteristics of BCC.

RESULTS

9,467 histologically verified BCC derived from 7,116 patients (54.1 % male, mean age 70 years) were analyzed. 33 % of patients had multiple tumors. The average vertical depth of invasion of BCC was 1.27 mm. It was increased significantly (p ≤ 0.001) in men (1.33 mm vs. 1.19 mm in women) and in persons over 70 years of age (1.36 mm vs. 1.14 mm). Controlled for age and sex, members of agricultural health-insurances (LKK) and of German local public health insurances (AOK) showed the highest tumor depths (1.45 mm resp.1.42 mm). The lowest depths (1.17 mm) were found in insurees of the substitute health funds (Ersatzkassen) (p ≤ 0.001). Vertical depth of invasion was significantly increased for patients living in rural counties (1.34 mm) compared to patients from urban areas (1.21 mm). Furthermore, the distribution of BCC locations varied by type of health insurance.

CONCLUSIONS

Area of residence, health insurance status, age and gender are relevant determinants of BCC health care in Germany. Prevention programs and activities to improve early detection by health insurances should take this into account.

Homepages of German dental schools - a target group-oriented evaluation

INTRODUCTION

The Internet represents the central communication medium in higher education. University applicants, students, teachers and scientists use the Internet when seeking information on medicine. The homepages of dental schools are not just sources of information, but also a means of presenting the school. No comparative studies have been undertaken concerning the content and extent of their Internet sites so far.

METHODS

Based on the literature and assessments of medical school websites, 136 criteria were defined within the setting of a Delphi procedure and drawn upon for a standardised evaluation of the websites of all 30 German dental schools. Structure and extent of the content of the websites were evaluated. Possible influencing factors, such as financial resources and number of applicants, were investigated.

RESULTS

The results yielded by the homepages varied considerably. The best Internet site received 84% of the possible points, the poorest 38%. On average, 62% of the criteria were fulfilled. Influencing factors, such as the amount of funding by the particular state government, could not be detected. Two-thirds of the dental schools addressed students, three-fourth teachers and scientists as target groups. More than 50% did not address applicants. Specific requirements regarding barrier-free accessibility of information were hardly met.

CONCLUSIONS

Individual faculties already have homepages of a high quality; for others, there is a need for improvement. General recommendations for university websites should be discussed at the European level to ensure a uniform standard of quality. The criteria presented here offer faculties the possibility to reflect upon their own Internet sites.

Neutrophilic myeloid-derived suppressor cells in cord blood modulate innate and adaptive immune responses

Neonates show an impaired anti-microbial host defence, but the underlying immune mechanisms are not understood fully. Myeloid-derived suppressor cells (MDSCs) represent an innate immune cell subset characterized by their capacity to suppress T cell immunity. In this study we demonstrate that a distinct MDSC subset with a neutrophilic/granulocytic phenotype (Gr-MDSCs) is highly increased in cord blood compared to peripheral blood of children and adults. Functionally, cord blood isolated Gr-MDSCs suppressed T cell proliferation efficiently as well as T helper type 1 (Th1), Th2 and Th17 cytokine secretion. Beyond T cells, cord blood Gr-MDSCs controlled natural killer (NK) cell cytotoxicity in a cell contact-dependent manner. These studies establish neutrophilic Gr-MDSCs as a novel immunosuppressive cell subset that controls innate (NK) and adaptive (T cell) immune responses in neonates. Increased MDSC activity in cord blood might serve as key fetomaternal immunosuppressive mechanism impairing neonatal host defence. Gr-MDSCs in cord blood might therefore represent a therapeutic target in neonatal infections.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

Drug supply for children with psoriasis in Germany

BACKGROUND

In Germany there is a lack of robust nationwide data on psoriasis therapy in children.

PATIENTS AND METHODS

Secondary data from the statutory health insurance Gmnder Ersatzkasse (GEK) of the year 2009 were analyzed. Continuously insured children with psoriasis vulgaris were identified by ICD-10 codes (L 40. X). Their treatment was determined on the basis of prescriptions according to ATC code.

RESULTS

1,313 of 293,181 children and adolescents had psoriasis (0.45%). Of these, n = 651 (49.6%) received at least one medication during the observation period. Topical and systemic corticosteroids were most frequently prescribed (70.8% and 4.0% respectively). The relative frequency of prescription of systemic corticosteroids was higher in children treated by pediatricians and family physicians (by a factor of 3 and 5, respectively) than in those treated by dermatologists. Vitamin D analogs were the second most frequently prescribed drugs, used far more often by dermatologists (14.7%) than by general practitioners (1.7%) and pediatricians (0.9%).

CONCLUSIONS

Drug supply for children with psoriasis in Germany appears to be inadequate. The consensus guidelines are not sufficiently considered and the use of systemic corticosteroids is still too high, even after adjustment for steroid-dependent indications. The data underline the necessity of guideline-oriented therapy and implementation of current therapeutic evidence in juvenile psoriasis.

The Hamburg polonium-210 case: Monitoring of internal contaminations in a malevolent act

The dead of Alexander Litvinenko in London in the late 2006 was linked with the visit of Dimitri Kovtun. So an investigation was started by the Hamburg Police. As the presence of polonium-210 was uncertain, the action was supported by the Federal Defense against Nuclear Hazards (NGA) of the Federal Office for Radiation Protection (BfS). Radiation measurements in some flats in Hamburg confirmed the suspicion of polonium-210 contaminations. As incorporations by ingestion or inhalation could not generally be excluded, the Coordinating Office on Incorporation Monitoring of the BfS (Leitstelle Inkorporationsüberwachung des BfS) was requested to clarify this issue. The BfS office then coordinated the required bioassay analyses of urine samples carried out at four officially appointed in-vitro laboratories for incorporation monitoring. The group of people to be examined included the members of the family involved living in the contaminated flats, the emergency forces, as well as potentially exposed members of the public. The calculation of the internal dose was based on standard assumptions and also conducted by the BfS. The internal radiation doses proved to be within the range of radiation doses due to natural exposures. Retrospectively it should be stressed that the collaboration and cooperation of all institutions involved in the operation in Hamburg was extremely good despite their differing organisational structures. As a result of the incident in Hamburg various middle and long-term measures have been taken since then by the BfS Coordinating Office on Incorporation Monitoring.

