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Acupuncture is increasingly used in patients with chronic pain, but there is a lack of evidence on the cost-benefit relationship of this treatment strategy. The objective of this study was to assess costs and cost-effectiveness of additional acupuncture treatment in patients with chronic neck pain compared to patients receiving routine care alone. A randomized controlled trial including patients (18 years of age) with chronic neck pain (>6 months) was carried out. We assessed the resource use and health related quality of life (SF-36) at baseline and after 3 months using complete social health insurance funds and standardized questionnaires, respectively. The main outcome parameters were direct and indirect cost differences during the 3 months study period and the incremental cost-effectiveness ratio (ICER) of acupuncture treatment. A total of 3,451 patients (1,753 acupuncture-group, 1,698 control-group) were randomized (31% men, age 53.5+/-12.9 years; 69% women, 49.2+/-12.7 years). Acupuncture treatment was associated with significantly higher costs over the 3 months study duration compared to routine care (925.53+/-1,551.06 euros vs. 648.06+/-1,459.13 euros; mean difference: 277.47 euros [95% CI: 175.71 euros-379.23 euros]). This cost increase was mainly due to costs of acupuncture (361.76+/-90.16 euros). The ICER was 12,469 euros per QALY gained and proved robust in additional sensitivity analyses. Since health insurance databases were used, private medical expenses such as over the counter medication were not included. Beyond the 3 months study duration, acupuncture might be associated with further health economic effects. According to international cost-effectiveness threshold values, acupuncture is a cost-effective treatment strategy in patients with chronic neck pain.

Acupuncture is widely used by patients with neck pain, but there is a lack of information about its effectiveness in routine medical care. The aim was to investigate the effectiveness of acupuncture in addition to routine care in patients with chronic neck pain compared to treatment with routine care alone. We performed a randomized controlled multicentre trial plus non-randomized cohort in general practices in Germany. 14,161 patients with chronic neck pain (duration >6 months). Patients were randomly allocated to an acupuncture group or a control group receiving no acupuncture. Patients in the acupuncture group received up to 15 acupuncture sessions over three months. Patients who did not consent to randomization received acupuncture treatment. All subjects were allowed to receive usual medical care in addition to study treatment. Neck pain and disability (NPAD Scale by Wheeler) after three months. Of 14,161 patients (mean age 50.9+/-13.1 years, 68% female) 1880 were randomized to acupuncture and 1886 to control, and 10,395 included into the non-randomized acupuncture group. At three months, neck pain and disability improved by 16.2 (SE: 0.4) to 38.3 (SE: 0.4); and by 3.9 (SE: 0.4) to 50.5 (SE: 0.4), difference 12.3 (p

There is a controversy as to whether gastroesophageal reflux disease (GERD) exists as a spectrum of disease severity or as a categorial disease in three distinct groups: nonerosive (NERD) and erosive reflux disease (ERD) and Barrett's esophagus (BE). Aim of the study was to assess progression or regression of GERD over 2 yr in a large cohort of patients (N = 3,894) under routine clinical care in Germany, Austria, and Switzerland (ProGERD study).Patients with predominant heartburn, with or without esophagitis, were recruited and classified according to endoscopic status at baseline, i.e., NERD, erosive reflux disease-Los Angeles (ERD-LA) grade A/B and ERD-LA grade C/D, and BE. After an initial treatment with esomeprazole, they were followed, regardless of their response. Medical therapy or endoscopy was initiated at the discretion of their primary care physician, in line with routine care. At 2 yr, endoscopy with biopsy was performed according to the protocol.After 2 yr, 25% of patients who had NERD at baseline progressed to LA A/B and 0.6% to LA C/D; 1.6% of patients who had LA A/B progressed to LA C/D and 61% regressed to NERD; 42% of patients who had LA C/D regressed to LA A/B and 50% regressed to NERD (all figures exclude patients with confirmed BE at baseline). At 2 yr, 22% of patients had been off medication for at least 3 months. Patients with ERD-LA grade C/D were at greatest risk of developing BE: 5.8% compared with 1.4% for ERD-LA grade A/B and 0.5% for NERD.GERD does not seem to be a categorial disease. Progression and regression between grades was observed in this large cohort of patients under routine clinical care.

OBJECTIVE: Descriptions of the interventions used in acupuncture studies are often incomplete. The aim of this paper is to describe participating trial physicians and interventions in a randomised trial of acupuncture for low back pain. DESIGN: Three-armed, randomized, controlled multicenter trial with 1-year follow-up. A total of 301 patients with low-back pain were randomized to 12 sessions of semistandardized acupuncture (at least six local and two distant points needled bilaterally from a selection of predefined points, but individual choice of additional body or ear acupuncture points possible), minimal acupuncture (superficial needling of at least 6 of 10 predefined, bilateral, distant nonacupuncture points), or a waiting list control (2 months no acupuncture followed by semistandardised acupuncture described above). OUTCOME MEASURES: Participating trial physicians and interventions. RESULTS: Forty-five (45) physicians specializing in acupuncture (mean age 44 +/- 7.8 years, 23 (51%) female) in 30 outpatient centers in Germany provided the interventions. The median duration of acupuncture training of trial physicians was 350 hours (range 140-2508). The most frequently reported Chinese diagnosis was Kidney deficiency (39%), followed by qi and Blood stagnation (24%), and bi syndrome (20%). The total number of needles used was 17.3 +/- 4.2 in the acupuncture group compared to 12.3 +/- 1.2 in the minimal acupuncture group. In total, 40 physicians (89%) stated that they would have treated patients similarly or in exactly the same way outside of the trial, whereas 5 (11%) stated that they would have treated patients differently. CONCLUSIONS: For most trial physicians, the semistandardized acupuncture strategy used in this trial was an acceptable compromise for an efficacy study. However, a relevant minority of participating trial physicians stated that they would have treated patients differently outside of the trial.

