Neural signatures of indirect pathway activity during subthalamic stimulation in Parkinson's disease

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) produces an electrophysiological signature called evoked resonant neural activity (ERNA); a high-frequency oscillation that has been linked to treatment efficacy. However, the single-neuron and synaptic bases of ERNA are unsubstantiated. This study proposes that ERNA is a subcortical neuronal circuit signature of DBS-mediated engagement of the basal ganglia indirect pathway network. In people with Parkinson's disease, we: (i) showed that each peak of the ERNA waveform is associated with temporally-locked neuronal inhibition in the STN; (ii) characterized the temporal dynamics of ERNA; (iii) identified a putative mesocircuit architecture, embedded with empirically-derived synaptic dynamics, that is necessary for the emergence of ERNA in silico; (iv) localized ERNA to the dorsal STN in electrophysiological and normative anatomical space; (v) used patient-wise hotspot locations to assess spatial relevance of ERNA with respect to DBS outcome; and (vi) characterized the local fiber activation profile associated with the derived group-level ERNA hotspot.

Is loneliness associated with cancellation of medical appointments during the COVID-19 pandemic? Evidence from the Hamburg City Health Study (HCHS)

BACKGROUND

The COVID-19 pandemic engendered numerous societal and economic challenges in addition to health-related concerns. Maintenance of healthcare utilization assumed immense significance during this period. However, few studies have examined the association between loneliness and cancelled medical appointments during the COVID-19 pandemic. This study aimed to examine whether medical appointments are less likely to be cancelled with increased loneliness during a pandemic. We analyzed the association between loneliness and both patient- and provider-initiated appointment cancellations.

METHODS

Cross-sectional data from the Hamburg City Health Study (HCHS) were collected during April 2020-November 2021. The analytical sample included 1,840 participants with an average age of 55.1 years (standard deviation: 6.5, range 45-76 years). Medical appointments cancelled by individuals-medical appointments in general, and GP, specialist, and dentist appointments-and appointments cancelled by healthcare providers served as outcome measures. Loneliness was quantified using a single item ranging from 0 to 10. Accordingly, we created empirical loneliness tertiles. Covariates were selected based on the Andersen model. Several penalized maximum likelihood logistic regressions were utilized to examine the association between loneliness and cancellation of medical appointments during the COVID-19 pandemic.

RESULTS

The penalized maximum likelihood logistic regressions showed that, compared to individuals in the lowest loneliness tertiles, individuals in the other two tertiles reported a higher chance of medical appointments cancellation by individuals, particularly driven by cancelled GP appointments. Except for age and sex, none of the covariates were comparably associated with the outcomes. When appointments cancelled by healthcare providers served as outcomes, only a higher number of chronic conditions was significantly positively associated with it.

CONCLUSIONS

Individuals scoring higher in loneliness had a greater chance of cancelling medical (particularly GP) appointments. This may contribute to a potential cascade of loneliness and skipped medical appointments in the future, resulting in adverse health outcomes over the medium-to-long term. Future research should examine whether lonely people are more likely to lack the social motivation to visit the doctor.

Oscillatory network markers of subcallosal cingulate deep brain stimulation for depression

Identifying functional biomarkers related to treatment success can aid in expediting therapy optimization, as well as contribute to a better understanding of the neural mechanisms of the treatment-resistant depression (TRD) and subcallosal cingulate deep brain stimulation (SCC-DBS). Magnetoencephalography data were obtained from 16 individuals with SCC-DBS for TRD and 25 healthy subjects. The first objective of the study was to identify region-specific oscillatory modulations that both (i) discriminate individuals with TRD (with SCC-DBS OFF) from healthy controls, and (ii) discriminate TRD treatment responders from non-responders (with SCC-DBS ON). The second objective of this work was to further explore the effects of stimulation intensity and frequency on oscillatory activity in the identified brain regions of interest. Oscillatory power analyses led to the identification of brain regions that differentiated responders from non-responders based on modulations of increased alpha (8-12 Hz) and decreased gamma (32-116 Hz) power within nodes of the default mode, central executive, and somatomotor networks, Broca's area, and lingual gyrus. Within these nodes, it was also found that low stimulation frequency had stronger effects on oscillatory modulation than increased stimulation intensity. The identified functional network biomarkers implicate modulation of TRD-related activity in brain regions involved in emotional control/processing, motor control, and the interaction between speech, vision, and memory, which have all been implicated in depression. These electrophysiological biomarkers have the potential to be used as functional proxies for therapy optimization. Additional stimulation parameter analyses revealed that oscillatory modulations can be strengthened by increasing stimulation intensity or reducing frequency, which may represent potential avenues of direction in non-responders.