Allergies in Germany -- prevalence and perception by the public

BACKGROUND

During the recent decades allergies have become more frequent all over the world. However, it is unclear how important the topic of allergies is for the general German population and how appropriately patients with allergies are treated.

PATIENTS AND METHODS

A telephone survey was performed on a representative random sample of n = 1,004 adults in Germany. The survey was performed by the Forsa Institute for Social Research and Statistical Analysis, Berlin, Germany, in the period from 31 January to 2 February 2012.

RESULTS

Of the interviewees 52% responded that the topic of allergies concerned them; in 33% actually an allergy had been diagnosed by a physician. The proportion of allergies in the population correlated with the level of school education and was higher among people with a higher educational status. No differences in allergy rates were found between Eastern and Western Germany. Among allergic persons, 53% reported to be burdened by their allergy, 48% suffered from impaired performance because of their allergic symptoms. Among people suffering from pollen allergy, only 28% received sublingual immune therapy, with which 70% were satisfied. While 58% practiced self-medication, only 21% of the allergic persons were treated with anti-allergic drugs during their allergy flares.

CONCLUSIONS

Allergic diseases are a common, often burdensome problem in the German population, but nevertheless the medical treatment of people affected is still insufficient. The proportion of patients receiving sublingual immune therapy as causal treatment is comparatively low. Active steps are needed to improve the utilization behavior of patients, e. g. to take advice of an allergy specialist.

Derivation of the stress-strain behavior of the constituents of bio-inspired layered TiO2/PE-nanocomposites by inverse modeling based on FE-simulations of nanoindentation test

Owing to the apparent simple morphology and peculiar properties, nacre, an iridescent layer, coating of the inner part of mollusk shells, has attracted considerable attention of biologists, material scientists and engineers. The basic structural motif in nacre is the assembly of oriented plate-like aragonite crystals with a 'brick' (CaCO3 crystals) and 'mortar' (macromolecular components like proteins) organization. Many scientific researchers recognize that such structures are associated with the excellent mechanical properties of nacre and biomimetic strategies have been proposed to produce new layered nanocomposites. During the past years, increasing efforts have been devoted towards exploiting nacre's structural design principle in the synthesis of novel nanocomposites. However, the direct transfer of nacre's architecture to an artificial inorganic material has not been achieved yet. In the present contribution we report on laminated architecture, composed of the inorganic oxide (TiO2) and organic polyelectrolyte (PE) layers which fulfill this task. To get a better insight and understanding concerning the mechanical behaviour of bio-inspired layered materials consisting of oxide ceramics and organic layers, the elastic-plastic properties of titanium dioxide and organic polyelectrolyte phase are determined via FE-modelling of the nanoindentation process. With the use of inverse modeling and based on numerical models which are applied on the microscopic scale, the material properties of the constituents are derived.

[Social integration after 4 years of heroin-assisted treatment]

BACKGROUND

Studies from several countries have by now shown the effectiveness of heroin-assisted treatment in comparison to methadone treatment. However, only few long-term results exist, and in particular data with a focus on social integration of the patients are scarce.

OBJECTIVE

The study analyzes the course of long-term social integration among the patients of the German diamorphine study.

METHODS

Individual changes in health, drug use and social integration among patients who had participated in a 4-year diamorphine treatment (n=156) were described and statistically tested by means of repeated measures analyses. The criteria used are based on the instruments OTI-HSS and SCL-90-R, on medical findings, urinalyses, and on variables as well as composite scores from the European Addiction Severity Index.

RESULTS

In all domains significant improvements were found after long-term treatment. The percentage of patients employed or currently working had increased 3-fold up to 40% after 4 years. Moreover, the living situation and leisure behaviour improved, and criminal activities declined markedly. The main influencing factor for successful social integration after 4 years of treatment is the ability to work.

CONCLUSIONS

Heroin-assisted treatment is a long-term effective treatment for severely dependent opiate addicts with respect to stabilization of health, reduction of illegal drug use and improvement of social integration. Furthermore, the results show that processes of social (re-)integration of drug users take time.

Cost-of-illness of leg ulcers in the community

Leg ulcer management is complex, time-consuming and of high socio-economic importance. Data on cost-of-illness in leg ulcer care are sparse. The objective of this study was to evaluate the cost-of-illness in leg ulcer treatment in the metropolitan area of Hamburg. About 147 institutions involved in wound care participated in a cross-sectional study. Patients consecutively recruited underwent a standardised interview and clinical examination. Main economic outcomes were direct, indirect and intangible costs from a societal perspective. Five hundred and two patients with a mean age of 71 years and mean wound duration of 9 years were enrolled. Annual total costs summed up to a mean of 9060€ /patient/year (8288€ direct, 772€ indirect costs). Direct costs carried by statutory health insurances amounted to 7680€ , patients themselves paid on average 607€. Leg ulcer is associated with high costs for health insurances, patients and the society. Exploratory predictor analyses suggest that early, interprofessional disease-management could lower treatment costs.