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Independence in activities of daily living depends to a large extent on the upper extremities; however, the instruments widely used in geriatrics to assess self-care abilities do not allow a focus on this body region. In order to map the fluctuating course of hand function-dependent daily living skills with a self-assessment instrument, rheumatologists have developed the Duruöz Hand Index (DHI).The German translation authorized by Duruöz was tested for its applicability in the assessment of geriatric outpatient and day hospital patients and test quality criteria were determined.Study participants completed the DHI three times. A postgraduate student blinded to the results performed an anamnesis and examination. The geriatric team made an inter-professional assessment of hand function-related daily living skills twice with at least 2‑week intervals.Data collection was performed from 16 November 2016 to 27 April 2017 on 101 geriatric day hospital or outpatient patients. Retest reliability was high (0.937), as was internal consistency (Cronbach's α 0.949). Difficulty with activities of daily living correlated more closely with joint mobility (Keitel Index) and fine motor skills (20 cents test) than with hand strength.The DHI provides a survey of difficulties with activities of daily living that is focused on the upper extremities. Because about one in three patients required assistance (answering follow-up questions, reading aloud) despite the exclusion of patients with more severely impaired cognition and vision, the examiner should remain present.HINTERGRUND: Die Selbstständigkeit in Alltagsaktivitäten hängt in hohem Maß von den oberen Extremitäten ab. Die in der Geriatrie breit eingesetzten Instrumente zur Erfassung der Selbstversorgungsfähigkeiten erlauben aber keine Fokussierung auf diese Körperregion. Um den fluktuierenden Verlauf von der Handfunktion abhängiger Alltagsfähigkeiten mit einem Selbstbeurteilungsinstrument abzubilden, haben Rheumatologen den Duruöz Hand-Index (DHI) entwickelt.Die von Duruöz autorisierte deutsche Übersetzung wurde auf ihre Anwendbarkeit im Assessment ambulanter und tagesklinischer geriatrischer Patienten überprüft, und Testgütekriterien wurden bestimmt.Die Studienteilnehmenden füllten den DHI 3‑mal aus. Eine für die Ergebnisse verblindete Doktorandin führte eine Anamnese und Untersuchung durch. Das geriatrische Team bewertete mit mindestens 2‑wöchigem Intervall 2‑mal die auf die Handfunktion bezogene Alltagskompetenz interprofessionell.Die Datenerhebung erfolgte vom 16.11.2016 bis 27.04.2017 an 101 tagesklinischen oder ambulanten Geriatriepatienten. Die Retest-Reliabilität war hoch (0,937), ebenso die interne Konsistenz (Cronbachs α 0,949). Schwierigkeiten bei Alltagsaktivitäten korrelierten enger mit der Gelenkbeweglichkeit (Keitel-Index) und Feinmotorik (20-Cents-Test) als mit der Handkraft.Der DHI ermöglicht eine auf die oberen Extremitäten fokussierte Erhebung der Schwierigkeiten bei Alltagsaktivitäten. Da trotz Ausschluss von Patienten mit höhergradig gestörter Kognition und Sehfähigkeit etwa jeder Dritte Unterstützung benötigte (Nachfragen beantworten, vorlesen), sollte der Untersucher anwesend bleiben.

Vascular dementias (VD, due to the various expressions of VD the plural form is used) are the second most common form of dementia after Alzheimer's dementia. These dementias play an important role especially in geriatric patients. They can occur due to acute events (e.g. stroke) and due to slowly progressive cerebrovascular damage. This article focuses on VD due to cortical and strategic infarcts, microangiopathic infarcts with lacunae as well as intracerebral bleeding. In addition to the clinical description and radiological findings, a special focus is on education, prevention and rehabilitation aspects.

The aim of this continuing medical education (CME) article (part II) is to describe the particular challenge of the treatment of hyponatremia, which occurs in older patients. This part II follows on from part I concerning the diagnosis in the previous volume. A staged approach is necessary. The best treatment is always when the underlying cause can be eliminated. Hyponatremia in older patients is mainly induced by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. The authors use a concept for the first, second and third line strategy: (1) changing or discontinuation of drugs, (2) fluid restriction and (3) tolvaptan medication. The algorithm for treatment should be simple. It also contains recommendations for the correction rate. Caution is also needed in order to avoid the occurrence of an osmotic demyelination syndrome (ODS).