Direct modulation index: A measure of phase amplitude coupling for neurophysiology data

Neural communication across different spatial and temporal scales is a topic of great interest in clinical and basic science. Phase-amplitude coupling (PAC) has attracted particular interest due to its functional role in a wide range of cognitive and motor functions. Here, we introduce a novel measure termed the direct modulation index (dMI). Based on the classical modulation index, dMI provides an estimate of PAC that is (1) bound to an absolute interval between 0 and +1, (2) resistant against noise, and (3) reliable even for small amounts of data. To highlight the properties of this newly-proposed measure, we evaluated dMI by comparing it to the classical modulation index, mean vector length, and phase-locking value using simulated data. We ascertained that dMI provides a more accurate estimate of PAC than the existing methods and that is resilient to varying noise levels and signal lengths. As such, dMI permits a reliable investigation of PAC, which may reveal insights crucial to our understanding of functional brain architecture in key contexts such as behaviour and cognition. A Python toolbox that implements dMI and other measures of PAC is freely available at https://github.com/neurophysiological-analysis/FiNN.

[Dermatological video consultations for German prisons : Experiences from teledermatological consultations 2020 to 2022]

BACKGROUND

With increasing shortage of medical personnel also in the medical care in German correctional facilities, telemedicine has been used since 2016, initially in projects and then for regular medical care. Since 2019, there is the possibility of dermatological expertise in regular video consultations.

OBJECTIVE

The benefits of an interdisciplinary online consultation with video and store and forward technology for dermatological issues are highlighted in terms of efficiency and feasibility.

MATERIAL AND METHODS

A descriptive analysis of 450 dermatological video consultations for German correctional facilities from February 2020 to July 2022 was carried out with respect to procedures, indications and demand.

RESULTS

Requests were made via a standardised form with optional photographs, which were sent via a secure cloud to the dermatology department in store and forward mode. The majority of cases could be presented live in a regular weekly video consultation and only single cases required an acute presentation within 24 h. The spectrum of skin diseases was comparable to cases presenting to a dermatology outpatient clinic. The interdisciplinary consultation management together with colleagues from general medicine enabled the transfer of the cases to the medical personnel at the correctional facility on site for follow-up and further medical procedures. Treatment could be started in all cases without delay.

CONCLUSION

Teledermatology represents an important contribution to medical care in German correctional facilities and the interdisciplinary cooperation saves time and resources in the presentation and treatment of skin diseases.

The development of a regional network for health care research in Hamburg, Germany

Background

At the University Medical Center Hamburg-Eppendorf (UKE), health care research has been established as one of five research priorities recommended by the Research Council with the founding of the Center for Health Care Research (CHCR) in 2006. The CHCR was involved in numerous research projects with the focus on strengthening regional networking. Despite the numerous initiatives, there is still potential for improvement with regard to a systematic and sustainable exchange in the region of Hamburg, Germany.

Methods

These requirements led to the initiation of the ‘Hamburg Network Health Services Research (HAM-NET)'. The mission of HAM-NET is to build an open forum for all relevant institutions, to concentrate their interests and needs in health services research and to promote and conduct innovative, efficient, needs-based and patient-centred health services research projects in the metropolitan area of Hamburg. Three main tasks were appointed: 1) linking health care research to relevant regional institutions, 2) promoting research activities and new fields of research and 3) using methodological expertise to promote young scientists.

