[Text Comprehensibility of Hospital Report Cards]

Objectives: Recently, the number of hospital report cards that compare quality of hospitals and present information from German quality reports has greatly increased. Objectives of this study were to a) identify suitable methods for measuring the readability and comprehensibility of hospital report cards, b) to obtain reliable information on the comprehensibility of texts for laymen, c) to give recommendations for improvements and d) to recommend public health actions. Methods: The readability and comprehensibility of the texts were tested with a) a computer-aided evaluation of formal text characteristics (readability indices Flesch (German formula) and 1. Wiener Sachtextformel formula), b) an expert-based heuristic analysis of readability and comprehensibility of texts (counting technical terms and analysis of text simplicity as well as brevity and conciseness using the Hamburg intelligibility model) and c) a survey of subjects about the comprehensibility of individual technical terms, the assessment of the comprehensibility of the presentations and the subjects' decisions in favour of one of the 5 presented clinics due to the better quality of data. In addition, the correlation between the results of the text analysis with the results from the survey of subjects was tested. Results: The assessment of texts with the computer-aided evaluations showed poor comprehensibility values. The assessment of text simplicity using the Hamburg intelligibility model showed poor comprehensibility values (-0.3). On average, 6.8% of the words used were technical terms. A review of 10 technical terms revealed that in all cases only a minority of respondents (from 4.4% to 39.1%) exactly knew what was meant by each of them. Most subjects (62.4%) also believed that unclear terms worsened their understanding of the information offered. The correlation analysis showed that presentations with a lower frequency of technical terms and better values for the text simplicity were better understood. Conclusion: The determination of the frequency of technical terms and the assessment of text simplicity using the Hamburg intelligibility model were suitable methods to determine the readability and comprehensibility of presentations of quality indicators. The analysis showed predominantly poor comprehensibility values and indicated the need to improve the texts of report cards.

[Efficacy and efficiency of searches for a physician using physician search and evaluation portals in comparison with Google]

OBJECTIVES

The Internet provides ways for patients to obtain information about doctors. The study poses the question whether it is possible and how long it takes to find a suitable doctor with an Internet search. It focuses on the effectiveness and efficiency of the search. Specialised physician rating and searching portals and Google are analysed when used to solve specific tasks.

METHODS

The behaviour of volunteers when searching a suitable ophthalmologist, dermatologist or dentist was observed in a usability lab. Additionally, interviews were carried out by means of structured questionnaires to measure the satisfaction of the users with the search and their results. Three physician rating and searching portals that are frequently used in Germany (Jameda.de, DocInsider.de and Arztauskunft.de) were analysed as well as Google.

RESULTS

When using Arztauskunft and Google most users found an appropriate physician. When using Docinsider or Jameda they found fewer doctors. Additionally, the time needed to locate a suitable doctor when using Docinsider and Jameda was higher compared to the time needed when using the Arztauskunft and Google. The satisfaction of users who used Google was significantly higher in comparison to those who used the specialised physician rating and searching portals.

CONCLUSION

It emerged from this study that there is no added value when using specialised physician rating and searching portals compared to using the search engine Google when trying to find a doctor having a particular specialty. The usage of several searching portals is recommended to identify as many suitable doctors as possible.

Public reporting in Germany: the content of physician rating websites

BACKGROUND

Physician rating websites (PRWs) are gaining in popularity among patients seeking quality information about physicians. However, little knowledge is available about the quantity and type of information provided on the websites.

OBJECTIVE

To determine and structure the quantity and type of information about physicians in the outpatient sector provided on German-language physician rating websites.

METHODS

In a first step, we identified PRWs through a systematic internet search using German keywords from a patient´s perspective in the two search engines Google and Yahoo. Afterwards, information about physicians available on the websites was collected and categorised according to Donabedian´s structure/process/outcome model. Furthermore, we investigated whether the information was related to the physician himself/ herself or to the practice as a whole.

RESULTS

In total, eight PRWs were detected. Our analysis turned up 139 different information items on eight websites; 67 are related to the structural quality, 4 to process quality, 5 to outcomes, and 63 to patient satisfaction/experience. In total, 37% of all items focus specifically on the physician and 63% on the physician's practice. In terms of the total amount of information provided on the PRWs, results range from 61 down to 13.5 items.

CONCLUSIONS

A broad range of information is available on German PRWs. While structural information can give a detailed overview of the financial, technical and human resources of a practice, other outcome measures have to be interpreted with caution. Specifically, patient satisfaction results are not risk-adjusted, and thus, are not appropriate to represent a provider's quality of care. Consequently, neither patients nor physicians should yet use the information provided to make their final decision for or against an individual physician.

