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Monitoring wound progression over time is a critical aspect for studies focused on in-depth molecular analysis or on evaluating the efficacy of potential novel therapies. Histopathological analysis of wound biopsies can provide significant insight into healing dynamics, yet there is no standardized and reproducible scoring system currently available. The purpose of this study was to develop and statistically validate a scoring system based on parameters in each phase of healing that can be easily and accurately assessed using either Hematoxylin & Eosin (H&E) or Masson's Trichrome (MT) staining. These parameters included re-epithelization, epithelial thickness index, keratinization, granulation tissue thickness, remodeling, and the scar elevation index. The initial phase of the study was to (1) optimize and clarify healing parameters to limit investigator bias and variability; (2) compare the consistency of parameters assessed using H&E versus MT staining. During the validation phase of this study, the accuracy and reproducibility of this scoring system was independently iterated upon and validated in four different types of murine skin wound models (Excisional; punch biopsy; pressure ulcers; burn wounds). A total of n = 54 histology sections were randomized, blinded, and assigned to two groups of independent investigators (n = 5 per group) for analysis. The sensitivity of each parameter (ranging between 80% and 95%) is reported with illustrations on the appropriate assessment method using ImageJ software. In the validated scoring system, the lowest score (score:0) is associated with an open/unhealed wound as is evident immediately and within the first day postinjury, whereas the highest score (score:12) is associated with a completely closed and healed wound without excessive scarring. This study defines and describes the minimum recommended criteria for assessing wound healing dynamics using the SPOT skin wound score. The acronym SPOT refers to the academic and scientific institutions that were involved in the development of the scoring system, namely, Stellenbosch University, Polish Academy of Sciences, Obatala Sciences, and the University of Texas Southwestern.

Adipose-derived stem cells (ASCs) isolated from domestic animals fulfill the qualitative criteria of mesenchymal stem cells, including the capacity to differentiate along multiple lineage pathways and to self-renew, as well as immunomodulatory capacities. Recent findings on human diseases derived from studying large animal models, have provided evidence that administration of autologous or allogenic ASCs can improve the process of healing. In a narrow group of large animals used in bioresearch studies, pigs and horses have been shown to be the best suited models for study of the wound healing process, cardiovascular and musculoskeletal disorders. To this end, current literature demonstrates that ASC-based therapies bring considerable benefits to animal health in both spontaneously occurring and experimentally induced clinical cases. The purpose of this review is to provide an overview of the diversity, isolation, and characterization of ASCs from livestock. Particular attention has been paid to the functional characteristics of the cells that facilitate their therapeutic application in large animal models of human disease. In this regard, we describe outcomes of ASCs utilization in translational research with pig and horse models of disease. Furthermore, we evaluate the current status of ASC-based therapy in veterinary practice, particularly in the rapidly developing field of equine regenerative medicine. In conclusion, this review presents arguments that support the relevance of animal ASCs in the field of regenerative medicine and it provides insights into the future perspectives of ASC utilization in animal husbandry. Graphical abstract

Residents in rural communities increasingly face shortages in health care service. Consequently, German municipalities are driven by a strong attempt to transform care trajectories in rural areas. This qualitative study aims to identify the preferences of rural community residents towards the future service provision. Semi-structured focus group interviews were performed by means of a structured interview guide developed on the basis of a systematic literature review on expectations towards the provision of health care service. Participants were recruited in three rural communities in Western Germany. In total, three focus group interviews including 21 participants were performed. Overall, the interviews resulted in ten attributes grouped in three major domains: access to care, service delivery characteristics, and service costs. The rural population in Germany rejects outpatient care performed by hospitals and favors the provision of health care services by familiar doctor offices and occasionally interprofessional forms of outpatient care. Focus groups are an effective means to categorize preferences of the general population regarding outpatient health care service delivery patterns.