BACKGROUND: The Global Allergy and Asthma European Network (GA2LEN) is a consortium of 26 leading European research centres committed to establish a European research area of excellence in the field of allergy and asthma. AIM: One of the GA2LEN work packages was designed to identify and compare the existing European birth cohort studies on asthma and atopic diseases. The present review compares their subjective and objective outcomes as well as exposure variables. METHODS: A common database was established to assess study characteristics of observational birth cohort studies designed to examine asthma and atopic diseases. Data were collected by visiting most of the participating research teams and interviewing all relevant study personnel. For each study, the type of objective/subjective outcome parameters and potentially influential factors were recorded precisely for every time point during follow-up. RESULTS: Eighteen birth cohort studies on asthma and atopic diseases were identified in eight European countries. Thirteen studies collected data on specific immunoglobulin E (IgE) to various inhalant and food allergens, whereas 12 performed skin prick tests (many at several time points during follow up). Several studies measured lung function, but across the cohorts no comparable standard procedures were used. For subjective evaluation of asthma and allergic rhinitis most studies applied the ISAAC questionnaire (sometimes modified), whereas the assessment of eczema was rather heterogeneous across the studies. CONCLUSION: This GA2LEN initiative established a unique common database of 18 European birth cohorts on asthma and atopic diseases. For selected cohorts, it seems that pooling data and performing common analyses may be possible to examine associations between certain exposure variables (e.g. pet ownership, tobacco smoke exposure and day-care) and selected outcome measures for atopy, asthma or allergic rhinitis (e.g. sensitization assessed by IgE or skin prick tests, doctor's diagnosis of asthma, parental perception regarding asthma/wheezing or hay fever symptoms).

In a randomized controlled trial plus a nonrandomized cohort, the authors investigated the effectiveness and costs of acupuncture in addition to routine care in the treatment of chronic low back pain and assessed whether the effects of acupuncture differed in randomized and nonrandomized patients. In 2001, German patients with chronic low back pain were allocated to an acupuncture group or a no-acupuncture control group. Persons who did not consent to randomization were included in a nonrandomized acupuncture group. All patients were allowed to receive routine medical care in addition to study treatment. Back function (Hannover Functional Ability Questionnaire), pain, and quality of life were assessed at baseline and after 3 and 6 months, and cost-effectiveness was analyzed. Of 11,630 patients (mean age=52.9 years (standard deviation, 13.7); 59% female), 1,549 were randomized to the acupuncture group and 1,544 to the control group; 8,537 were included in the nonrandomized acupuncture group. At 3 months, back function improved by 12.1 (standard error (SE), 0.4) to 74.5 (SE, 0.4) points in the acupuncture group and by 2.7 (SE, 0.4) to 65.1 (SE, 0.4) points among controls (difference=9.4 points (95% confidence interval 8.3, 10.5); p

Homeopathic drugs even with dilutions beyond 10(23) (high potencies) are frequently used, although their working mechanism is still unknown. Curative information preserved in solvent structure is postulated to exert biologic effects.The objective was to test for a stimulating or inhibiting effect of high potencies of the homeopathic remedy HgCl2 (Mercurius corrosivus) on two sugar hydrolases.High potencies were produced using stepwise dilution plus shaking. Controls included potentized solvent (aqua bidestillata), equimolar dilutions without shaking, and enzyme-free references. Tested were potencies with dilution factors 1:200 (CC) on diastase extract from winter barley, and 1:100 (C) on alpha-amylase from hog pancreas. Enzyme activity was colorimetrically determined by Lugol's iodine-starch reaction.An inhibiting effect of HgCl2 on enzyme activities was observed only in low potencies and dilutions. Statistically significant differences between potencies and controls were not found in randomized and blinded experiments.This experimental design provided independent reproducible results of cell-free in vitro assays. However, it did not indicate an effect of potentized HgCl2 on hydrolases. Demonstrating potency effects may require additional experimental features.

BACKGROUND AND PURPOSE: Many patients develop a depression after having suffered a stroke. Such a Post-Stroke Depression (PSD) impairs rehabilitation and quality of life. PSD is underdiagnosed in spite of available treatment. Several questionnaires have been created to diagnose a PSD. But questionnaires have been considered cumbersome and time-consuming. The aim of this study was to find out whether two simple, standardised questions will identify those stroke patients, who have developed a PSD. METHODS: The two case-finding questions and the Beck Depression Inventory (BDI) were sent to patients of the Berlin Acute Stroke Study (BASS) four years after their stroke. Incomplete questionnaires were complemented via mail or telephone. Severity of depression was assessed by means of BDI. RESULTS: Out of 211 patients, 199 responded to the questionnaire (94 %). 193 questionnaires were complete (97 %). Forty-two patients affirmed both case-finding questions (22 %). Compared to patients, who did not affirm both questions, these patients had a higher BDI score (19 +/- 8 vs. 7 +/- 5; p < 0.001). The sensitivity and specificity of the two questions were 89 % and 90 %, respectively. The positive and negative predictive value were 60 % and 98 % respectively. The number of confirmed questions (0, 1, 2) correlated well with the BDI score (r (2) = 0.67, p < 0.001). CONCLUSIONS: Two standardized questions can identify patients with PSD for further diagnostic evaluation and therapy. Diagnosis of PSD might be facilitated by using them as screening instrument.

Background and Purpose—Increased knowledge of stroke risk factors in the general population may lead to improved prevention of stroke. The objective of the present study was to assess knowledge of stroke risk factors and to determine factors associated with knowledge.Methods—In a population-based survey, we sent a questionnaire to randomly selected residents in Berlin who were ≥50 years of age enquiring about knowledge of stroke risk factors. Knowledge was assessed in an open-ended question. In addition, we enquired about the source of participants’ information. Sociodemographic factors, including age, sex, educational level, and nationality, were also assessed.Results—A total of 28 090 of 75 720 residents (response rate, 37%) responded to the questionnaire. Of all respondents, 68% were able to name ≥1 correct stroke risk factor, and 13% named 4 correct risk factors. The majority of respondents named mass media as source of information (82%), followed by family/friends (45%) and by general physicians (20%). In multivariable analysis, increased knowledge of stroke risk factors was significantly associated with younger age, a higher educational level, not living alone, a German nationality, and having received any information about stroke during the last year. However, characteristics of respondents using the respective sources of information varied significantly.Conclusions—Mass media was most frequently named as a source of information about stroke risk factors. Source of information used varied according to population characteristics. Health education programs should take this into account and be adapted accordingly.