Results

By today 40 institutions from all sectors of health care joined HAM-NET. The regularly general meetings offer exchange and advice. Internal communication is promoted by mailing lists and newsletters. Also, HAM-NET presents itself with a website, logo and by organizing recurring events and participating in international and national congresses and networks. Within two funding phases a total of four overarching research projects were developed and implemented. Furthermore, a person with lived experience committee was established.

Conclusions

For the further development of health care research as one the core disciplines of public health a regional network with an efficient infrastructure is needed. HAM-NET promotes this with the implementation of an innovative, efficient and patient-oriented network.

Key messages

• Regional networks help to integrate multiple public health initiatives and community stakeholders.

• Public health networks can be established on multidisciplinary cooperations in different out- and inpatient sector levels.

FiNN: A toolbox for neurophysiological network analysis

Recently, neuroscience has seen a shift from localist approaches to network-wide investigations of brain function. Neurophysiological signals across different spatial and temporal scales provide insight into neural communication. However, additional methodological considerations arise when investigating network-wide brain dynamics rather than local effects. Specifically, larger amounts of data, investigated across a higher dimensional space, are necessary.

Here, we present FiNN (Find Neurophysiological Networks), a novel toolbox for the analysis of neurophysiological data with a focus on functional and effective connectivity. FiNN provides a wide range of data processing methods, and statistical and visualization tools to facilitate inspection of connectivity estimates and the resulting metrics of brain dynamics. The Python toolbox (https://github.com/neurophysiological-analysis/FiNN) and its documentation (https://neurophysiological-analysis.github.io/FiNN/) are freely available.

We evaluated FiNN against a number of established frameworks on both a conceptual and an implementation level. We found FiNN to require much less processing time and memory than other toolboxes. In addition, FiNN adheres to a design philosophy of easy access and modifiability, while providing efficient data processing implementations. Since the investigation of network-level neural dynamics is experiencing increasing interest, we place FiNN at the disposal of the neuroscientific community as open-source software.

Dislocations in ceramic electrolytes for solid-state Li batteries

High power solid-state Li batteries (SSLB) are hindered by the formation of dendrite-like structures at high current rates. Hence, new design principles are needed to overcome this limitation. By introducing dislocations, we aim to tailor mechanical properties in order to withstand the mechanical stress leading to Li penetration and resulting in a short circuit by a crack-opening mechanism. Such defect engineering, furthermore, appears to enable whisker-like Li metal electrodes for high-rate Li plating. To reach these goals, the challenge of introducing dislocations into ceramic electrolytes needs to be addressed which requires to establish fundamental understanding of the mechanics of dislocations in the particular ceramics. Here we evaluate uniaxial deformation at elevated temperatures as one possible approach to introduce dislocations. By using hot-pressed pellets and single crystals grown by Czochralski method of Li6.4La3Zr1.4Ta0.6O12 garnets as a model system the plastic deformation by more than 10% is demonstrated. While conclusions on the predominating deformation mechanism remain challenging, analysis of activation energy, activation volume, diffusion creep, and the defect structure potentially point to a deformation mechanism involving dislocations. These parameters allow identification of a process window and are a key step on the road of making dislocations available as a design element for SSLB.

Grief and loss in old age: Exploration of the association between grief and depression

BACKGROUND

The proportion of older adults is increasing due to demographic changes. Depression belongs to the most common mental disorders in late life. The loss of an emotionally significant person is a risk factor for the development of depression. The aim of this study is to analyze the association between depression and grief burden resulting from loss. Based on prior evidence, we examined loneliness as a possible mediator and social support as possible moderator of this association.