The article discusses issues related to the implemented system of monitoring the road transport of sensitive goods. The Act of March 9, 2017, on the road freight transport monitoring system, came into force on April 18, 2017 and introduced procedures to fight dishonest entities involved in illicit trade in goods without paying taxes to the state budget. The Act specifies the rules of the goods tracking system covered by this legal act, as well as liability for the breach of duties, at every stage of the supply chain of road freight transport, i.e. at the level of the sending and receiving entity, the carrier and the driver of the means of transport. The goods covered by the obligatory declaration, both in the wording of the Act and in the justification to the draft act, are referred to as "sensitive goods". The registration tool used for monitoring the transport of the indicated goods is a register of notifications, which is kept in the ICT system by the head of the National Tax Administration. The transport of sensitive goods is subject to the obligation to report to this register.

Eines der moglichen Residuen des Schlaganfalls ist die Spastik der oberen Extremitat mit einer Haufigkeit von 19 % bei Patienten 3 Monate nach einem Schlaganfall bis hin zu 38 % ein Jahr nach einem Schlaganfall. Bei fokaler, multifokaler und segmentaler Spastik kann eine intramuskulare Injektion von Botulinumtoxin indiziert sein. Derzeit wird in Deutschland hinsichtlich der Behandlung der Spastiksymptome nach einem Schlaganfall mit Botulinumtoxin eine Unterversorgung angenommen. Das Ziel der vorliegenden Untersuchung besteht darin, die Versorgungssituation von Patienten mit einer Spastik der oberen Extremitat infolge eines Schlaganfalls unter besonderer Berucksichtigung des Einsatzes von Botulinumtoxin als eine Behandlungsoption zu evaluieren. Mittels eines standardisierten Fragebogens wurde eine postalische Befragung einer reprasentativen bundesweiten Stichprobe von 800 Neurologen und Nervenarzten durchgefuhrt. Die Rucklaufquote der postalischen Befragung betrug 37 %. 59 % der befragten Arzte antworteten, dass sie nie Botulinumtoxin in der Therapie einsetzen. Insgesamt 87 % der Arzte sehen Hurden hinsichtlich des Einsatzes von Botulinumtoxin. Dabei werden die Hohe der Honorierung der arztlichen Leistung mit 40 % und die fehlende Kostenubernahme durch die Gesetzliche Krankenversicherung bei Off-Label-Use mit 60 % sowie das Erlangen einer Fort-/Weiterbildung zur Behandlung mit Botulinumtoxin genannt. Insgesamt kann trotz eines Rucklaufs bei der postalischen Befragung von 37 % ein Selektionsbias nicht ausgeschlossen werden. Viele der teilnehmenden Facharzte setzen Botulinumtoxin nicht in der Therapie ein, obwohl es bei entsprechender Indikation fur die Behandlung in den Leitlinien empfohlen wird. Grunde hierfur lassen sich in den oben dargestellten Hurden erkennen.

Der zunehmende Grad an Digitalisierung bringt für die Produktion der Zukunft weitreichende Änderungen. Neben den Auswirkungen auf die Industrie und Technik sieht sich auch der Mensch konfrontiert mit neuen Anforderungen an sich und sein soziales Umfeld. Dieser Beitrag beschreibt im Rahmen des Forschungsprojekts „Innowas“ einen Ansatz, den Lernprozess und die Reflexion vorhandenen Wissens der Mitarbeitenden durch Nutzung von multimedialen Autorensystemen zu unterstützen. The rising significance of digitalization and globalization forces far-reaching changes on the production of the future. It not only leads to changes in industry and technology but also affects human beings as well as their social environment. As part of the research project “Innowas“, this paper describes an approach to enhance the learning capabilities of employees by authoring systems. Furthermore, the technology is used to reflect existent knowledge and broaden the knowledge base at all.

Since there are limited studies analyzing the impact of age, sex and obesity on cutaneous repair, the current study evaluated excisional skin wound healing as a function of age, sex and diet in C57BL/6 mice subjected to either low (LFD) or high (HFD) fat diet. Older mice accumulated increased body fat relative to younger mice under HFD. Skin wound healing at particular stages was affected by age in the aspect of Tgfβ-1, MCP-1, Mmp-9 and Mmp-13 expression. The most profound, cumulative effect was observed for the combination of two parameters: age and sex. While skin of younger males displayed extremely high collagen 1 and collagen 3 expression, younger females showed exceptionally high Mmp-13 expression at day 3 and 7 after injury. Diet as a single variable modified the thickness of dermis due to increased dermal White Adipose Tissue (dWAT) accumulation in mice fed HFD. The combination of age and diet affected the re-epithelialization and inflammatory response of injured skin. Overall, our data indicate that age has the most fundamental impact although all components (age, sex and diet) contribute to skin repair.