We determined the factors leading to emergency department (ED) delays in patients with acute stroke. Data were collected prospectively in four Berlin inner-city hospitals by ED documentation, medical records, imaging files and patient interviews. An extended Cox proportional hazards model was fitted to the data. Analyses were performed in 558 patients with confirmed diagnosis of stroke. Median time from admission at ED to beginning of computed tomography/magnetic resonance imaging (CT/MRI) was 108 min. In a subgroup of patients potentially eligible for thrombolysis with a pre-hospital delay120 min and a National Institutes of Health Stroke Scale (NIHSS)4 (n = 74), the median interval to imaging was 68 min. Multivariable analysis revealed that a more severe initial NIHSS, a pre-hospital delay3 h, admission at two specific hospitals, admission at weekends, and private health insurance were significantly associated with reduced delays. In stroke patients, the time interval between ED admission and imaging depends both on factors that emerge from clinical needs and on factors independent of clinical necessities. Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for both improvement of in-hospital management and of medical and non-medical factors influencing pre-hospital delays.

Background: The reasons for the rise in asthma and allergies remain unclear. To identify risk or protective factors, it is essential to carry out longitudinal epidemiological studies, preferably birth cohort studies. In Europe, several birth cohort studies on asthma and atopic diseases have been initiated over the last two decades. Aim: One of the work packages within the Global Allergy and Asthma European Network (GA 2 LEN) project was designed to identify and compare European birth cohorts on asthma and atopic diseases. The present review (part I) describes their objectives, study settings, recruitment process and follow-up rates. A subsequent review (part II) will compare outcome and exposure parameters. Methods: For each birth cohort, we collected detailed information regarding recruitment process, study setting, baseline data (pregnancy, birth, parents/siblings) as well as follow-up rates, outcome and exposure parameters at each time point. Results: We identified and assessed 18 European birth cohorts on asthma, allergic rhinitis and eczema. Six of these studies also focused on food allergies. The birth cohorts were mostly initiated in the 1990s with predominantly urban/ metropolitan settings. Many studies were able to maintain high follow-up rates, even after five or more years. Conclusions: Due to the unique cooperation within the GA 2 LEN project a common database was established containing study characteristics of European birth cohorts on asthma and atopic diseases. This can be used as a basis for evaluating the possibility to pool data and perform meta-analyses, as well as to recommend criteria for conducting future birth cohorts.

Objective To investigate the effectiveness of acupuncture in addition to routine care, compared with routine care alone, in the treatment of patients with chronic pain due to osteoarthritis (OA) of the knee or hip. Methods In a randomized, controlled trial, patients with chronic pain due to OA of the knee or hip were randomly allocated to undergo up to 15 sessions of acupuncture in a 3-month period or to a control group receiving no acupuncture. Another group of patients who did not consent to randomization underwent acupuncture treatment. All patients were allowed to receive usual medical care in addition to the study treatment. Clinical OA severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and health-related quality of life (Short Form 36) were assessed at baseline and after 3 months and 6 months. Results Of 3,633 patients (mean ± SD age 61.8 ± 10.8 years; 61% female), 357 were randomized to the acupuncture group and 355 to the control group, and 2,921 were included in the nonrandomized acupuncture group. At 3 months, the WOMAC had improved by a mean ± SEM of 17.6 ± 1.0 in the acupuncture group and 0.9 ± 1.0 in the control group (3-month scores 30.5 ± 1.0 and 47.3 ± 1.0, respectively [difference in improvement 16.7 ± 1.4; P < 0.001]). Similarly, quality of life improvements were more pronounced in the acupuncture group versus the control group (P < 0.001). Treatment success was maintained through 6 months. The changes in outcome in nonrandomized patients were comparable with those in randomized patients who received acupuncture. Conclusion These results indicate that acupuncture plus routine care is associated with marked clinical improvement in patients with chronic OA–associated pain of the knee or hip.

Im Gesundheitswesen steigt die Nachfrage nach gesundheitsokonomischen Analysen, um Kosteneinsparungen oder Effizienzsteigerungen zu erreichen. Diese Analysen basieren auf klassischen Literaturstudien bzw. auf den Ergebnissen klinischer Studien oder aber auf routinemasig erhobenen und in Datenbanken zusammengefuhrten Daten, die bisher fehlende Informationen zum Versorgungsalltag erganzen. Mittels Datenbanken konnen Versorgungsstrukturen und angewandte bzw. neu einzufuhrende medizinische Technologien schneller analysiert und verglichen werden als durch Primarstudien. Routinemasig erhobene und potenziell nutzbare Daten entstammen oft Surveys oder administrativen Quellen. Fur die Gesundheitsokonomie sind diese Daten — trotz klarer Einschrankungen — insbesondere aufgrund ihrer Realitatsnahe in Bezug auf die Inanspruchnahme von Leistungen interessant. Sie konnen zum besseren Verstandnis des Versorgungsalltags beitragen und helfen Einschatzungen uber gesundheitsokonomisch sinnvolle medizinische Masnahmen/Technologien und Therapiestrategien zu treffen.

Study Objective: Differences between men and women in management and outcome following cerebrovascular events have been described. However, most of the differences observed have only been partially adjusted for baseline differences, or not at all. The objective of the present study was to compare acute and follow-up management between men and women after stroke and transitory ischemic attacks, adjusting for potential confounders. Design: Patients with symptoms of stroke were included at admission to one of four participating hospitals in the inner city of Berlin, Germany. Risk factors, clinical characteristics, and acute management were assessed from medical records. Patients were asked about socioeconomic factors and follow-up management in a baseline interview and by postal questionnaire, respectively. The follow-up was 12 months. Multiple logistic regression analyses were used to assess odds ratios for management variables. Results: A total of 558 patients were included (55% men, mean age 65 ± 13 years; 45% women, 69 ± 14 years). Indications for admission were stroke (74%) and transitory ischemic attacks (26%). In multivariable analyses, there were no differences in diagnostic procedures performed at baseline and in follow-up management between men and women. However, women were significantly more likely to receive hypoglycemic drugs (odds ratio 2.49; 95% confidence interval 1.33–4.63) in the acute management period. Regarding the need for nursing support/a nursing home after 12 months, there were no significant differences between men and women. Conclusions: After adjustment for differences in baseline characteristics, we only found few differences in acute and long-term management between men and women following hospital admission after suffering a cerebrovascular event.