[The Abbreviated Injury Scale (AIS). Options and problems in application]

The new AIS (Abbreviated Injury Scale) was released with an update by the AAAM (Association for the Advancement of Automotive Medicine) in 2008. It is a universal scoring system in the field of trauma applicable in clinic and research. In engineering it is used as a classification system for vehicle safety. The AIS can therefore be considered as an international, interdisciplinary and universal code of injury severity. This review focuses on a historical overview, potential applications and new coding options in the current version and also outlines the associated problems.

Short-term reproducibility of computed tomography-based lung density measurements in alpha-1 antitrypsin deficiency and smokers with emphysema

PURPOSE

To study the short-term reproducibility of lung density measurements by multi-slice computed tomography (CT) using three different radiation doses and three reconstruction algorithms.

MATERIAL AND METHODS

Twenty-five patients with smoker's emphysema and 25 patients with alpha1-antitrypsin deficiency underwent 3 scans at 2-week intervals. Low-dose protocol was applied, and images were reconstructed with bone, detail, and soft algorithms. Total lung volume (TLV), 15th percentile density (PD-15), and relative area at -910 Hounsfield units (RA-910) were obtained from the images using Pulmo-CMS software. Reproducibility of PD-15 and RA-910 and the influence of radiation dose, reconstruction algorithm, and type of emphysema were then analysed.

RESULTS

The overall coefficient of variation of volume adjusted PD-15 for all combinations of radiation dose and reconstruction algorithm was 3.7%. The overall standard deviation of volume-adjusted RA-910 was 1.7% (corresponding to a coefficient of variation of 6.8%). Radiation dose, reconstruction algorithm, and type of emphysema had no significant influence on the reproducibility of PD-15 and RA-910. However, bone algorithm and very low radiation dose result in overestimation of the extent of emphysema.

CONCLUSION

Lung density measurement by CT is a sensitive marker for quantitating both subtypes of emphysema. A CT-protocol with radiation dose down to 16 mAs and soft or detail reconstruction algorithm is recommended.

IgG and IgE immune response against the surface glycoprotein gp200 of Saccharomyces cerevisiae in patients with atopic dermatitis

The heat-stable and soluble glycoprotein gp200 (molecular weight 200 kDa) is part of the cell wall of S. cerevisiae. Recently, an association was shown between IgA and IgG against gp200 and inflammation in Crohn's disease. Gp200 is able to induce a proliferation of human lymphocytes in vitro, together with a natural killer cell associated cytotoxicity. Specific IgE against Saccharomyces cerevisiae (baker's or brewer's yeast) may be detected in approximately 73%, against Candida albicans in 68% of those patients suffering from severe atopic dermatitis. The aim of this study was to elucidate the possible role of an anti-gp200 immune response for the pathogenesis of atopic dermatitis by immunoblot analysis. Anti-gp200 IgE was found in 55% of healthy individuals, in 67% of individuals with atopic predisposition without eczema, in 63% of the patients with mild atopic dermatitis, and in 86% of patients with severe atopic dermatitis, respectively. On the contrary, anti-gp200 IgG could be shown in 55% of healthy individuals, in 89% of individuals with atopic predisposition but without eczema, in 100% of patients with mild atopic dermatitis, and in 79% with severe atopic dermatitis, respectively. No immunoreactivity was found when an extract of Arxula adeninivorans was used as antigen. These results underline the specificity of the immunoblot results with gp200 from Saccharomyces cerevisiae. It can be concluded that occurrence of specific IgE against Saccharomyces cerevisiae cannot be explained by a cross reactivity, e.g., against Candida albicans allergens. Further investigations with the recombinant gp200 will give information on the role of this glycoprotein both in atopic dermatitis and Morbus Crohn.

Coiling phagocytosis of trypanosomatids and fungal cells

Coiling phagocytosis has previously been studied only with the bacteria Legionella pneumophila and Borrelia burgdorferi, and the results were inconsistent. To learn more about this unconventional phagocytic mechanism, the uptake of various eukaryotic microorganisms by human monocytes, murine macrophages, and murine dendritic cells was investigated in vitro by video and electron microscopy. Unconventional phagocytosis of Leishmania spp. promastigotes, Trypanosoma cruzi trypomastigotes, Candida albicans hyphae, and zymosan particles from Saccharomyces cerevisiae differed in (i) morphology (rotating unilateral pseudopods with the trypanosomatids, overlapping bilateral pseudopods with the fungi), (ii) frequency (high with Leishmania; occasional with the fungi; rare with T. cruzi), (iii) duration (rapid with zymosan; moderate with the trypanosomatids; slow with C. albicans), (iv) localization along the promastigotes (flagellum of Leishmania major and L. aethiopica; flagellum or posterior pole of L. donovani), and (v) dependence on complement (strong with L. major and L. donovani; moderate with the fungi; none with L. aethiopica). All of these various types of unconventional phagocytosis gave rise to similar pseudopod stacks which eventually transformed to a regular phagosome. Further video microscopic studies with L. major provided evidence for a cytosolic localization, synchronized replication, and exocytic release of the parasites, extending traditional concepts about leishmanial infection of host cells. It is concluded that coiling phagocytosis comprises phenotypically similar consequences of various disturbances in conventional phagocytosis rather than representing a single separate mechanism.