This paper presents an approach for the operational controlling of the assembly in timed assembly cycles focussing on large-scale products. In order to handle the assembly of small quantities and long assembly times a controlling method based on predefined actions initiated according to the deviation of four KPIs (key performance indicator) can be implemented. The selected KPIs are missing parts, disturbances, resources and overdue work on the critical path of the assembly process to focus on the early fault detection during the assembly. Therefore the predefined actions in the operational controlling are taskforces, escalation, people shift between stations and overtime.

OBJECTIVE In unstable ankle fractures the associated soft tissue damage can be a therapeutic challenge. The aim of this study was to optimize planning of minimally invasive stabilization of ankle fractures by calcaneotibial transfixation, which is a demanding technique due to the complex hind foot anatomy. METHODS In a retrospective radiographic analysis the angles and dimensions of a safe drill tunnel for calcaneotibial K-wire insertion were defined on standard radiographs of the ankle joint. 165 lateral weight-bearing radiographs (77 right; 88 left) and 147 (80 right; 67 left) mortise views of 186 (90 right; 96 left) uninjured feet from 123 patients (74 women (114 feet); 49 men (72 feet)) were included in this study. The average patient age was 49 (range, 13-85) years. Inter- and intra-observer reliability was evaluated on 20 randomized radiographs that were analyzed in a default set, three times, by two different examiners on three different days. RESULTS In the lateral view the drilling tunnel was orientated at 59.4° to the plantar plane with a maximum proximal variance of 7.1 image-mm. Distal variance cannot be tolerated since an ankle joint injury would ensue. In the mortise view the drill tunnel was directed with a mean angle of 18.4° to the distal tibial articular surface. At most a mean of 11° fibular- and 13.4° tibial- expansion can be tolerated. Intra- and inter-observer reliability was higher for the angles than for the drill corridors. CONCLUSION The three-dimensional (3D) orientation for safe K-wire placement for calcaneotibial transfixation should adhere to the drill tunnels established in this study.

Background The Network for Mental Health (NWpG-IC) is an integrated mental health care program implemented in 2009 by cooperation between health insurance companies and community mental health providers in Germany. Meanwhile about 10,000 patients have been enrolled. This is the first study evaluating the effectiveness of the program in comparison to standard mental health care in Germany. Methods In a parallel-group controlled trial over 18 months conducted in five regions across Germany, a total of 260 patients enrolled in NWpG-IC and 251 patients in standard mental health care (TAU) were recruited between August 2013 and November 2014. The NWpG-IC patients had access to special services such as community-based multi-professional teams, case management, crisis intervention and family-oriented psychoeducation in addition to standard mental health care. The primary outcome empowerment (EPAS) and the secondary outcomes quality of life (WHO-QoL-BREF), satisfaction with psychiatric treatment (CSQ-8), psychosocial and clinical impairment (HoNOS) and information about mental health service needs (CAN) were measured four times at 6-month intervals. Linear mixed-effect regression models were used to estimate the main effects and interaction effects of treatment, time and primary diagnosis. Due to the non-randomised group assignment, propensity score adjustment was used to control the selection bias. Results NWpG-IC and TAU groups did not differ with respect to most primary and secondary outcomes in our participating patients who showed a broad spectrum of psychiatric diagnoses and illness severities. However, a significant improvement in terms of patients’ satisfaction with psychiatric care and their perception of treatment participation in favour of the NWpG-IC group was found. Conclusions Providing integrated mental health care for unspecific mentally ill target groups increases treatment participation and service satisfaction but seems not suitable to enhance the overall outcomes of mental health care in Germany. The implementation of strategies for ameliorating the needs orientation of the NWpG-IC should be considered. Trial registration German Clinical Trial Register DRKS00005111, registered 26 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12888-017-1441-9) contains supplementary material, which is available to authorized users.