To investigate trace elements in liquid homeopathic preparations and the influence of container material, storage duration, and potentisation.Using inductively coupled plasma-mass spectroscopy (ICP-MS), we investigated (a) aqua bidestillata (ABD) stored for 12 h in either brown glass or high density polyethylene (HDPE) bottles; (b) ABD stored for 2 h in HDPE, the same additionally filled in brown glass bottle, and ABD potentised in brown glass up to C30; (c) -- at 3 different sample ages and with statistical analysis -- ABD C30 (brown glass), AgNO3 C30 (brown glass), and controls (unsuccussed, brown glass and HDPE).Contamination of the initial ABD increased and element concentrations changed far more when stored in brown glass bottles than in HDPE. Effects were strongest during initial storage time and during the first potentisation step from mother tincture to C1; subsequent potentising steps produced no relevant changes. Potencies of AgNO3 and potencies of water contained similar contamination.Potentising accelerates material exchange between container and solvent, mostly during succussion. Research on potentised preparations should use potentised controls with equal preparation and storage time. If physical and biological effects of potencies exist, contaminants might be one factor for their generation.

Aims Chronic noise exposure is associated with adverse pathophysiological effects and may contribute to the progression of cardiovascular disease. We, therefore, determined the risk of noise for the incidence of myocardial infarction. Methods and results In a case–control study, 4115 patients (3054 men, 56±9 years; 1061 women, 58±9 years) consecutively admitted to all 32 major hospitals in Berlin with confirmed diagnosis of acute myocardial infarction were enrolled from 1998 to 2001 in the Noise and Risk of Myocardial Infarction (NaRoMI) study. Controls were matched for gender, age, and hospital. In standardized interviews, information was obtained on environmental and work noise annoyance. The sound levels of environmental and work noise were assessed using traffic noise maps as proxy and international standards for workplaces, respectively. In multivariate logistic regression models, the adjusted odds ratios of noise variables were determined. There was a marginally increased risk of myocardial infarction associated with annoyance by environmental noise in women (adjusted odds ratio 1.47, 95% confidence interval 0.95–2.25, P =0.081) but not in men, and not associated with annoyance by work noise. Environmental sound levels were associated with increased risk in men and women (odds ratios 1.46, 1.02–2.09, P =0.040 and 3.36, 1.40–8.06, P =0.007) and work sound levels in men only (1.31, 1.01–1.70, P =0.045). Conclusion Chronic noise burden is associated with the risk of myocardial infarction. The risk increase appears more closely associated with sound levels than with subjective annoyance. Further investigation of the gender-related risk of noise exposure may aid in improving prevention.

The purpose of this study was to determine the 12 months medical resource use following admission to hospital with acute stroke and to calculate costs from a societal perspective. Data of consecutive patients with confirmed stroke were analysed. Acute hospital data were taken from medical records, socio-demographic variables from patients' interviews. A follow-up questionnaire about resource utilization was completed by patients or proxies 12 months after acute hospital admission. Costs were calculated by multiplying medical resource units used with cost factors per unit. Mean age of a total of 383 patients was 65 years and 41% were female. The median length of the initial stay in the acute hospital was 12 days at an average cost of 4650 per patient (49% of direct costs). Rehabilitation (16%), readmission (11%), medication (9%), and nursing costs (6%) were other contributors to the direct costs which amounted to a total of 9452 +/- 7599 per patient during 12 months. Indirect cost amounted to a total of 2014 +/- 5312. Patients' age, severity and type of stroke influenced the total stroke-associated costs. The large economic burden of stroke indicates the need for assessing and improving efficient health care for affected patients.

Ob sich klinische Symptome von transitorisch ischamischer Attacke (TIA) und Schlaganfall abgesehen vom zeitlichen Verlauf unterscheiden, ist unklar. Anamnestische Beschwerden und klinische Symptome von Patienten mit TIA und Schlaganfall wurden prospektiv erfasst und anhand einer altersadjustierten, logistischen Regression verglichen. Risikofaktoren, Medikamenteneinnahme und Diagnostik gingen in die vergleichende Analyse ein. 405 Schlaganfallpatienten (68±12 Jahre, 45% weiblich) und 143 TIA-Patienten (64±14 Jahre, 48% weiblich) wurden einbezogen. Sowohl als anamnestische Beschwerde, als auch im klinischen Befund hatten TIA-Patienten signifikant seltener „klassische“ Symptome wie Parese (48% vs. 71%, p

Herz-Kreislauf-Erkrankungen sind fur fast 50% der Gesamt mortalitat in Deutschland verantwortlich. Eine regelmasige korperliche Aktivitat ist langer fristig mit einer deutlichen Reduktion kardiovaskularer Morbiditat und Mortalitat sowohl in der Primar- als auch in der Sekundarpravention bei bereits bestehender Erkrankung assoziiert. Prospektive epidemiologische Studien haben gezeigt, dass sich sowohl moderate als auch intensive korperliche Aktivitat langer fristig positiv auf das Herz-Kreislauf-Risiko auswirken. Auch die Aufnahme einer moderaten korperlichen Aktivitat erst in einem mittleren oder hoheren Lebensalter ist mit einer Risikoreduktion fur Herz-Kreislauf-Erkrankungen verbunden. Allerdings ist akute Anstrengung mit einem erhohten Risiko assoziiert, ein koronares Ereignis auszulosen, vor allem bei untrainierten Patienten mit bestehender koronarer Herzkrankheit. Auch bei korperlich sehr aktiven Menschen ist das Risiko wahrend und nach einer akuten Anstrengung signifikant erhoht. Menschen, die regelmasig korperlich aktiv sind, haben allerdings wahrend der akuten Anstrengung ein deutlich geringeres Risiko fur einen plotzlichen Herztod oder einen akuten Myokardinfarkt als Menschen, die sich selten korperlich betatigen. Trotz des erhohten Risikos wahrend der akuten Anstrengung ist die regelmasige korperliche Aktivitat langer fristig ein wesentlicher Bestandteil der Pravention kardiovaskularer und weiterer Erkrankungen. Daher empfehlen aktuelle Leitlinien einheitlich die regelmasige korperliche Aktivitat zur Pravention von Herz-Kreislauf-Erkrankungen.

