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ABSTRACT: This study aimed to determine the effects of infrared beak treatment on the behavior and welfare of male and female turkeys reared to 12 wk of age. To do this, poults (236 males and 324 females) were assigned to one of 2 beak treatments: infrared beak treated on day of hatch (IR) or sham untreated control (C). Data collected included heterophil/lymphocyte (H/L) ratio, pecking force, feather cover, behavioral expression, and beak histology. Data were analyzed as a 2 × 2 factorial of beak treatment and gender, in a completely randomized design and analyzed using PROC MIXED (SAS 9.4). H/L ratio (indicative of a stress response) did not differ between treated and control poults during early life, except at 20 d of age when H/L ratio was higher for C poults than IR poults. Pecking force, measured as a method of monitoring pain, was different only at 1 wk of age, when IR poults pecked with more force than C poults. Feather cover was better in IR poults at 12 wk of age. Differences in behavior between treatments were minor over the 12-wk period. Overall, infrared beak treatment of commercial turkeys had minimal negative impacts on behavior and welfare. The results suggest that stress may be reduced in flocks that are beak treated and that the procedure itself does not cause a pain response.

ABSTRACT: Controlling injurious pecking in commercial turkeys remains a significant challenge to producers and the industry. Infrared beak treatment is an effective method of controlling injurious pecking in chickens; however, the effects of infrared beak treatment on turkey performance are still largely unknown. Two experiments were conducted to determine the impact of infrared beak treatment on the beak length and performance of turkeys raised to 12 wk of age. Experiment 1 tested both toms (n = 236) and hens (n = 324), while Experiment 2 focused on hens (n = 608). Poults for each experiment were assigned to 1 of 2 beak treatments: infrared beak treated (IR) on the day of hatch at a commercial hatchery or sham untreated control (C). Data collected included beak length, body weight, feed intake, feed efficiency, and mortality. Data were analyzed using a 1 or 2-way ANOVA, followed by Tukey's range test for mean separation when interactions were found. Results showed that beak length (Experiment 1 only) was significantly shorter in IR poults from 2 to 12 wk of age. In the same experiment, IR toms had lighter body weight than C toms, but IR hens were heavier than C hens from 2 to 4 wk of age. By 12 wk, IR poults were heavier than C poults, regardless of gender. In experiment 2, IR hens had lighter body weight from 2 to 4 wk of age. In conclusion, infrared beak treatment had minimal effects on feed intake, feed efficiency, or mortality over the 12-wk periods of both experiments.

Background and Objectives: Hospitalisation influences drug therapy in ambulatory care and this influence is generally negatively perceived. The few studies that have explored changes in benzodiazepine or sleep medication use as a function of hospitalisation failed to precisely determine the hospital's role in initiating, continuing and discontinuing these drugs on a valid basis. The aim of the study was to ascertain the overall influence of hospitalisation on the prescription of benzodiazepines and Z-drugs in outpatient care with a special focus on the role of different hospital departments and drug classes., Methods: In a secondary data analysis, we used prescription data for 181 037 patients who visited 127 hospitals and compared the numbers of patients with prescriptions of benzodiazepines and Z-drugs 50 days before and 50 or 100 days after hospitalisation., Results: The proportion of patients who received benzodiazepines or Z-drugs increased from 3.1% before admission to 3.6% at 50 days after discharge and fell to the former level after an additional 50 days. A multivariable logistic regression showed that gender and department had an additional impact on these results. Of those patients without a prescription for a benzodiazepine or Z-drug before admission, 0.6% received a prescription in both time-windows after discharge. Of those patients who were prescribed a benzodiazepine, 38.0% received short-acting substances and 40.3% received long-acting substances before hospitalisation. After hospitalisation, these rates changed to favour short-acting substances (44.4% and 34.4%, respectively)., Conclusions: The hospital effect on initiating and increasing hypnotic or sedative drug use seems to be only moderate and temporary. A change in favour of short-acting substances is even welcome. In less than 1% of patients, the hospital initiated the continuous use of benzodiazepines and Z-drugs, which may put pressure on primary care physicians. However, the widespread use of these drugs in hospitals does not seem to be continued on a large scale in primary care.