METHODS

The cross-sectional analyses are based on a sample (N = 863) of study participants aged 75+ (M = 81.4 years, SD = 4.4, 62.2% female) with loss experience deriving from the multicenter prospective German cohort study AgeMooDe. Regression analyses (moderated mediation) were performed.

RESULTS

With increasing age (β = 0.10, p = .005) and grief burden (β = 0.33, p <. 001) depression severity increased. There was an indirect mediating effect of loneliness on the correlation of grief burden and depression (b = 0.04, CI [0.03, 0.05]), but no moderating effect of social support on the correlation of grief burden and loneliness. People living alone had a significantly higher risk of depression, increased loneliness and lack of social support.

LIMITATIONS

Assessments were based on self-reporting and recorded dimensionally. The cross-sectional design limits conclusions about directions and causality of associations. Sampling bias cannot be completely excluded.

CONCLUSION

The study provides empirical evidence and a better understanding of the association between grief and depression among the very old and the mediating role of loneliness.

Online Mapping With the Deep Brain Stimulation Lead: A Novel Targeting Tool in Parkinson's Disease

BACKGROUND

Beta-frequency oscillations (13-30 Hz) are a subthalamic hallmark in patients with Parkinson's disease, and there is increased interest in their utility as an intraoperative marker.

OBJECTIVES

The objectives of this study were to assess whether beta activity measured directly from macrocontacts of deep brain stimulation leads could be used (a) as an intraoperative electrophysiological approach for guiding lead placements and (b) for physiologically informed stimulation delivery.

METHODS

Every millimeter along the surgical trajectory, local field-potential data were collected from each macrocontact, and power spectral densities were calculated and visualized (n = 39 patients). This was done for online intraoperative functional mapping and post hoc statistical analyses using 2 methods: generating distributions of spectral activity along surgical trajectories and direct delineation (presence versus lack) of beta peaks. In a subset of patients, this approach was corroborated by microelectrode recordings. Furthermore, the match rate between beta peaks at the final target position and the clinically determined best stimulation site were assessed.

RESULTS

Subthalamic recording sites were delineated by both methods of reconstructing functional topographies of spectral activity along surgical trajectories at the group level (P < 0.0001). Beta peaks were detected when any portion of the 1.5 mm macrocontact was within the microelectrode-defined subthalamic border. The highest beta peak at the final implantation site corresponded to the site of active stimulation in 73.3% of hemispheres (P < 0.0001). In 93.3% of hemispheres, active stimulation corresponded to the first-highest or second-highest beta peak.

CONCLUSIONS

Online measures of beta activity with the deep brain stimulation macroelectrode can be used to inform surgical lead placement and contribute to optimization of stimulation programming procedures. © 2020 International Parkinson and Movement Disorder Society.

Influences on students' empathy in medical education: an exploratory interview study with medical students in their third and last year

BACKGROUND

Empathy is beneficial for patients and physicians. It facilitates treatment and improves physical and psychosocial outcomes. The therapeutic relevance of empathy emphasizes the need to help medical students develop their empathic abilities. Our study aimed to identify factors which promote or hinder the development and expression of empathy in medical students during the course of their studies.

METHODS

We interviewed 24 medical students (six male and six female students in their 6th semester as well as six male and six female students in their final clinical year) using semi-structured interviews. The interviews were recorded, transcribed verbatim and analyzed using Braun & Clarke's thematic analysis.

RESULTS

We identified four main themes influencing the development and expression of empathy. 1) Course of studies: hands-on-experience, role models, science and theory, and emphasis on the importance of empathy; 2) students: insecurities and lack of routine, increasing professionalism, previous work experiences, professional distance, mood, maturity, and personal level of empathy; 3) patients: "easy" and "difficult" patients including their state of health; and 4) surrounding conditions: time pressure/stress, work environment, and job dissatisfaction.