As of January 2004, a new DRG (diagnosis related groups) based system has been introduced for the reimbursement of hospital services in Germany. As current data on the treatment cost of patients with myocardial infarction (MI), ischaemic stroke (IS), and peripheral arterial occlusive disease (PAD) are lacking from the third-party payer’s perspective, a bottom-up cost analysis was conducted as a first approach to show treatment cost, based on the DRG system. The evaluation is focused on patients who are hospitalized for an initial cardiovascular event, such as MI, IS or PAD. In order to describe the resource utilization following an initial event owing to MI, IS and PAD, an expert panel was convened in 1997, which included cardiologists, neurologists, angiologists, internists and general practitioners (GP). To update the 1997 expert panel resource utilization data, four specialists for atherothrombotic diseases in Germany were interviewed in 2004. Prices and charges for drugs and medical services were adapted to the current payment system. Annual costs and costs for a subsequent 6-month period were calculated. Patients with MI incurred on average 11,672 EUR in the first year after the initial event and 981 EUR in the subsequent 6-month period. Annual costs in the first year in patients with IS and PAD were 17,864 EUR and 7,674 EUR, respectively. Treatment costs for the subsequent 6-month period were 5,280 EUR in IS patients and 1,172 EUR in PAD patients. This is a first approach to outline the longitudinal dimension of treatment costs from the third-party payer’s perspective in patients with MI, IS and PAD, based on the DRG system in Germany.The evaluation provides basic data for further decision-making, including assessment of treatment strategies for MI, IS and PAD in Germany.

Summary Objectives: To evaluate the effectiveness of homoeopathy versus conventional treatment in routine care. Design: Comparative cohort study. Setting: Patients with selected chronic diagnoses were enrolled in medical practice. Interventions: Conventional treatment or homeopathy. Outcome measures: Severity of symptoms assessed by patients and physicians (visual rating scale, 0–10) at baseline, 6 and 12 months and costs. Results: The analyses of 493 patients (315 adults, 178 children) indicated greater improvement in patients' assessments after homoeopathic versus conventional treatment (adults: homeopathy from 5.7 to 3.2; conventional, 5.9–4.4; p =0.002; children from 5.1 to 2.6 and from 4.5 to 3.2). Physician assessments were also more favourable for children who had received homoeopathic treatment (4.6–2.0 and 3.9–2.7; p p =0.856; children, €1471 versus €786, p =0.137). Conclusion: Patients seeking homoeopathic treatment had a better outcome overall compared with patients on conventional treatment, whereas total costs in both groups were similar.

Heart failure is a frequent cause of morbidity and mortality (particularly post myocardial infarction) and has been moved into the focus of public health care in the last few years. Apart from patho-physiological, clinical, and epidemiological research questions, health economic aspects are increasingly becoming more important. The present model determines the epidemiological and health economic disease burden of post myocardial infarction heart failure in Germany. Basis for the analysis was a literature review of relevant publications since 1990. The incidence of post myocardial infarction heart failure was estimated for two scenarios and, using a Markov model, the course of the disease and the associated use of resources over a period of nine years was calculated. Subsequently, the annual cost of all prevalent cases was determined. The calculation of the incidence in Germany varies between 50,000 (best case scenario) and 90,000 (worst case scenario) per year. These patients cause total costs of € 1.4–2.5 billion during the selected observation period (direct costs account for approx. 55 %). The prevalence per year is estimated to be 250,000 to 450,000. These patients cause a financial burden of approximately € 0.9–1.6 billion per year. The majority is due to hospital treatment (€ 0.3–0.5 billion) and the loss of productivity due to premature mortality (€ 0.2–0.4 billion). Apart from the monetary consequences, it has to be assumed that heart failure reduces the quality of life for these patients by about 50 % compared to that of the normal population at a comparable age. In light of the heavy financial burden in particular due to hospital treatment and loss of productivity associated with the manifestation of heart failure, an early and effective therapy of the initial myocardial infarction (e. g. by adequate lysis or PTCA therapy) is essential. If heart failure nevertheless develops after myocardial infarction, best possible secondary prevention strategies are necessary.

Mortality rates from ischaemic heart disease have consistently been higher in East compared to West Germany both prior to and since reunification. Coronary care is inversely related to mortality from ischaemic heart disease. The objective of the present study was, therefore, to compare cardiovascular medication in East and West German patients following cardiac rehabilitation.East German (n = 530) and West German (n = 1638) patients were included at admission to one of 18 rehabilitation centres. Inclusion criteria were myocardial infarction, coronary artery bypass grafting and percutaneous transluminal coronary angioplasty. The follow-up period was 12 months.At admission, East and West German patients differed with regard to sociodemographic variables, risk factors and medical conditions. At 12 months, a higher percentage of West compared to East German patients were prescribed beta-blockers (71% vs. 65%, P = 0.04) and lipid-lowering agents (64% vs. 55%, P = 0.002). Angiotensin converting enzyme (ACE) inhibitors, on the other hand, were prescribed more frequently in the East compared to the West (60% vs. 48%, P0.001). In multivariable analyses, region of residence remained a significant predictor for the prescription of lipid-lowering agents (East vs. West: OR 0.61, 95% CI 0.46-0.81) and ACE inhibitors (East vs. West: OR 1.78, 95% CI 1.33-2.39).There is a considerable variation in the prescription of cardiovascular medication in secondary prevention within Germany. Some, but not all, of this variation can be explained by differences in patient characteristics.