Background: Increasing prevalence of dementia is a major challenge for the German healthcare system. The study DelpHi-MV ("Dementia: life- and person-centered help in Mecklenburg-Western Pomerania") aims to implement and evaluate an innovative subsidiary support system for persons with dementia (PwDs) living at home and their caregivers., Methods: DelpHi-MV is a GP-based cluster randomized controlled intervention trial. DelpHi-Intervention aims to provide "optimum care" by integrating multi-professional and multimodal strategies to individualize and optimize treatment of dementia within the framework of the established healthcare and social service system. The intervention is conducted by Dementia Care Managers (DCMs)--nurses with dementia-specific training--at the people's homes. Based on German guidelines for evidence-based diagnoses and treatment of dementia, a comprehensive set of 95 interventio--modules--the "DelpHi-Standard"--was defined. Each module consists of predefined trigger condition(s), a subsequent intervention task, as well as at least one criterion for its completion. The intervention begins with a comprehensive assessment of the care situation, needs, and resources. The DCM develops and implements an intervention plan tailored to the individual conditions in close cooperation with the GP. EXPECTED RESULTS AND CONCLUSIONS: We expect statistically significant differences between control and intervention group in primary outcomes (quality of life, behavioral and psychological symptoms of dementia, pharmacotherapy, caregiver burden). Results can provide evidence for the effectiveness and efficacy of dementia care management according to the "Delphi-Standard"--prerequisites for implementing this concept into routine healthcare.

Background: As the population ages, the relative and absolute number of age-associated diseases such as dementia will increase. Evaluation of the suitability and intake of medication and pharmacological treatment is an important aspect of care for people with dementia, especially if they live at home. Regular medication reviews and systematic cooperation between physicians and pharmacists are not common in routine care. Medication management (MM), based on such a comprehensive home medication review could help to reduce drug-related problems and costs. The present article presents a medication management specifically for the application in the ambulatory setting and describes its implementation as part of a larger trial., Methods/design: A home medication review (HMR) and MM is implemented as part of the DelpHi study, a population based prospective, cluster-randomized controlled intervention study to test the efficacy and efficiency of the implementation of a collaborative care model in primary care., Participants: people with dementia (PWD) and their caregivers are recruited by the patient's general practitioner. Inclusion criteria are a positive screening result for dementia, living at home and regular intake of drugs. PWD are asked to specify their regular pharmacy which is asked to participate in the study, too., Intervention: a comprehensive HMR is conducted as computer-assisted personal interview by specifically qualified Dementia Care Manager (DCM) at the people's home. It includes detailed information about drugs taken, their storage, administration, adherence and adverse events. The MM is conducted in cooperation between DCM, pharmacist and general practitioner and consists of a pharmaceutical evaluation, pharmaceutical recommendations and their application. Pharmacists are trained and provided with regularly updated information. The MM is designed to give information and recommendations concerning antidementia drugs, occurrence of drug related problems, intake of anticholinergic drugs, potentially clinically relevant drug-drug-interactions, adverse drug events and medication adherence., Discussion: The DelpHi-approach for medication management employs comprehensive instruments and procedures in the primary care setting under routine care conditions, and this approach should be useful in improving pharmacotherapy as part of the comprehensive treatment and care for people with dementia., Trial Registration: The trial is registered at ClinicalTrials.gov, number NCT01401582.

Background: Data of the German population-based cohort SHIP (Study of Health in Pomerania) were analysed to examine treatment rates, antihypertensive substances prescribed, and the proportion of hypertensive study participants reaching target values for blood pressure as well as determinants., Methods: The study population was defined using baseline data of the cohort (collected between 1997 and 2001). Participants with blood pressure values ≥140/90 mmHg and/or antihypertensive medication with known hypertension and participants with risk-comorbidity (diabetes, stroke, angina pectoris, and/or myocardial infarction) and blood pressure values ≥130/80 mmHg were included. The analysis of treatment and target values was based on the 5-year follow-up of the cohort (collected between 2002 and 2006). Logistic regression was used to identify determinants for a normotensive blood pressure., Results: 3278 SHIP-participants with hypertensive blood pressure values were included (mean age: 55.5 years; SD 13.6, range 21-80 years). The raw hypertension prevalence was 50.9% (N = 1761). 58.7% (N = 1074) of all hypertensive patients reported some form of antihypertensive treatment. Thereof 65.1% (N = 728) received combination therapy. Of the patients without risk-comorbidity, 42.1% (N = 489) reached their target blood pressure values at the time of the 5-year follow-up of the cohort. Of the patients with any risk-comorbidity this proportion was only 21.7% (N = 131). Significant determinants for reaching the target values were being female and having antihypertensive combination therapy. Increasing age, having risk-comorbidities, and obesity were negatively associated with reaching the target values., Conclusions: Both the proportion of participants receiving therapy and the number of participants reaching their target blood pressure values are very low. Combination therapy is associated with better blood pressure control as compared to mono therapy. However, even in the subgroup of hypertensive patients under combination therapy only 36% (both patients with and without comorbidity) reach target values.

Background: The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system.The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home., Methods and Study Design: The study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication., Discussion: The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths., Trial Registration: NCT01401582.

