Erfolgsfaktoren im deutschen Krankenhausmarkt

The German hospital market is in a state of transition due to the introduction of diagnosis-related groups (DRGs) and a constant change of the reimbursement, demographic, economical and technical framework. To date mainly public hospitals were bought by private hospital chains, but this trend has currently reached university hospitals. During recent months a consolidation within the market of private hospitals took place, while new market players such as foreign hospital chains, US universities and private equity firms emerged on the scene. The target of the privatisation process, however, turns more and more to larger hospitals. Central key values remain the cluster formation and centralisation of key competences such as food supply, purchasing and pharmacy. Within a network of clinics the representation of different care components (basic, regular and maximum care provider) and care levels (low, normal, intermediate and intensive care) remain important elements of efficient hospital management. Today, successful hospital operation is based on the successful competition for patients and even more for qualified staff. In this aspect, university hospitals could play a decisive role, because of their combination of maximum acute care provision and educational mandate. No such network has yet been formed due to the different interests of the owners, however, given the new market situation this alternative concept could become more attractive.

Interleukin-6-174-genotype, sepsis and cerebral injury in very low birth weight infants

We investigated the association between the interleukin 6 (IL-6)-174-genotype and unfavorable outcomes in preterm infants since it has been reported that the IL-6-174GG-genotype is associated with increased susceptibility to sepsis, and the IL-6-174CC-genotype is more common in preterm infants with severe intraventricular hemorrhage (IVH). We studied 1206 preterm infants with a birth weight below 1500 g. In contrast to previously published data, the frequency of IVH grade IV, periventricular leukomalacia, ventricular-peritoneal-shunting or death was not different between infants with different IL-6-genotypes: IL-6-174GG (n = 430) 8%, IL-6-174GC (n = 605) 9% and IL-6-174CC (n = 167) 12% (P = 0.2 for IL-6-174CC vs GG + GC). Furthermore, we were not able to confirm previously reported association between sepsis and the IL-6-174GG-genotype. Blood-culture-proven sepsis occurred in 19% of IL-6-174GG-carriers (n = 157), 26% of IL-6-174GC-carriers (n = 193) and 27% of infants carrying the IL-6-174CC-genotype (n = 67). We were not able to confirm previously reported associations between sepsis, cerebral injury and the IL-6-174-genotype in VLBW-infants.

Bullying in the school environment: an injury risk factor?

OBJECTIVE

To describe a research project assessing the role of bullying at school as an injury trigger and the modification effect of the socio-economic environment of the victims. Preliminary results are also presented.

METHOD

A case-crossover and a case-referent design were combined. The study base consisted of all children aged 10-15 years residing in the Stockholm county in 2000-02. Cases were recruited at the county's children hospital and interviewed shortly after the injury, using a specially designed questionnaire.

RESULTS

Preliminary analyses (261 interviews) reveal that about two injured children out of 10 reported having been bullied during the school term. Also, one out of 10 had been bullied shortly enough before the injury for bullying to be considered as a trigger. The circumstances of occurrence of those injuries varied.

CONCLUSION

Bullying, apart from being frequent in the school environment, is quite likely to act as an injury trigger.

Universitätskliniken im Spannungsfeld des Krankenhausmarktes

In recent years Germany has faced a growing economization and competition among hospitals. To protect their interests hospitals have to operate similarly to other commercial businesses. Academic hospitals face difficult circumstances in this competition. They have to facilitate research and education activities which require additional financial and personnel resources but also provide maximum acute care treatment at all times. This causes additional disadvantages in terms of financial resources, compared to private hospital chains. Such examples of financial shortcomings have led to the privatization of academic research centres in Germany. An alternative strategy to privatization of academic acute care hospitals is the change of their legal status into a capital company or into a foundation, according to US experiences. Public private partnerships (PPPs) may also represent a potential alternative, as they have already produced a growing number of successful examples in the public sector in Germany. Academic acute care hospitals can also choose a strategic reorganization of their targets, similar to their privately held competitors in the market. Potential economies in scale may be achieved in areas such as medical treatment, research and personnel planning.However, it is vital that academic acute care hospitals start to act productively and also individually. This article provides a number of managerial pathways and options to maintain and strengthen operational competitiveness.