CONCLUSIONS

The development and use of empathy could be promoted by increasing: hands-on-experiences, possibilities to experience the patient's point of view and offering patient contact early in the curriculum. Students need support in reflecting on their actions, behavior and experiences with patients. Instructors need time and opportunities to reflect on their own communication with and treatment of patients, on their teaching behavior, and on their function as role models for treating patients empathically and preventing stress. Practical experiences should be made less stressful for students. The current changes implemented in some medical school curriculums (e.g., in Germany) seem to go in the right direction by integrating patient contact early on in the curriculum and focusing more on teaching adequate communication and interaction behaviors.

Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study

BACKGROUND

Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.

METHODS

We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.

RESULTS

Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.

CONCLUSIONS

There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

[Informal care for dementia according to type of service]

BACKGROUND

Dementia is a major challenge for society and its impact will grow in the future. Informal care is an essential part of dementia care. Previous studies considered informal care as a whole and not by its components.

OBJECTIVE

We aimed to assess the degree of association between specific informal care services and dementia.

MATERIAL AND METHODS

This analysis is based on data from the seventh wave of the AgeCoDe/AgeQualiDe study. Dementia was diagnosed based on the DSM-IV criteria. Severity of dementia was assessed and categorized by means of the Clinical Dementia Rating and eight individual informal care services were considered. Logistic regression models were used to assess associations.

RESULTS

Of the 864 participants 18% suffered from dementia (very mild: 4%; mild: 6%; moderate: 5%; severe: 3%). All informal care services were significantly associated with dementia, with an emphasis on "supervision", "regulation of financial matters" and "assistance in the intake of medication". Considering different degrees of dementia severity, similar results arose from the analyses. All three aforementioned services showed a pronounced association with all degrees of dementia severity, except for supervision and very mild dementia.

CONCLUSION

The provision of all types of informal care services is associated with dementia. The association is pronounced for services that can be more easily integrated into the daily routines of the informal caregiver. Policy makers who plan to integrate informal care into the general care arrangements for dementia should consider this.

A multivariate investigation into the relationship between pharmaceutical characteristics and patient preferences of bioequivalent ibuprofen tablets

BACKGROUND

In Spain the price of all ibuprofen 600 mg tablet generic products is the same due to reimbursement existing rules so for the patient there is not any economic incentive to choose a particular one. Bearing in mind that the quality of generic products should be similar, it could be questioned if differences in patient preferences evaluated as sales could be related to differences on their pharmaceutical properties. The aims of this work were to study the variability on the pharmaceutical characteristics of marketed bioequivalent tablet formulations and its impact on patient preferences.

METHODS

Thirty-six batches corresponding to fourteen different generic products were chosen among the best-selling products of the Spanish market in the years 2011 and 2015 and were compared to the reference product. The effect on patient preferences of six variables was studied through a multivariate analysis. The first two variables were marketing characteristics: 1) years in the market and 2) the number of other generic products marketed by the same manufacturer, which could be related to the size and service provided by the manufacturer. The other four variables studied were pharmaceutical tablet properties: 3) mean weight, 4) hardness, 5) disintegration, and 6) dissolution. A multiple linear regression analysis was performed to identify the effect on sales of the six variables studied.

RESULTS

The disintegration time was the most significant (P=0.018) factor affecting the sales of Ibuprofen tablets which may be related to the onset of action.

CONCLUSION

The faster the tablet disintegration, the higher its sales. Two possible explanations are suggested: 1) the most specialized ibuprofen tablet manufacturer considers fast disintegration as a key parameter and/or 2) habitual consumers of ibuprofen can detect small differences on the onset of action among different marketed formulations. In this work, all marketed ibuprofen tablets comply with the pharmacopoeia specifications.

Longitudinal Analysis of Outpatient Physician Visits in the Oldest Old: Results of the AgeQualiDe Prospective Cohort Study

OBJECTIVES

The aim of this study was to identify determinants of outpatient health care utilization among the oldest old in Germany longitudinally.

DESIGN

Multicenter prospective cohort "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe).

SETTING

Individuals in very old age were recruited via GP offices at six study centers in Germany. The course of outpatient health care was observed over 10 months (two waves).