Aim False positive antigen specificities (FPAS) from the Luminex Single Antigen (LSA) Assay are difficult to identify due to multiple interfering factors and various corresponding resolving approaches. Over calling antibodies limits a patient’s access to deceased donor organs and can result in erroneous immune therapy. Here we report how to properly identify and resolve FPAS from LSA assays to precisely provide HLA-antibody results in supporting Thoracic Organ Transplantation (TOT). Methods We retrospectively studied 66 TOT cases that had suspected FPAS reactions with LSA assays. The initial antibody work up was tested by LSA and FlowPRA Screening Beads. Discordance between the two assays and/or ambiguity were verified by Luminex Phenotype Beads. LSA was used for all antibody follow up. If an obvious antibody increase was observed, further investigation for sensitizing events and/or possible interfering medication (such as IvIg), warranted additional testing. Detailed approaches for FPAS identification and resolution are listed in Table 1a. Results Of the 66 FPAS cases, 56 (85%) were caused by denatured antigen (dAg) and 10 (15%) were due to IvIg infusion. The distribution of complete FPAS and partial FPAS (the mixture of true positive and FPAS) from dAg and IvIg were almost equal, 54% vs 46% and 50% vs 50%, respectively. The FPAS dAg patterns with highest occurring frequencies were Cw1, Cw12, Cw15 (27%) from class I and DP1, DP11, DP13, DP6, DQ4 (34%) from class II. The elimination of FPAS reduced the average PRA by 67% from dAg and 78% from IvIg interference. 22 cases received TOT after FPAS were ruled out (Table 1b). Conclusions FPAS is the prevalent issue of LSA when false negativity is eliminated by serum EDTA treatment. Alternative assays by multiple platforms, supplementary LSA data analysis, and referencing clinical records are warranted for ruling out FPAS. This provides precise antibody testing results for successful access to TOT.

This paper presents an approach for manufacturing startup companies to reconfigure their organization and processes as a consequence of changing preconditions. Startup companies can be agile and adapt their organization continuously towards their preconditions and given resources better than established companies. The presented approach comprises three main levers for the configuration: process standardization, form of organization and the strategy for growth. Within the three dimensions the configuration can be done between process effectiveness or efficiency, between organization with specialists or generalist and between fast growth or sustainability in the organization.

This research work pertained to establishment of timing relationship for two sludge composting phases proceeding in different conditions. The first phase was performed in a dynamical reactor and the second – in periodically turned windrows. The research was carried out in three independent repetitions with five test series cycles in each varying in the hot phase timing. The compost windrows ripening phase was monitored for 5 months. The determined physical and chemical indicators (independent variables) made a basis for calculation of compost ripeness indices. To perform the numerical analysis an artificial neural network performing the generalised regression task was used. Using specific values of particular indices, as the ripeness criterion, a td = f(tp) model was created, in form of decreasing linear function, interpreting the relationship between time of compost keeping in the reactor and the time of compost windrow ripening. The obtained results suggest that keeping the batch in reactor for a period in excess of 18 days is groundless, therefore, ineffective as it does not shorten significantly the compost ripening phase.

Somatostatin receptor scintigraphy (SRS) was performed in 14 patients (five men, nine women; mean age 51.5 [20-71] years) with Zollinger-Ellison syndrome (ZES), a gastrinoma proven in 7 and suspected on clinical or biochemical grounds in 7. The results were compared with those obtained by other methods (ultrasound, computed tomography, angiography). All 12 known tumour manifestations were demonstrated by SRS in seven patients with histologically confirmed gastrinoma. In four patients previously non-localized tumour was revealed by SRS, while in seven other patients the procedure led to modification of the treatment (primary tumour resection: n = 3, resection of metastases: n = 2, percutaneous radiation or chemoembolization: one each). These results suggest the following indications for SRS: (1) staging or re-staging in histologically proven gastrinoma and (2) search for primary tumour in clinically and biochemically suspected ZES.