[Myocardial perfusion scintigraphy with Tc-99m MIBI in patients with left bundle branch block: Visual quantification of the anteroseptal perfusion imaging for the diagnosis of left anterior descending artery stenosis]

INTRODUCTION

The non-invasive detection of myocardial ischaemia in patients with left bundle branch block (LBBB) remains a challenge. It is often associated with coronary artery disease or hypertension, but frequently there is no indication of cardiovascular pathology at presentation. Exercise-induced electrocardiographic ST segment changes are non-diagnostic. Confirming coronary artery disease has obvious implications for management. Several studies have shown greater cardiac mortality in the presence of LBBB. Generally, a good prognosis has been found in patients with LBBB and normal or near-normal myocardial perfusion scintigraphy (MPS). Various investigators report frequent anteroseptal defects with MPS in patients with LBBB in the absence of significant left anterior descending (LAD) coronary artery disease. Several mechanisms have been proposed to explain this false-positive phenomenon. Various interpretative methods and stress techniques have been evaluated in an attempt to improve the specificity of noninvasive studies for detecting LAD disease. A number of software packages for quantifying myocardial perfusion are commercially available. Quantification is recommended to improve diagnostic accuracy and intra- and inter-observer reproducibility.41 METHODS: Patients with LBBB on ECG, who were referred to our institution (February 2002 to September 2003) for myocardial perfusion scintigraphy, were included in the study. Patients with previous myocardial infarction were excluded, unless the location was confirmed to be not anteroseptal before the onset of LBBB. Patients who did not undergo coronary angiography within six months were also excluded, unless a LAD lesion of > or = 50% was diagnosed more than six months prior to MPS without subsequent intervention, or angiography more than six months later showed a LAD lesion of < or = 50%. Treadmill exercise, dipyridamole or dobutamine infusion were used according to standard protocols and imaging commenced 15-60 minutes later. QPS quantitative software, used to reconstruct the images and quantify perfusion, is described in detail elsewhere. Three experienced nuclear physicians interpreted the studies. Stress and rest perfusion, as well as reversibility, to the anteroseptal wall (excluding the apex), anteroseptal wall and apex, and apex only, were graded on a scale of 0 (normal) to 4 (absent perfusion), where 1 represents mild, 2 moderate, and 3 severe impairment of perfusion. A final decision was made by consensus. Using QPS, summed stress, rest and difference scores were obtained for the same regions. Angiographic correlation was obtained by reviewing the patients' records. Stenosis of the LAD or graft vessel to the LAD of > or =50% was regarded as significant. The Kruskal-Wallace non-parametric test was used to compare the groups with and without significant LAD stenosis. A Bonferroni correction was applied to make provision for multiple testing. Receiver operating characteristic (ROC) analysis was utilised to determine the optimal threshold of the significant measurements to distinguish between the two groups; for this threshold, the sensitivity and specificity were calculated.

RESULTS

Nine men and nine women (42-78 years) satisfied the inclusion criteria and were included in the study. Dipyridamole was used in nine patients, exercise in seven, dobutamine in one, and one patient was injected during a period of typical chest pain. Ten patients had a LAD stenosis of < 50% and eight > or = 50%. The only measurement that yielded a significant difference between the groups was visual improvement in perfusion to the anteroseptal wall and apex between the stress and rest study (p < 0.0096). Even after applying a Bonferroni correction, the value tended towards significance (p = 0.16). A ROC curve was calculated and an optimal threshold of 0.5 determined, which in turn had a sensitivity of 88% and specificity of 67%.

DISCUSSION

Our findings suggest that visual reversibility in the anteroseptal wall and apex gives an indication of significant LAD stenosis in patients with LBBB. This finding agrees with that of Mairesse et al. Wackers argues that cardiomyopathic changes cause anteroseptal perfusion defects in LBBB. It is possible that irreversible perfusion defects in the anteroseptal wall and apex are caused by a constant, stress-independent mechanism, whereas reversible defects indicate underlying ischaemia. Interestingly, quantitative analysis was not helpful in predicting LAD disease. The quantitative software we used is well validated. On the other hand, Svenssson et al. compared three myocardial perfusion quantification software packages and found considerable variation, especially in the presence of perfusion defects. The state of perfusion to the apex was not helpful to detect significant LAD disease. It is known that the LAD usually supplies the apex. Matzer et al. found that requiring the presence of an apical defect improved specificity. This could not be confirmed by Lebtahi et al. or Vaduganathan et al.

LIMITATIONS

A definite limitation of our study was that treadmill stress testing was performed in seven patients. It is currently recommended by most authors that pharmacological stress be performed in patients with LBBB Selection bias is also a limitation because only patients who also had angiography were included in the study (18 out of 91).