PARTICIPANTS

Primary care patients aged 85 years and over (at baseline: n=861, with mean age of 89.0 years±2.9 years; 85-100 years).

MEASUREMENTS

Self-reported numbers of outpatient visits to general practitioners (GP) and specialists in the past three months were used as dependent variables. Widely used scales were used to quantify explanatory variables (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale, or Global Deterioration Scale).

RESULTS

Fixed effects regressions showed that increases in GP visits were associated with increases in cognitive impairment, whereas they were not associated with changes in marital status, functional decline, increasing number of chronic conditions, increasing age, and changes in social network. Increases in specialist visits were not associated with changes in the explanatory variables.

CONCLUSION

Our findings underline the importance of cognitive impairment for GP visits. Creating strategies to postpone cognitive decline might be beneficial for the health care system.

Project Career: Perceived benefits of iPad apps among college students with Traumatic Brain Injury (TBI)

BACKGROUND

Project Career is an interprofessional five-year development project designed to improve academic and employment success of undergraduate students with a traumatic brain injury (TBI) at two- and four-year colleges and universities. Students receive technology in the form of iPad applications ("apps") to support them in and out of the classroom.

OBJECTIVE

To assess participants' perspectives on technology at baseline and perceived benefit of apps after 6 and 12 months of use.

METHODS

This article address a component of a larger study. Participants included 50 college-aged students with traumatic brain injuries. Statistical analysis included data from two Matching Person and Technology (MPT) assessment forms, including the Survey of Technology Use at baseline and the Assistive Technology Use Follow-Up Survey: Apps Currently Using, administered at 6- and 12-months re-evaluation. Analyses included frequencies and descriptives.

RESULTS

Average scores at baseline indicated positive perspectives on technology. At 6 months, quality of life (67%) and academics (76%) improved moderately or more from the use of iPad apps. At 12 months, quality of life (65%) and academics (82%) improved moderately or more from the use of iPad apps.

CONCLUSION

Students with a TBI have positive perspectives on technology use. The results on perceived benefit of apps indicated that students with a TBI (including civilians and veterans) report that the apps help them perform in daily life and academic settings.

Regional variations of perceived problems in ambulatory care from the perspective of general practitioners and their patients - an exploratory focus group study in urban and rural regions of northern Germany

BACKGROUND

Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients.

METHODS

We conducted 27 focus groups with general practitioners (n = 65) and patients (n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories.

RESULTS

General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs.

CONCLUSIONS

While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way.

Does Visual Impairment Affect Social Ties in Late Life? Findings of a Multicenter Prospective Cohort Study in Germany

OBJECTIVE

To investigate how visual impairment affects social ties in late life longitudinally.

DESIGN

Population-based prospective cohort study.

SETTING

Individuals in old age were recruited via general practitioners' offices (at six study centers) in Germany. They were interviewed every 18 months.

PARTICIPANTS

Individuals aged 75 years and above at baseline. Follow-up wave 2 (36 months after baseline, n=2,443) and wave 4 (72 months after baseline, n=1,618) were used for the analyses presented here.

MEASUREMENTS

Social ties were assessed using the 14-item form of the questionnaire for social support (F-SozU K-14). Visual impairment was self-rated on a three level Likert scale (no impairment, mild visual impairment, or severe/profound visual impairment).

RESULTS

Adjusting for sociodemographic factors, hearing impairment and comorbidity, fixed effects regressions revealed that the onset of mild visual impairment decreased the social support score, in particular the emotional support score. Additionally, the onset of mild hearing impairment decreased the social support score in men. Moreover, increasing age decreased the social support score in the total sample and in both sexes. Loss of spouse and increasing comorbidity did not affect the social support score.

CONCLUSION

Our results highlight the importance of visual impairment for social ties in late life. Consequently, appropriate strategies in order to delay visual impairment might help to maintain social ties in old age.