Humoral immune response to a 200-kDa glycoprotein antigen of Saccharomyces cerevisiae is common in man

According to Heelan et al. patients suffering from Crohn's disease (CD) produce antibodies against a cell wall associated glycoprotein antigen gp200 of the yeast Saccharomyces cerevisiae, while healthy people do not. Here the authors show, that antibodies against this glycoprotein gp200 can also be detected in the sera of healthy humans. The intensity of the antibody titer which is measured by immunoblot experiments is independent from the state of health. The Saccharomyces cerevisiae specific gp200 is a highly glycosylated protein localized not only in the cell wall but also accumulated in the culture medium. Some of the tested sera from CD patients, as well as from healthy adults, also reacted with a 120-kDa glycoprotein which is to be found in preparations containing secreted proteins. Because the binding of antibodies is greatly reduced by periodate treatment of gp200 and by the 120-kDa polypeptide, it is very likely that their carbohydrate moieties are the antigenic determinants against which the specific human antibodies are directed. The human humoral immune response applies only to Saccharomyces cerevisiae antigens, because no analogous immune responses could be detected against antigens derived from the yeast Arxula adeninivorans.

[Comparison of perforated metal ceiling systems (supported airflow ceilings) with laminar airflow ceilings in type A (DIN 1946 T.4) operating rooms under surgical conditions]

In eleven centrally ventilated operating theatres the concentration of particles and airborne germs in wound vicinity was measured on three workdays. Five theatres were equipped with air supply ceilings with supporting flow outlets (supporting flow ceilings), five with laminar air flow ceilings and one with an air supply ceiling, a body exhaust system and a partition wall between the anesthetic and operating areas. Under routine conditions the air supply of the laminar air flow ceiling with its lower turbulence shielded the operating field from the largely staff-related air contamination in the rest of the theatre better than in the case of the supporting flow ceilings. Particles and airborne germs were removed from the endangered wound area faster. A spatial separation between the anesthetic and the operating areas as well as a body exhaust system lead to a considerable reduction of the contamination. Two theatres were conspicuous by reason of their considerably raised values due to defective control engineering and the wrongly positioning of the operating table. From the point of view of ventilation technique the laminar air flow ceilings with lower turbulence are superior to air supply ceilings with supporting flow outlets in the working day of an operating theatre. In order to minimize the influence of the staff, which up till now has been neglected in testing specifications, constructional possibilities such as the size of ceiling, the partitioning off of operating and anaesthetic areas and the positioning of the operating table in relation to the incoming air should be coordinated rationally. Taking measurements regularly during operations can provide the impulse for considerable improvements in both operational and planning phases.

[Clinical study of the effectiveness of a new preservative-free polyvidon preparation in therapy of dry-eye disorders]

BACKGROUND

Diseases of the ocular surface very frequently seen are related to irregularities of wetting. Patients often have complaints and feeling of ill-health, although under symptomatic therapy. Tolerability of the tear substitutes plays a key role in these cases. It is improved with unpreserved medication.

METHOD

59 patients with 'dry eye condition' of various etiology were enrolled in an open multicentre study and treated 8 weeks with a new preservative-free tear substitute. All patients had a history of previous ineffective treatment with artificial tears. The product was formulated with polyvidone and electrolytes in a composition which resembles natural tears. The therapeutic effect was evaluated by ratings of patients' self assessment of their complaints, tear film break up time (BUT), Schirmer I test, visual acuity, biomicroscopic examination and physicians' assessment.

RESULTS

Based on the key criteria patients's self assessment and BUT, the new agent (Oculotect fluid sine) improved symptoms and reduced discomfort significantly compared with the previous treatment (paired t test, two-sided, level of significance p < or = 0.05). The improved condition was confirmed by the other findings taken.

CONCLUSION

In 4/5 of patients, as typically met in ophthalmologists' offices, whose complaints were insufficiently relieved by previously applied tear substitutes, treatment with the new preservative-free product resulted in a distinct improvement of their condition. The lack of preservatives contributed to better tolerability and acceptance of tear substitution.