Concept and design of an independent scientific evaluation of different pathways of care for schizophrenia patients in Germany with respect to effectiveness and efficiency are presented. In this prospective, observational study, schizophrenia patients receiving an integrated care treatment, the intervention group (IG), are compared with patients under routine care conditions treated by the same physician (first control group, CG 1). A second control group (CG 2) of patients treated by office-based psychiatrists not participating in the integrated care program will be recruited and their data compared with the two other groups. The total amount of psychiatric hospital days after 12 months is defined as primary outcome parameter. Secondary outcome parameters comprise the frequency of psychiatric inpatient readmissions, severity of schizophrenia symptoms, remission rates and quality of life. Patients undergo assessments at baseline, month 6 and 12 using standardized and experimental questionnaires. Routine data of a regional German social health insurance fund complement information on included patients. Additionally, a cost-effectiveness and cost-utility analysis will be performed. Until now, 137 psychiatrists included 980 patients in the integrated care project in Lower Saxony, Germany, and 47 psychiatrists (IG and both CGs) are willing to participate in the independent evaluation. For the first time, a prospective observational controlled evaluation study of a countrywide integrated care project planning to recruit 500 schizophrenia patients has started using comprehensive assessments as well as routine data of a social health insurance fund.

Die Exzision von Sentinel-Lymphknoten (LK) bekommt eine zunehmende Bedeutung bei der Diagnostik von Mundhohlen- und Oropharynxkarzinomen im Falle eines N0-Halses. Die Sentinel-Node-Biopsie (SNB) wurde in ihrer Wertigkeit als einzige chirurgische Staging-Masnahme untersucht. Im Rahmen eines multimodalen Behandlungskonzeptes wurde die SNB ohne elektive Neck-Dissection (ND) bei 70 Patienten im Rahmen der Operation des Primarius durchgefuhrt. Die Kontrolle der Genauigkeit erfolgte uber die Manifestation von Hals-LK-Metastasen bei 45 Patienten, die keine postoperative Bestrahlung erhalten hatten. Es konnten in 94% der Falle Sentinel-LK exzidiert werden; 9 Patienten (13%) hatten positive LK und erhielten eine therapeutische ND. Es kam zu 2 Hals-LK-Metastasen im Zusammenhang mit Zweitkarzinomen, alle anderen Patienten blieben regionar unauffallig (mediane Beobachtungszeit: 26 Monate). Die SNB konnte als Staging-Masnahme beim N0-Hals und T1- bis T3-Tumoren zu einer erheblichen Reduktion der Anzahl elektiver NDs fuhren. Sie kann gut in ein multimodales Behandlungsschema integriert werden.

Since 2009 some German health insurance companies have implemented integrated mental health care services along the principles of assertive community treatment in collaboration with local mental health service providers across Germany. Focus of this study is the analysis of effectiveness and cost-effectiveness of this integrated care programme compared to care as usual in routine care surroundings in five regions in Germany. In this 18-month multi-centre observational trial 250 patients enrolled in an integrated mental health care programme and 250 patients who receive treatment as usual from five catchment areas will be included. In addition, in each group about 125 relatives of the participating patients will be included. The primary outcome criterion is the improvement of empowerment; secondary outcomes are subjective quality of life, functional impairment and costs of illness. Data will be collected at baseline and three follow-ups after 6, 12 and 18 months. Data will be analysed by means of mixed effects regression models. Propensity score methods are used for selection bias control. Study results are expected to provide information about how integrated care programmes in their present form contribute to the improvement of mental health care. In addition, the study will provide hints to weaknesses of the current integrated care programme and options to overcome them. The major strengths of this study are the real-world character of the study intervention with a simultaneous high level of academic rigour. However, the fact that patients are not randomised to study groups and that there is no blinding might limit the study. German Clinical Trial Register DRKS00005111 .