A number of large randomized controlled trials (RCTs) have documented the effectiveness of HMG-CoA reductase inhibitor (‘statin’) therapy for both primary and secondary prevention of coronary heart disease. Current international guidelines, therefore, recommend the use of statin therapy in patients with or at high risk for coronary heart disease. Unfortunately, patient adherence to statin therapy is unsatisfactory. In patients taking statins for secondary prevention, non-adherence ranges from 42% to 64%; for those taking these drugs for primary prevention, non-adherence is even higher (e.g. 75%). Interventions to increase patient adherence to statin therapy are therefore required. In this review, we summarize the existing evidence relating to interventions for increasing adherence to statin therapy. After searching MEDLINE, CINAHL, EMBASE, CENTRAL and the Health Technology Assessment databases using appropriate search terms, we found ten RCTs, one non-randomized controlled trial, and four ‘before-after’ trials. In four of the ten RCTs and in the non-randomized controlled trial, intervention was associated with a significant increase in the percentage of patients adhering to statin therapy compared with the control group. The remaining six RCTs found no significant difference in adherence between the intervention and control groups. All four before-after trials reported an increase in adherence to statin therapy after the intervention. However, this increase may also have been due to secular trends and changes in medical practice following the publication of the landmark statin trials. Given the inconsistency of the findings and the limitations of certain study designs, RCTs with a large sample size are needed to further investigate the effectiveness of adherence-increasing interventions in patients with statin therapy.

Introduction: There is a growing demand for complementary and alternative medicine (CAM) in Western societies. This trend has lead to the gradual integration of CAM courses into medical school curricula. The aim of this study was to survey key decision makers at German medical schools with regard to their views on CAM and to examine the extent to which CAM has already been integrated in the German medical school system. Materials and Methods: A questionnaire was sent to 753 clinic and institute directors at German medical schools. Results: A total of 500 questionnaires (66%) were returned. 39% of respondents had a positive opinion of CAM, 27% had a neutral opinion and 31% had a negative opinion. 3% of respondents were unsure. The CAM therapies viewed most positively were osteopathy (52%), acupuncture (48%), and naturopathy (41%). Most respondents were in favor of integrating CAM into the medical system. However, a larger percentage favored its use in research (61%) and teaching (59%) rather than in the treatment of patients (58%). Only 191 respondents (38%) indicated that CAM treatment methods had been integrated into the curriculum of their respective medical schools. In these schools, CAM was mainly used in patient treatment (35%), followed by research (22%) and education (21%). Conclusions: Our data show that the majority of respondents were in favor of integrating CAM into medical school curricula. However, at the time of our survey, only a small percentage of medical schools had actually put this into practice. The reasons for this discrepancy are unclear and should be further investigated. Hintergrund: Die Inanspruchnahme von Naturheilverfahren und Komplementärmedizin (complementary and alternative medicine, CAM) steigt in den westlichen Industrienationen. Dieser Trend fördert die Integration von Lehrinhalten von Naturheilverfahren und Komplementärmedizin an den medizinischen Hochschulen. Ziel der Umfragestudie war es, die Meinung von Entscheidungsträgern an den medizinischen Hochschulen Deutschlands bezüglich Naturheilverfahren und Komplementärmedizin zu erfragen und den Stand der Integration von CAM in die medizinischen Hochschulen zu dokumentieren. Material und Methoden: Ein Fragebogen wurde an insgesamt 753 Klinikdirektoren und ausgewählte Institutsleiter an medizinischen Hochschulen in Deutschland verschickt. Ergebnisse: Insgesamt wurden 500 Fragebögen (66%) zurückgesandt. 39% der Antwortenden hatten eine positive Meinung zu CAM, wohingegen 27% eine neutrale und 31% eine ablehnende persönliche Meinung hatten (3% unklar). Osteopathie (52%), Akupunktur (48%) und Naturheilverfahren (41%) waren die am häufigsten positiv eingeschätzten Therapieverfahren. Die meisten Antwortenden sprachen sich für die Integration von CAM in Forschung (61%), Lehre (59%) und Patientenversorgung (58%) an den medizinischen Hochschulen aus. 38% der Antwortenden gaben an, dass CAM in ihre universitären Kliniken bzw. Institute integriert wurden, wobei der Fokus auf der Patientenversorgung (35%), gefolgt von Forschung (22%) und Lehre (21%) lag. Schlussfolgerungen: Die Studienergebnisse zeigen, dass sich die Mehrzahl der Antwortenden für eine Integration von CAM an den medizinischen Hochschulen ausspricht. Allerdings wurde dies bisher nur zu einem sehr geringen Prozentsatz in die Praxis umgesetzt. Die Gründe für diesen Widerspruch sind unklar und sollten weiter erforscht werden.

To determine in a series of randomized blinded experiments using the REDEM technology whether differences between high homeopathic potencies and similarly potentized solvent can be detected.A REDEM device was employed as a black box. Samples were measured in a capacitor that was connected to 60 individual oscillator circuits at frequencies between 250 and 930 KHz; their oscillation damping was recorded. In two experiments (3 and 4 replications) stable differences between a potentized 'mother tincture' and potentized solvent were assessed. Statistical analysis was done using ANCOVA.Significant differences (p0.01) between remedy and control were found, mostly at the same oscillator frequencies. Those differences found for only one remedy always were at frequencies adjacent to frequencies with differences for other remedies. VISUAL ANALYSIS: Where output curves were not near 0, remedy values were higher than controls. Curves within a replication ran parallel, their distances varied. Between replications, curve shapes and remedy- control differences were similar, however, control curves varied in height. Control and remedy curves between experiments varied in shape. Effects increased with time and sample conductivity. Ethanol 43% as solvent eliminated the observed effects, use of polyethylene containers considerably attenuated them.A probably physical difference was seen between potentized homeopathic remedies and potentized solvent. The differences are associated with sample age, solvent, and container material. The REDEM technology requires further investigation to determine the nature of the underlying mechanisms of the observed differences.

