[One Health: a perspective of the informal ministerial network : "What if the One Health approach became the guiding theme of cooperation at the national, European and global level?"]

In the view of the German government, the One Health approach is a pioneering compass for inter- and transdisciplinary thinking, networking, and action. To protect the health of humans, animals, plants, and ecosystems, it should always receive attention at all its interfaces and activities. The One Health approach has gained political importance in recent years and is being taken into account in several strategies.This article reports on the current strategies using a One Health approach. These include the German Antibiotic Resistance Strategy, the German Strategy for Adaptation to Climate Change, the global initiative Nature for Health, and the international pandemic agreement, which is currently being drafted and in which prevention also plays an important role. The issues of biodiversity loss and climate protection must be placed in a common context that takes into account the interdependencies of the health status of humans, animals, plants, and ecosystems. By involving relevant disciplines at different levels as a matter of course, we can succeed in making a joint contribution to sustainable development, as required by the United Nations' Agenda 2030. This perspective guides Germany's global engagement in global health policy toward greater stability, freedom, diversity, solidarity, and respect for human rights. Thus, a holistic approach such as One Health can contribute to achieving sustainability and strengthening democratic principles.

How to improve drug dosing for patients with renal impairment in primary care - a cluster-randomized controlled trial

Background

Patients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing. The aim of this study was to examine whether a multifaceted intervention including the use of a software programme for the estimation of creatinine clearance and recommendation of individual dosage requirements may improve correct dosage adjustment of relevant medications for patients with CKD in primary care.

Methods

A cluster-randomized controlled trial was conducted between January and December 2007 in small primary care practices in Germany. Practices were randomly allocated to intervention or control groups. In each practice, we included patients with known CKD and elderly patients (≥70 years) suffering from hypertension. The practices in the intervention group received interactive training and were provided a software programme to assist with individual dose adjustment. The control group performed usual care. Data were collected at baseline and at 6 months. The outcome measures, analyzed across individual patients, included prescriptions exceeding recommended maximum daily doses, with the primary outcome being prescriptions exceeding recommended standard daily doses by more than 30%.

Results

Data from 44 general practitioners and 404 patients are included. The intervention was effective in reducing prescriptions exceeding the maximum daily dose per patients, with a trend in reducing prescriptions exceeding the standard daily dose by more than 30%.

Conclusions

A multifaceted intervention including the use of a software program effectively reduced inappropriately high doses of renally excreted medications in patients with CKD in the setting of small primary care practices.

Trial registration

Current Controlled Trials ISRCTN02900734

[New perspectives in the primary care of the chronically ill--against the "tyranny of the urgent". Part 2: The chronic care model und case management as the basis of a forward-looking approach to primary care]

Family medicine remains strongly influenced by reactive medicine ('tyranny of the urgent') and the fragmentation of healthcare associated with it. In the first part of the present article the increasing practical and economic relevance of chronic diseases and multimorbidity were analyzed as a fundamental challenge for primary care and family medicine in particular. Part two describes a forward-looking approach to guidelines and special tools which are able to guide and support future healthcare tasks of general practice. Wagner's Chronic Care Model, which was developed on the basis of numerous controlled studies, integrates empirical results, theoretical ideas and real experience within a comprehensive concept for the treatment of chronic diseases. The model focuses on the'productive interaction' between an active patient and a proactive practice team. The various elements of the model help to better understand healthcare in general practices, for example by establishing reminder and recall systems by means of a structured reorganization, through patient registers, the implementation of consultation hours for chronically ill patients as well as patient training. 'Case management' is essential to the success of structured care. Taking care of patients with major depression as an example, it is demonstrated how case management through practice assistants in general practices enables the individual needs of chronically ill patients to be better taken into account. The professionalism of the practice team with new roles and task sharing as well as the implementation of modern strategies for the care of chronically ill patients provide a new chance and a sharpened profile for general practices of the future.