Establishing a diagnosis of temporomandibular joint disorder is mainly based on clinical assessment, functional examination, nuclear magnetic resonance imaging (MRI) and axiography. Sonographic examination was compared with MRI and axiography in assessing temporomandibular joint (TMJ) function in 55 patients.Fifty-five patients with different TMJ problems were examined clinically, by means of axiography, sonography and some also by MRI. The range of motion was measured by sonography and axiography and the results compared using Student's t-test. Anatomical details diagnostic for disc-displacement were tested by sonography and MRI.The average time required for sonography was 2 min and for axiography 20 min. The mean measurement differences for condylar movement in maximal mouth opening was 1.7 mm, for protrusion 1.6 mm and for mediotrusion 2.5 mm. The range of condylar movement as measured by sonography and axiography coincided for opening and for protrusion (statistically significant). No significance was found for lateral excursions. The concordance in diagnosis of disc dislocation, hypermobility and impaired range of motion when comparing ultrasound with MRI was 83%. All sonographic examinations were performed by one person only. Sixty repeat examinations in patients produced no complaints and showed an absolute range of difference of 0.6 mm, with a relative range of 7%. Student's t-test was significant (p0.05) (two repetitive measurements).Sonography proved to be a fast and reliable method for evaluating the range of movement of the TMJ. The lateral joint capsule, lateral disc, and upper condyle could be demonstrated. Pathological processes such as anterior or lateral disc displacement, disc perforation, seroma following contusion, capsular fibrosis, crystalline structures in the synovia and fracture dislocation of the condyle could be diagnosed with considerable reliability when compared with MRI. However, the medial aspect of the joint, medial disc dislocation and the angulation of the condylar slope could not be seen.

Introduction / Background: Against the background of demographic trends and an increasing prevalence of age-associated diseases, there is a raising importance of care programs for patients with Alzheimer`s disease in public health systems. According to WHO the number of people living with dementia worldwide in 2010 is estimated at 35.6 million and is projected to nearly double every 20 years, to 65.7 million in 2030 [1]. Currently 1.2 million people with dementia are living in Germany and the incidence amounts 250,000 new cases every year [2]. The care management of multiple sclerosis is characterized by a multi-disciplinary and cross-sectoral treatment. Globally, the median estimated prevalence of MS is 30 per 100 000 population [3]. There are approximately 120,000 to 180,000 people with MS living in Germany [4]. Both indications are characterized by a high level of care and significant consumption of resources leading to a great economic importance. Aim of this survey is to identify evaluations concerning the effectiveness and / or costeffectiveness of care management programs for the indications of Alzheimer's disease and multiple sclerosis financing by the statutory health insurances. This survey was initiated because of the absence of a systematic overview of German care management programs for the inspected indications. Furthermore a survey of the statutory German health insurance presents an appropriate method for identification of all programs and their evaluations.

Introduction: Provision of chronic care constitutes a main aspect in international health care systems. According to data from the WHO, 46% of the world population are suffering from chronic diseases. By 2020, the number of those is expected to have increased to 60%. Care for the chronically ill in the German health care system has been characterized as deficient. Situations of over and under supply of care, or even lack of appropriate care indicate that there is still efficiency potential that must be leveraged. [1]. In this context, the coordination between different health care sectors (outpatient, inpatient, rehabilitative) and between different (medical) disciplines is a problem that has to be overcome. Preventive and rehabilitative measures are often disregarded and treatment is not based on the principles of evidence based medicine. The optimization of the care structures through managed care in order to eliminate existing deficits has become a common goal of relevant players within the health care system. The question concerning contents, outcomes and effectiveness of managed care programs is of high importance to improve care for the chronically ill. Aims: Analysis of possibilities and requirements for efficient managed care and identification of potential limits by means of an interdisciplinary research project. Results: A research project consisting of five work packages has been set up. Within a preparation phase, the two chronic diseases, Multiple sclerosis and Alzheimer’s disease, have 13 th international Conference on Integrated Care, Berlin, Germany, April 11-12, 2013 2 International Journal of Integrated Care – Volume 13, 23 October – URN:NBN:NL:UI:10-1-114661– http://www.ijic.org/ been selected to be exemplarily analyzed, especially due to its strong need for interdisciplinary and intersectoral care. Work packages 1 and 2 constitute a systematic national and international literature review to identify deficits in the care of both diseases and to investigate evaluations regarding the effectiveness and cost-effectiveness of established care management programs. In addition, a standardized questionnaire has been sent to German statutory health insurances to identify the existence of care management programs and to analyze their contents and evaluations. Moreover, interviews about care deficits are conducted with representatives from e.g. patient organizations and associations of medical specialists. This national analysis is supplemented by an international situation review to identify managed care instruments regarding Multiple sclerosis and Alzheimer’s disease which address the identified care deficits. Based on the findings of work packages 1 and 2, scenarios for optimization the care of MS and dementia will be developed using the Delphi Method. The deduction of recommendations for action and the dissemination of the project results are subject of the fourth respectively the fifth work package. Conclusions: Currently, the project is still in process. First results of work package one have been identified care deficits for both diseases as being of structural nature. In this context, shortcomings, regarding diagnosis and therapy have been found. However, only a few manage care programs for MS and even less programs for dementia addressing these deficits do exist. Furthermore there is only a limited number of evaluations regarding the effectiveness and cost-effectiveness of the mentioned managed care programs.