[Ventilation method plan in daily operations--a practical study]

On three days each we measured particles and airborne bacteria in ten ventilated operating theatres. Modern air conditioning systems achieved a significant reduction of air-pollution. Vertical systems proved to be more effective than horizontal systems. Workday conditions made several problems: During high personal activity a body exhaust system was not able to reduce the concentration of airborne bacteria; doors near the operating table and objects in the airstream had a negative effect; there was more personal than necessary in the operating theatres; some activities took place without a specific purpose and resulted in raised particle and bacteria contamination; early clearing of materials, before the operation ended, increased turbulences and door movements. A short break in personal activity before the first skin cut is recommended to reduce high air contamination due to the preparation of the operating room and the patient. One of the ventilation systems was insufficiently operated by personal. We recommend continuous measurement of particles near the operating field in order to control the input of airborne particles and bacteria into the wound.

Symptomatic xanthogranuloma of choroid plexus with unilateral hydrocephalus. Case report

Xanthogranulomas involving the choroid plexus of the lateral ventricles are generally asymptomatic lesions. The case is reported of a 50-year-old man in whom a xanthogranuloma of the choroid plexus had occluded the left trigone, causing unilateral hydrocephalus of the left temporal horn and neurological symptoms. A review of the literature shows that xanthogranulomas of the glomus of the lateral ventricles differ from the xanthomatous cystic lesions of the third ventricle, which are probably akin to colloid cysts.

Diagnostic significance of flow cytometric DNA analysis applied for the detection of cancer cells in bronchial washing fluid

Since both DNA aneuploidy and increased proliferative activity are important characteristics of malignant neoplasms, flow cytometric (FCM) analysis was used to examine the cell content in bronchial washing samples obtained via fiberoptic bronchoscopy from 73 patients. The results were compared with the results of histology and conventional cytology. The patients included 30 with bronchial carcinomas, 12 with bronchopneumonia and 31 with no evidence of lung disease. Of the 30 patients with histologically confirmed lung cancers, 25 showed either aneuploid stem lines (19 cases) or high levels of proliferation (6 cases) as determined by analysis of cell-cycle stages. The same rate of cancer cell detection was obtained by cytology. In the 43 cases with neither histologic nor clinical evidence of malignancy, FCM data yielded 5 false-positive results, as compared to 4 erroneous suspicions of cancer by cytology. From these data, it is concluded that FCM measurements of both DNA ploidy and proliferative activity may complement conventional cytology in the recognition of bronchial carcinomas.

Mouse monoclonal antibodies specific for endothelial cells

Balb/c mice were immunized with a human endothelial cell pool. Spleen cells were then fused with a NS-O hybridoma cell line. A number of hybridomas secreted antibodies that reacted with the immunizing endothelial cell pool as well as with every other tested umbilical cord vein derived human endothelial cell. These monoclonal antibodies also stained pig, rabbit and ox aortic endothelial cells indicating their specificity for this cell type. Five of 16 monoclonal antibodies additionally reacted with human fibroblasts (HFIB). The produced monoclonal antibodies did not recognize FVIIIR:AG or MHC determinants. They can therefore be regarded as additional and reliable markers for endothelial cells in vitro.

[The 0-degree ophthalmologic-assistant microscope of the Zeiss Co., an important advance in microsurgery]

Description of a newly developed 0 degree stereo coworker microscope manufactured by the Zeiss company; it gives the coworker a stereoptic view of the surgical field, with coaxial illumination.

[Treatment of non-small cell bronchial cancer with high-dosage cisplatin and vindesine. Results of a prospective study]

Thirty-seven patients with advanced, histologically confirmed non-small-cell lung cancer received combination chemotherapy with high-dose (120 mg/m2, day 1 and 29, thereafter every 6 weeks) cisplatin and vindesine (3 mg/m2, day 1, 8, 15, 22, and 29, thereafter every two weeks). All patients had measurable disease and had not previously received chemotherapy. 20 out of 37 patients responded to therapy. Two patients with adenocarcinoma, and one patient with squamous carcinoma of the lung experienced complete remission, 11 out of 37 patients partial remission, three patients a minor response, while in three patients the tumour neither remitted nor progressed. Despite chemotherapy cancer progressed in 17 out of 37 patients. Under supportive care including prehydratation, diuresis, administration of high-dose metoclopramide this aggressive chemotherapy was well tolerated. The response rate was similar to that of other chemotherapeutic regimens. The remission duration (9.5 months) and the survival time (16.5 months) are, however, somewhat better.

[Gastrointestinal tuberculosis--a diagnostic challenge]

Gastrointestinal tuberculosis has become a rare disease. Lesions are predominantly located in the ileocecal region, but all parts of intestinum can be involved. Occurrence in the esophagus is very rare. Protean manifestations often prevent an accurate diagnosis on time, especially if pulmonary symptoms are absent or misjudged. The further clinical course is determined by late complications of tuberculosis. We present 3 cases of gastrointestinal tuberculosis (two of esophagus, one of ileocecal region) in order to remind of this rare disease, which is associated with so many pitfalls.