Background Previous studies investigating the effectiveness of compliance programs in patients with cardiovascular risk factors have been inconclusive and have not included economic analyses. The primary aim of this Open Label Primary Care Study: Rosuvastatin Based Compliance Initiatives To Achievements of LDL Goals (ORBITAL) study is to determine the long-term cost-effectiveness of a compliance-enhancing intervention in patients with hypercholesterolemia (HC). Secondary objectives include the assessment of compliance, cardiovascular events, and health-related quality of life. Study design A total of 7598 patients (56% men, age 60 ± 10 years, and 44% women, 64 ± 10 years) with HC requiring statin therapy according to the Second Joint European Guidelines were recruited at presentation to 1961 primary care physicians in Germany. Patients were randomized to rosuvastatin therapy with or without a compliance-enhancing program (including standardized contacts between the study center and patients, 9 mailings, 6 telephone calls, and access to a Web page and hotline) for 12 months. Following the intervention phase, there will be a 24-month observational period with patients receiving usual care. Baseline and 6-monthly follow-up assessments are to be obtained from patients and their physicians using standardized questionnaires to evaluate medical and economic parameters. Cumulative direct and indirect disease-related costs (including resource utilization for ambulatory, hospital, rehabilitative, and nursing care, medication, physiotherapy, and transportation, and loss of productivity) will be compared applying a societal perspective. Conclusions The results of this ORBITAL study will provide a basis to develop cost-effective compliance strategies and eventually improve medical care for patients with HC.

Study objective We determine the interval between stroke symptom onset and time to emergency department (ED) arrival and factors associated with delays in presentation. Methods All patients with acute stroke presenting at 4 hospitals in a metropolitan area and consenting to an interview were prospectively included over a 12-month period, excluding patients with presentation greater than 7 days after onset of symptoms and discharge or death within 24 hours after ED arrival. Initially, National Institutes of Health Stroke Scale and times of symptom onset and of ED arrival were registered by a neurologist. Sociodemographic factors and data about the course of events were obtained by standardized interview conducted with patients or proxies. In a multivariable analysis, an extended Cox proportional hazards model was used, and hazard ratios were determined. Results Primary analyses were performed for 558 interviewed patients (mean age 66.8±13.5 years, 45% female patients) with confirmed stroke; 452 (81%) patients had a known onset of symptoms. Median interval between symptom onset and ED arrival was 151 minutes (range 5 to 9,590 minutes). Transport by emergency medical services (adjusted hazard ratio 0.28 [95% confidence interval (CI) 0.19 to 0.41]), increasing age (hazard ratio 0.99 [95% CI 0.98 to 0.99]), greater stroke severity (National Institutes of Health Stroke Scale score; hazard ratio 0.93 [95% CI 0.90 to 0.96]), having transient ischemic attack rather than persistent symptoms (hazard ratio 0.32 [95% CI 0.22 to 0.46]) and symptoms considered urgent (hazard ratio 0.68 [95% CI 0.55 to 0.84]) were the factors most strongly associated with a shorter out-of-hospital interval. Conclusion There are considerable delays between stroke symptom onset and ED arrival. Programs to improve awareness of patients with stroke to seek medical help immediately may reduce unnecessary delays to ED arrival.

Budesonide/formoterol in a single inhaler is an effective therapy for asthma. We investigated whether adjustable maintenance dosing with budesonide/formoterol could maintain health-related quality of life (HRQL) and asthma control.Asthma patients (n = 4025) received budesonide/formoterol (Symbicort 160/4.5 microg) 2 inhalations twice daily (b.i.d.) for 4 weeks during run-in of this open, multicentre study. Patients were randomised to adjustable dosing (budesonide/formoterol 1 inhalation b.i.d.; stepping up to 2 or 4 inhalations bid for 1 week if asthma worsened) or fixed dosing (budesonide/formoterol 2 inhalations b.i.d.), for 12 weeks. Change in HRQL (standardised Asthma Quality of Life Questionnaire, AQLQ[S], score) during randomised treatment was the primary efficacy variable. Secondary variables included asthma control (peak expiratory flow [PEF], symptom-severity score, nocturnal awakenings, reliever-medication use) and study-medication intake.Clinically significant (or = 0.5) improvements in AQLQ(S) score (mean 0.73), morning and evening PEF (mean 42.5 and 24.8 L/min, respectively), and symptom-severity score (mean 0.36) were achieved during run-in. The improvements were maintained in both groups although, overall, adjustable-dosing patients took fewer daily inhalations of budesonide/formoterol than fixed-dosing patients (mean 2.63 versus 3.82, p0.001).Adjustable maintenance dosing with budesonide/formoterol maintains HRQL and asthma control as effectively as fixed dosing and is associated with a reduced drug load overall.

Reprise du travail apres une readaptation cardiologique Objectif: L'objectif de l'etude etait d'analyser la reprise du travail apres une readaptation cardiologique et de determiner les facteurs associes avec la reprise du travail. Methodes: Les patients ont ete inclus a l'admission aux Services pour readaptation participants (n = 18). Les indications primaires pour l'admission etaient un infarctus du myocarde, un pontage aorto-coronaire ou une angioplastie coronaire. Resultats: Parmi les 2441 patients inclus, 1907 etaient de sexe masculin avec un âge moyen de 60 ′ 10 ans, et 534 de sexe feminin avec un âge moyen de 65 ′ 10 ans. Avant la readaptation, 43% des patients travaillaient. Six mois apres l'hospitalisation, 65 % des patients ont repris leur travail et 12 mois apres l'hospitalisation 67%. La reprise du travail apres 12 mois a ete significativement associee avec l'âge jeune, un travail non-physique, un travail independant, une meilleure qualite de vie physique et mentale et un bon resultat de l'epreuve d'effort. Conclusions: La reprise du travail a ete associee avec des facteurs socio-demographiques, la qualite de vie et le resultat de l'epreuve d'effort. La determination des facteurs associes avec la reprise du travail peut faciliter l'identification des patients avec un risque augmente de ne pas reprendre leur travail.

Cardiovascular disease is the leading cause of death in Germany. Cardiovascular events are characterised by high resource consumption. Clopidogrel in unstable angina reduces the risk of cardiovascular events. The objective of this analysis is to compare the cost-effectiveness of Clopidogrel in addition to Acetyl Salicyl Acid (ASA) vs. ASA alone in Germany based on the CURE trial.