Background: The provision of care to chronically ill patients in Germany is regarded as deficient. In order to improve quality of care and to cut costs of chronic care, the German legislator has gradually introduced integrated care programs to the statutory health insurance (SHI) since the beginning of 1990s. According to current estimates, between 120,000 and 180,000 people suffer from the chronic disease multiple sclerosis (MS) in Germany [1]. MS causes a significant economic burden as about one out of three patients is affected by early retirement in consequence of MS [2]. Due to its broad range of neurologic symptoms, MS is characterized by a strong need for interdisciplinary and cross-sectoral care programs. Against this background, it was aim of the study to identify existing deficits in MS care, as the identification of deficits provides the basis for the development of efficient health care structures. In a second step, the study addresses the question whether care management programs for MS exist and how they are designed. Methods: Initially, a systematic literature review regarding care deficits and management programs for MS was conducted in the medical databases Embase and Scopus. The systematic search was supplemented by further internet search. Currently, expert interviews regarding care deficits are conducted with representatives from e.g. SHI funds, associations of involved professionals and patient organizations. Furthermore, the 40 largest SHI funds in Germany are surveyed by means of a standardized questionnaire regarding the existence of management programs for MS and their content. The empirical analysis is carried out anonymously.

Background: Care for the chronically ill in the German health care system has been characterized as deficient. Legislation from the past 20 years introduced new forms of integrated care management gradually for statutory health insurance (SHI) in order to improve care, especially for the chronically ill. Considering the demographic change, a substantial increase in the number of those suffering from dementia is predicted. By 2050, the number of dementia patients in Germany is expected to have increased from 1.1 million to 2.6 million. Alzheimer's disease is considered to be the most common form of dementia illness. The intention of this study is to analyze deficits in the care of Alzheimer's patients and persons providing services for them. The identification of care deficits is the foundation for developing efficient health care structures. Furthermore, the study examines whether care management programs exist that address the identified care deficits. Methods: In the initial phase of the study, a systematic literature review within the medical databases Embase and Scopus was conducted to identify care deficits and care management programs for Alzheimer’s disease. The literature review was complemented with further internet research. Currently, expert interviews about care deficits are conducted with representatives from e.g. SHI, medical specialist societies and patient organizations. In addition, a standardized questionnaire has been sent to the 40 largest SHI to identify the existence of care management programs and to analyze their contents. The empirical analysis is being carried out anonymously. 13 th international Conference on Integrated Care, Berlin, Germany, April 11-12, 2013 2 International Journal of Integrated Care – Volume 13, 23 October – URN:NBN:NL:UI:10-1-114705– http://www.ijic.org/ Results: Currently, the results of the systematic literature review and internet research have been compiled. Among other deficits, the deficits in the care of Alzheimer's disease have been identified as being of structural nature. In this context, shortcomings, regarding e.g. too few institutions for diagnosis and therapy (e.g. memory clinics) have been found. In many cases another problem is the delayed diagnosis. As a consequence of general practitioners’ insufficient knowledge regarding geriatric and geronto-psychiatric topics, many potential patients suffering from dementia are overseen. In the therapeutic area, an insufficient use of dementia-specific medication has been identified on the one hand, while on the other, a large volume of medication prescription without any evidence-based effect has been observed. Furthermore, psychiatric and neurological comorbidities have often been inappropriately treated. In addition, nursing homes, where many dementia patients reside, are inadequately equipped. Currently, the empirical data collection is being conducted. Responses to the questionnaires are expected by the end of January 2013. The expert interviews are expected to be completed by the end of February 2013. Discussion and Conclusion: Many deficits in the care of Alzheimer’s disease, which are of structural nature and also regarding diagnosis and therapy, have been identified in literature. The expert interviews serve as validation regarding whether these deficits can be confirmed by those involved in the care of dementia. In addition, the interviews should identify whether any further care deficits exist. The survey of the health insurances regarding the existence and content of health management programs should give an overview whether SHI have already addressed these problems.