CONCLUSION

A visual improvement in anteroseptal and apical myocardial perfusion between stress and rest with Tc-99m MIBI in patients with LBBB probably indicates significant LAD stenosis. In our hands, quantitative software did not aid in the diagnosis. A well-designed, prospective study using a standardized stress protocol (probably dipyridamole or adenosine), which specifically evaluates visual reversibility in the anteroseptal wall and apex, will obviate the need for a Bonferroni correction, and could confirm these findings.

Brain potentials related to self-generated and external information used for performance monitoring

OBJECTIVE

Humans need to supervise and adjust their own behavior by means of an error detection and correction system as well as by using externally available information. The purpose of the present study was to compare the electrophysiological effects related to self-generated internal and to external (feedback) information used for performance monitoring.

METHODS

Fourteen young normal subjects learned to associate each of several line-drawings with either a left-hand or right-hand response. In the experiment proper multi-channel ERPs were obtained time-locked to (a) the line-drawings, (b) the button-press, and (c) subsequent feedback stimuli. Feedback was either affirmative, negative, or equivocal. Event-related potentials were quantified and statistically evaluated using standard methodology.

RESULTS

Response-locked ERPs showed a typical error-related negativity (ERN) for erroneous responses. ERPs to negative and equivocal feedback stimuli contained a negativity with a more posterior distribution than that of the ERN, which occurred earlier and had a higher peak amplitude in the equivocal condition. Dipole modeling suggests that this feedback-related negativity is generated by medial prefrontal and posterior cingulate cortex areas.

CONCLUSIONS

Different brain systems support the use of internal and external information necessary for performance monitoring and modification.

SIGNIFICANCE

The flexible use of internal and external information for performance control is a core executive function. The delineation of the corresponding brain correlates will further our understanding of executive dysfunction in neurological disorders.

Polymorphisms of genes involved in innate immunity: association with preterm delivery

An altered inflammatory activity due to functionally relevant polymorphisms of the innate immune system may influence pathways leading to labour and, therefore, impact on the frequency of preterm birth. We examined five polymorphisms of the innate immune system in a large cohort of preterm very-low-birth-weight (VLBW, n = 909) and term-born infants (n = 491) and their mothers (n = 747). The primary outcome was preterm versus term birth. Frequencies of polymorphisms in mothers of term-born infants versus mothers of VLBW infants and term infants versus preterm VLBW infants (singletons) are given. Homozygous CD14-159T: 18.5 versus 21.8% (mothers) and 19.6 versus 21.2% (infants). Homozygous interleukin IL-6-174G: 28.8 versus 38% (P = 0.018, mothers) and 30 versus 32.7% (infants). Homozygous or heterozygous nuclear oligomerization domain NOD2-3020insC: 6.9 versus 6.1% (mothers) and 5.7 versus 5.1% (infants). Heterozygous or homozygous toll-like-receptor TLR2-Arg753Gln: 6.9 versus 6.1% (mothers) and 5.7 versus 5.1% (infants). Homozygous or heterozygous TLR4-896G: 8.1 versus 11.5% (mothers) and 11.6 versus 10.5% (infants). Although the homozygous maternal IL-6-174G genotype was found to be independently associated with preterm delivery in multivariate regression analysis, the incidence of intrauterine infection was not significantly increased in mothers of preterm VLBW-infants, carrying this or other polymorphisms of the innate immune system. The overall influence of the investigated polymorphisms on the development of preterm delivery seems moderate, since only the maternal IL6-174G genotype was associated with preterm birth and none of the polymorphisms were associated with intrauterine infection as the cause of preterm birth.

Is perceived failure in school performance a trigger of physical injury? A case-crossover study of children in Stockholm County

OBJECTIVES

To investigate whether perceived failure in school performance increases the potential for children to be physically injured.

SUBJECTS

Children aged 10-15 years residing in the Stockholm County and hospitalised or called back for a medical check up because of a physical injury during the school years 2000-2001 and 2001-2002 (n = 592).

METHODS

A case-crossover design was used and information on potential injury triggers was gathered by interview. Information about family socioeconomic circumstances was gathered by a questionnaire filled in by parents during the child interview (response rate 87%).

RESULTS

Perceived failure in school performance has the potential to trigger injury within up to 10 hours subsequent to exposure (relative risk = 2.70; 95% confidence intervals = 1.2 to 5.8). The risk is significantly higher among pre-adolescents and among children from families at a higher education level.

CONCLUSIONS

Experiencing feelings of failure may affect children's physical safety, in particular among pre-adolescents. Possible mechanisms are perceptual deficits and response changes occasioned by the stress experienced after exposure.