[New perspectives in the primary care of the chronically ill--against the "tyranny of the urgent". Part 1: chronic diseases as a challenge for primary care]

Chronic diseases and multimorbidity are becoming a fundamental challenge for primary care which already requires a very high input of resources. Due to their broad range and continuity, general practices play a major role, but are poorly prepared to succeed in the structured healthcare of chronically ill patients. The reality of care in everyday practice is primarily characterized by the 'tyranny of the urgent', and such a reaction to acute problems leads to noticeable deficits in permanent care. Part one of a two-part article series asks to what extent demographic changes and medical progress are responsible for this development. Meanwhile, a large quantity of empirical evidence indicates that results improve when case management is implemented for chronically ill patients. Though disease management programs are being increasingly established in Germany, many general practices are only poorly prepared for their tangible implementation in everyday routine. The comparison of two case studies shows how the primary care of chronically ill patients might look like in the future. On the basis of both scientific evidence and the globally acknowledged 'Chronic Care Model', part two of the article looks at sustainable strategies and special tools which allow for an adequate care of chronically ill patients in general practice.

Development and prevention of skeletal muscle structural alterations after experimental myocardial infarction

The present study was designed to assess whether structural alterations develop within skeletal muscle 1 yr after myocardial infarction (MI) and failure and, if so, whether these structural alterations can be prevented by angiotensin-converting enzyme (ACE) inhibition. Infarcted rats were randomized and treated for 1 yr with either placebo (MI-IP, n = 9), a low dose of lisinopril (MI-LL, 0.5 mg.kg-1.day-1, n = 12), or a high dose of lisinopril (MI-LH, 5 mg.kg-1.day-1, n = 9). Sham-operated animals served as controls (SH, n = 14). One year after MI, in situ fixation of rat hindlimb was performed to investigate interstitial collagen volume fraction (CVF), capillary density, and media thickness of resistance vessels (80-200 microns) of musculus quadriceps femoris muscle. Infarct size was similar in all infarct groups and averaged 26 +/- 4%. Right ventricular weight was increased in MI-IP compared with SH, MI-LL, and MI-LH. Both left ventricular (LV) CVF and skeletal muscle CVF were increased in MI-IP. LV CVF and skeletal muscle CVF were closely related to each other (n = 44, r = 0.5377, P < 0.002). In infarcted rats, high-dose ACE inhibition significantly reduced skeletal muscle and LV CVF. Skeletal muscle capillary density and capillary-to-muscle fiber ratio were significantly decreased in infarcted rats but were restored by low- and high-dose ACE inhibition. Media thickness of intramuscular resistance vessels was increased in the MI-IP group and significantly reduced by high-dose ACE inhibition.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of four new gastric cancer cell lines

Four well differentiated gastric adenocarcinoma cell lines from German patients have been established from primary tumors (St 23132, St 3051) and lymph node metastases (St 2474, St 2957). The tumor cells were isolated by enzymatic or mechanical treatment. All four lines grew as solid tumors in nude mice and formed colonies in soft agar. The doubling time of the cells in culture was 25-32 h. Further characteristics of the lines were a considerable chromosomal aneuploidy, (the chromosomal numbers varying from 30-109 with many numerical and structural abnormalities), a stable keratin expression (Ck 8, 18, 19), the expression and secretion of CEA and CA-19-9 and the overexpression of c-myc. The four stomach cancer cell lines described here are not only a useful addition to the small number of existing lines, but also represent ideal tools for studying tumorigenicity of human stomach cancers in vitro and in vivo.

Cytogenetic differences between intestinal and diffuse types of human gastric carcinoma

This study concerns the cytogenetics of 23 gastric carcinomas, classified histologically as intestinal or diffuse types. In carcinomas of the diffuse type, the only numerical changes observed were Y chromosome loss associated with X-chromosome disomy in four of seven male patients. A 46, XX karyotype without recognizable alterations was observed in three of five female patients, and rare structural changes in diffuse carcinomas involved chromosomes 1 and 18. In contrast, intestinal type tumors were exclusively aneuploid, with chromosome modes ranging from 48 to 84. The most consistent change was trisomy 20 in seven of 11 patients, each of which displayed a number of both single and clonal structural aberrations. Frequent structural changes were translocations involving chromosome 13 (including a putative isochromosome 13q in three of 11 patients), and alterations in chromosomes 1, 6 and 12. This study therefore suggests that diffuse and intestinal types of gastric carcinomas do not share a common sequence of genetic changes. The tumor with the worse prognosis (diffuse type) is surprisingly diploid, with uniform X-disomy in both males and females. The clinically less aggressive tumors (intestinal type) show multiple changes, both numerical and structural, of which some are reminiscent of changes seen in tumors of the lower gastrointestinal tract. Cytogenetics may thus be a valuable adjunct in establishing the diagnosis, classification, and prognosis of gastric carcinomas.