Extraskeletal osteogenic sarcoma of the head and neck are extremely rare. This case report describes a 55-year-old patient who has suffered from four squamous cell carcinomas (SCC) of the mouth since 1985. Thirteen years after successful radical resection of the SCC of the planum buccale left and radiotherapy, the patient developed a radiation-induced extraskeletal submandibular sarcoma on the left [7, 8, 9, 12]. The primary sarcoma developed in the planum buccale, the area which had been repeatedly exposed to radiotherapy, and spread into the soft tissue. The difficulties of the clinical diagnosis, the morphology of the tumor and therapeutic procedure are described. This case demonstrates the problems of radiotherapy in SCC.

Aim Recent years have witnessed remarkable advances in the ability to detect and characterize HLA antibodies and ability to predict results of flow crossmatch virtually. In this study we compare the crossmatch results and HLA antibody profile among one heart and one kidney transplant recipients. Methods Pre-Tx and serial post-Tx HLA antibody testing was performed using Luminex based assays (One Lambda Thermo fisher) for detection of total HLA IgG, IgG subclasses, IgM, C1q. Sera were tested for total IgG at neat and 1:8 dilution. Antibody testing results were used to predict virtual crossmatch results. Crossmatches were performed by flow cytometry and extended incubation CDC. Results The following table shows pre-Tx and most recent post-Tx DSA characteristics, crossmatch results, biopsy results and graft outcomes in the 2 cases. Conclusion These data provide a cautionary note that pre-Tx DSA characteristics and virtual crossmatch predictions even when consistent with physical crossmatch results (both Pos and Neg), may not correlate with clinical outcomes particularly in highly allosensitized patients. Download : Download full-size image

Background HLA-DQ Donor Specific Antibody (DSA) is implicated in the negative impact of allograft function after lung transplantation. Non-HLA antibody to Protein Kinase C- ζ [(PKC- Z ) Ab] was reported to associate with graft injury in the absence of C4d deposition. Here we demonstrate DQ DSAs on chronic and acute graft injury elevated by (PKC- Z ) Ab following lung transplants. Case Report A 28-yo old male patient with cystic fibrosis underwent 1st Bilateral Lung Transplant (BLT) in 8/2011 with negative HLA DSA and cross-matches. Low titer (PKC- Z ) Ab was detectable. Graft function performed well in room air after BLT. In 9/2011 bronchoscopy biopsy showed A1B1 along with the appearance of DQ6 de novo DSA, but both biopsy and DSA turned negative following prednisone taper treatment. In 10/2014, he was admitted for cellular and antibody mediated rejection (CMR and AMR) with bronchoscopy biopsy A3B2R and significant increase of DQ6 without C4d deposition. At that time, (PKC- Z ) Ab was unchanged. One month later, (PKC- Z ) Ab abruptly increased to around 2.5-fold and DQ6 peaked (Fig. 1A1, A2). Patient lost allograft and received 2nd BLT on 11/19/2014 with negative cross-matches, DQ9 preformed DSA, and high titer (PKC- Z ) Ab. He was readmitted in 3/2015 for aggressive therapy for acute AMR with ×5 plasmapheresis, rituximab and bortezomib, and IVIG ×5 due to the significant drop of allograft function. AMR was aborted with remarkable decline of DQ9 DSA and (PKC- Z ) Ab on 4/21/2015 (Fig. 1B1, B2) resulting in improved graft function. Summary De novo DQ6 DSA with concurrent CMR resulted in chronic allograft rejection while preformed DQ9 DSA lead to acute allograft rejection after HLT. This negative impact of DQ DSAs to lung allograft injury and/or dysfunction was exacerbated by high titer (PKC- Z ) Ab. Download : Download full-size image