Old age is a strong independent risk factor for hyponatremia. Dizziness, fatigue, reduced vigilance, cognitive impairment, gait deficits, nausea, vomiting, headache, falls, osteoporosis and fractures, coma and seizures are more frequent and severe than in middle-aged patients. Hyponatremia is mainly caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and also including drugs. Hyponatremia is multifactorial in a significant proportion of older patients. Hyponatremia requires a staged diagnostic approach to identify the underlying cause. The aim of this continuing medical education (CME) report (part I) is to emphasize the special challenges in the diagnostics of hyponatremia, which occur in older patients. Diagnostics should be kept simple. A special algorithm is presented. Part II concerning treatment will follow.

In February 2013, the law on the improvement of the rights of patients enacted a whole series of legal regulations for different areas of health care. In terms of physician liability, the Patient Rights Act and the introduction of sections 630a-h in the Civil Code (BGB) brought a transparency-oriented representation of general contractual aspects, a comprehensive legal regulation regarding patient education and consent, standardization of the treatment documentation, and a new basis for the right of access to the treatment file. The specificities of the treatment contract developed in the framework of supreme judicial jurisprudence were translated into legal form, and the presumed facts known from established case law and considered favorable to the patient under certain conditions were then summarized as exceptions to the principle of the objective burden of proof. In this paper the regulations in the new sections 630a-h of the Civil Code are presented and examined with regard to the consequences to be taken into account by the medical expert in the physician liability process.Mit dem Gesetz zur Verbesserung der Rechte von Patientinnen und Patienten (Patientenrechtegesetz) wurden im Februar 2013 eine ganze Reihe gesetzlicher Neuregelungen für unterschiedliche Geltungsbereiche des Gesundheitswesens in Kraft gesetzt. Für die Arzthaftung brachte das Patientenrechtegesetz mit der Einführung der Paragraphen 630a–h in das Bürgerliche Gesetzbuch (BGB) eine auf Transparenz ausgerichtete Darstellung allgemeiner vertragstypischer Aspekte, eine zusammenfassende gesetzliche Regelung der Patientenaufklärung und -einwilligung, die Normierung der Behandlungsdokumentation und eine neue Grundlage für die Einsichtsrechte in die Behandlungsakte. Dabei wurden die im Rahmen höchstrichterlicher Rechtsprechung entwickelten Besonderheiten des Behandlungsvertrags in Gesetzesform überführt und die aus der gefestigten Rechtsprechung bekannten, unter bestimmten Voraussetzungen für den Patienten als günstig anzunehmenden Tatsachenvermutungen als Ausnahmen vom Prinzip der objektiven Beweislast abschließend zusammengefasst. In der vorliegenden Arbeit werden die Regelungen der neuen Paragraphen 630a–h im BGB vorgestellt und im Hinblick auf die vom ärztlichen Sachverständigen im Arzthaftungsprozess zu berücksichtigenden Konsequenzen untersucht.

The incidence of spondylodiscitis is increasing and attributable to an aging population with multimorbidities. Spondylodiscitis represents a life-threatening disease. Typical clinical manifestations often involve nonspecific symptoms with back pain; however, due to the frequent absence of fever the disease is often overlooked. Pathogen detection and spinal imaging with magnetic resonance imaging (MRI) are essential for the diagnosis. Identification of the causative pathogen is particularly important for initiating targeted antibiotic treatment. Debridement and stabilization are the mainstays of surgical management, even though foreign material must be implanted into the focus of inflammation.

In the contribution presented here a computer model for the description of non-spherical particle deposition in the upper human respiratory tract is introduced. The theoretical approach is mainly based on the principle of the aerodynamic diameter, whose calculation was carried out according to most current scientific findings. With the help of this parameter deposition patterns for various particle categories (fibers and oblate disks) and breathing conditions (sitting, light-work and hard-work breathing) were simulated. Concerning cylindrical fibers with a diameteror = 1 microm, an increase of the aspect ratio beta (i.e. particle length/particle diameter) causes a significant enhancement of deposition in the uppermost regions of the respiratory tract (oropharynx, larynx, trachea). This effect is additionally intensified by an increase of the inhalative flow. Regarding the oblate disks with a diameteror = 1 microm, any decrease of the aspect ratio leads to an enhancement of deposition in the deeper lung regions, representing an effect contrary to that observed for fibers. An increase of the inhalative flow only induces a limited decrease of the effect.