Background: drug intake is associated with the risk of drug-related problems (DRPs), e.g. the intake of PIM., Objective: the proportion of potentially inappropriate medication (PIM) taken by elderly people was analysed., Design: community-based, prospective cohort study., Setting: ambulatory health-care sector in a German rural area., Subjects: seven hundred and forty-four patients with age >65 years and regular intake of drugs., Methods: comprehensive home medication review (HMR) provided by specially qualified assistants of GP practices using electronic case reporting forms (eCRFs), and GP's diagnoses were extracted from patients' health records. Updated Beers' list of Fick et al. was used to detect PIM for patients >65 years and drug-condition interaction., Results: a total of 18% (n= 134) of the patients received 163 inappropriate drugs. Out of these drugs, most prevalent PIM were benzodiazepine derivates (n= 45). Out of all drugs, 25 drug-condition interactions were identified. The intake of PIM was slightly associated with self-reported falls (: 0.1074; P= 0.0244). Multivariate logistic regression showed significant results for the number of taken substances (OR = 1.176; 95% CI 1.121-1.234, P< 0.001)., Conclusions: a high proportion of patients taking PIM in a community-based setting were investigated. Statistical associations with self-reported falls were found. Confounding may influence data. Further research to investigate findings is needed.

Background: In many rural regions in Germany, the proportion of the elderly population increases rapidly. Simultaneously, about one-third of the presently active GPs will retire until 2010. Often it is difficult to find successors for vacant GP-practices. These regions require innovative concepts to avoid the imminent shortage in primary health care.The AGnES-concept comprises the delegation of GP-home visits to qualified AGnES-practice assistants (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention). Main objectives were the assessment of the acceptance of the AGnES-concept by the participating GPs, patients, and AGnES-practice assistants, the kind of delegated tasks, and the feasibility of home telecare in a GP-practice., Methods: In this paper, we report first results of the implementation of this concept in regular GP-practices, conducted November 2005--March 2007 on the Island of Rügen, Mecklenburg-Western Pomerania, Germany. This study was meant as a proof of concept.The GP delegated routine home-visits to qualified practice employees (here: registered nurses). Eligible patients were provided with telecare-devices to monitor disease-related physiological values.All delegated tasks, modules conducted and questionnaire responses were documented. The participating patients were asked for their acceptance based on standardized questionnaires. The GPs and AGnES-practice assistants were asked for their judgement about different project components, the quality of health care provision and the competences of the AGnES-practice assistants., Results: 550 home visits were conducted. 105 patients, two GPs and three AGnES-practice assistants (all registered nurses) participated in the project. 48 patients used telecare-devices to monitor health parameters. 87.4% of the patients accepted AGnES-care as comparable to common GP-care. In the course of the project, the GPs delegated an increasing number of both monitoring and interventional tasks to the AGnES-practice assistants. The GPs agreed that delegating tasks to a qualified practice assistant relieves them in their daily work., Conclusion: A part of the GPs home visits can be delegated to AGnES-practice assistants to support GPs in regions with an imminent or already existing undersupply in primary care. The project triggered discussions among the institutions involved in the German healthcare system and supported a reconciliation of the respective competences of physicians and other medical professions.

Background: The German AGnES (community-based, e-health-assisted systemic support for primary care) project allows general practitioners (GPs) to delegate certain elements of medical care, including house calls, to qualified AGnES employees and thereby provide primary care to a larger number of patients. AGnES projects of various types have been carried out in a number of German federal states from 2005 onward. In this article, an evaluation of the AGnES projects to date is presented., Methods: Patient data (age, sex, diagnoses, level of care, mobility, etc.) and each of the specific activities carried out in the AGnES framework were documented with standardized computer-based instruments. The GPs, AGnES employees, and patients also underwent standardized interviews. The acceptance of the AGnES project, competence of the AGnES employees, and quality of medical care within the projects were evaluated. The participating GPs themselves assessed the quality of medical care., Results: By July 8, 2008, 8386 house calls on a total of 1486 patients had been made within the framework of the AGnES projects. The evaluation revealed a high degree of acceptance of the project among the participating GPs, AGnES employees, and patients. The GPs considered the quality of medical care within the AGnES project to be good for the vast majority of patients., Conclusion: Structural redundancy is avoided by directly placing the AGnES employees in the general practitioners' practices. Based on the results of the AGnES projects, the law in Germany has now been amended to enable implementation of the AGnES project in the regular health care system from January 2009 onward. The next steps to be taken are the establishment of adequate reimbursement within the catalog of the statutory health insurance scheme and a detailed definition of the required qualifications.