After a mathematical extension of the existing model for the theoretical description of the aerosol bolus dispersion, the behavior of particle pulses in diseased lung structures was simulated. The geometry usedJbr healthy lungs was modified in two aspects: First, a modelling of possible airway obstructions, which usually occur in patients with chronic bronchitis, chronic asthma or cystic fibrosis, was carried out and, second, a theoretical approximation of the emphysema, being observed in lungs of smokers, but also as an accompanying phenomenon in obstructive diseases, was established. According to the modified model, in lungs with airway obstructions the exhaled bolus exhibited a decreased dispersion with respect to healthy subjects, whereas in emphysematous lungs the respective half-width of the peak was increased. Standard deviation and skewness of the bolus were similarly influenced by the modified lung architecture. A combination of airway obstruction and emphysema caused an extensive compensation of individual dispersion effects, complicating a secure distinction from the healthy lung. According to the model, a special diagnostic value may be assigned to the bolus deposition, showing significant deviations from the normal case for all simulated diseases.

Aerosol bolus dispersion, which has excited enormous interest in lung medicine due to its possible use as an efficient toolfor the non-invasive clinical diagnosis of lung function, was simulated by a Monte Carlo model based on the concept of effective diffusivities and a stochastic lung geometry. The mathematical approach enabled the computation of essential characteristics of the exhaled bolus (half width, standard deviation, skewness, and mode shift) as well as the estimation of their dependence upon the volumetric lung depth (VLD) of the inhaled bolus. Results of the dispersion model generally show a very good correspondence with preliminary published experimental data. Half width and standard deviation of the exhaled bolus increase with VLD according to specific functions, whereas skewness and mode shift are subject to a decrease. While no correlation between bolus dispersion and flow rate could be worked out with the model, dispersion linearly increased with total lung capacity (TLC).

The present contribution discusses the utilization of the healthcare system by elderly patients in Germany. First, the paper focuses on the detailed characterization of a group of people aged 60 years or more (N = 73,454). Second, the objective is to analyze the data for high utilization of healthcare services by older men and women. The analysis is based on data regularly recorded by a German health insurance agency for the year 2000. High utilization is operationalized by a 10% cutoff for users with the highest number of treatments, highest costs and/or other criteria depending on the respective health service sector. The insured group investigated received approximately 1.4 million prescriptions, producing costs of 42 million E. High utilizers account for 32% of all prescriptions and 44% of the costs, respectively. At the same time, the age groups with the highest prescription rates do not cause the highest costs: So the relationship between age and prescription drug expenses as well as between age and prescription rates does not display an arithmetically increasing pattern. Within the timeframe investigated 26,000 hospital treatments were accounted for by 21.75% of the elderly under research. In total, they caused expenses of 88 million E. High utilization in the hospital sector was operationalized by four criteria. Sex- and age-specific analysis of high utilization of hospital treatment revealed that the four different criteria apply to different insured groups. In summary, the high utilization of healthcare services appears to be a multidimensional phenomenon.

The present paper provides a detailed description of an extension of the Monte Carlo computer model IDEAL, which enables the generation of spatial particle deposition patterns in the human lung. Randomly determined particle trajectories are transformed to a Cartesian coordinate system within which the orientation of the trachea corresponds to the z-direction. At the same time, the determination of particle deposition sites is carried out by application of a grid composed of specific volume elements (voxel). The calculation of particle deposition are based on the physical mechanisms of Brownian diffusion, sedimentation, and inertial impaction. After their storage in a matrix, the deposition data are subject to graphical processing. This allows the presentation of spatial particle distribution patterns (3d-density plots) and of the lung surface itself as well as the generation of two-dimensional distributions by sectioning the three-dimensional structures at pre-defined positions. The results of different model simulations (variation of particle size and breathing conditions) are discussed in detail.