To assess the evidence of published experiments on homeopathic preparations (potencies) that target physical properties (i.e., assumed structural changes in solvents).A suitable instrument (the Score for Assessment of Physical Experiments on Homeopathy [SAPEH]) was developed through consensus procedure: a scale with 8 items covering 10 criteria, based on the 3 constructs, methodology, presentation, and experiment standardization. REVIEWED PUBLICATIONS: Written reports providing at least minimal details on physical experiments with methods to identify structural changes in solvents were collected. These reports were scored when they concerned agitated preparations in a dilution less than 10(-23), with no other restrictions. We found 44 publications that included 36 experiments (the identity of 2 was unclear). They were classified into 6 types (dielectric strength, 6; galvanic effects, 5; light absorption, 4; nuclear magnetic resonance [NMR], 18; Raman spectroscopy, 7; black boxes of undisclosed design, 4).Most publications were of low quality (SAPEH6), only 6 were of high quality (SAPEH7, including 2 points for adequate controls). These report 3 experiments (1 NMR, 2 black boxes), of which 2 claim specific features for homeopathic remedies, as does the only medium-quality experiment with sufficient controls.Most physical experiments of homeopathic preparations were performed with inadequate controls or had other serious flaws that prevented any meaningful conclusion. Except for those of high quality, all experiments should be repeated using stricter methodology and standardization before they are accepted as indications of special features of homeopathic potencies.

This article represents the update of ‘European Stroke Initiative Recommendations for Stroke Management’, first published in this Journal in 2000. The recommendations are endorsed by the 3 European societies which are represented in the European Stroke Initiative: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Objective We evaluated the long-term effect of a smoking intervention embedded in an adherence program in patients with an increased risk for cardiovascular disease. Method Secondary analysis of a randomized controlled trial: In 2002–2004, 8108 patients with hypercholesterolemia were enrolled from general practices in Germany. Patients received a 12-month adherence program and statin medication (intervention) or statin medication only (control). The program aimed to improve adherence to medication and lifestyle by educational material, mailings, and phone calls. Smoking was self-reported at baseline and every 6 months during the 3-year follow-up. Results In total, 7640 patients were analyzed. At baseline, smoking prevalence was 21.7% in the intervention and 21.5% in the control group. Prevalence decreased in both groups to 16.6% vs. 19.5%, 15.3% vs. 16.8%, and 14.2% vs. 15.6% at the 12-, 24-, and 36-month follow-up. The intervention had a beneficial effect on smoking differing over time (group × time: P = 0.005). The effect was largest after 6 and 12 months [odds ratios (95% confidence intervals): 0.67 (0.54–0.82) and 0.63 (0.51–0.78)]. The effect decreased until the 18-month follow-up [0.72 (0.58–0.90)] and was not significant after 24 months. Conclusion A low-intensity smoking intervention embedded in an adherence program can contribute to smoking cessation although the intervention effect diminished over time. Trial Registration: ClinicalTrials.gov ( www.clinicaltrials.gov ): NCT00379249 .

Background and Purpose— Physical inactivity and unfavorable dietary and lifestyle patterns are related to cardiovascular disease and premature death. Their relationship to atherosclerosis of the carotid arteries and subsequent stroke is unclear. The objective of this study was to investigate the association between those behavioral cardiovascular risk factors and asymptomatic atherosclerosis of the carotid arteries in a population of former East Germany. Methods— The Study of Health in Pomerania (SHIP) is a cross-sectional survey in northeast Germany. In 1632 individuals aged 45 to 70 years, high-resolution B-mode ultrasound was used to assess the mean intima-media thickness of the right and left common carotid arteries. Carotid plaques and stenosis were recorded. Physical activity, dietary patterns, and cardiovascular risk factors were assessed in interviews with the use of standardized scales. Physically active participants with optimal dietary patterns were classified in the optimal lifestyle group, and those inactive with unfavorable diet were classified in the unfavorable group. Results— After adjustment for sex and age, significant decreasing trends were found for both intima-media thickness and severe asymptomatic atherosclerosis from unfavorable to optimal lifestyle patterns in never smokers but not in smokers. Regression analysis revealed an increased risk of severe asymptomatic atherosclerosis in subjects with an unfavorable lifestyle pattern compared with those with an optimal pattern (odds ratio 2.68; 95% CI, 1.13 to 6.37), following a significant linear trend. Conclusions— Physical activity and optimal diet are associated with reduced risk of early atherosclerosis in subjects who never smoked, while no benefit of an otherwise optimal lifestyle is observed in smokers.

Kurzlich erschienene Publikationen zum Thema Ballaststoffe und Darmkrebs haben eine grundsatzliche Diskussion uber die empirische Evidenz fur bestehende und neu zu entwickelnde Ernahrungsempfehlungen auch in Deutschland ausgelost. Ziel dieses Artikels ist es, Uberlegungen zum Thema Evidenzfindung, d.h. Evidenzkriterien und -bewertung, im Bereich Von ,Public Health Nutrition’ anzustellen.

We aimed to investigate: (1) whether patient and intervention characteristics, design-independent quality aspects, and response rates differ between randomized and non-randomized trials of acupuncture for chronic headache; (2) whether non-randomized studies provide useful additional information (regarding long-term effects, prognostic factors, adverse effects, and generalizability); (3) reasons for potential differences in response rates. Studies including at least five patients and reporting clinical outcome data were identified through searches in Medline, Embase, the Cochrane Controlled Trials Register, other databases and checking of bibliographies. Twenty-four randomized trials and 35 non-randomized studies (five non-randomized controlled cohort studies, 10 prospective uncontrolled studies, 10 case series, and 10 cross-sectional surveys) met the inclusion criteria. Studies were heterogeneous regarding patients, interventions, outcome measurements and results. On average, randomized trials had smaller sample sizes, met more quality criteria, and had lower response rates (0.59 [95% confidence interval 0.48-0.69] vs. 0.78 [0.72-0.83]). Whether randomized or not, studies meeting more quality criteria had lower response rates. Non-randomized studies did not have significantly longer follow-up periods, three included an analysis of prognostic variables, only one reported on adverse effects, and the degree of generalizability was unclear. In the case of acupuncture for chronic headache, non-randomized studies confirmed the finding of a systematic review of randomized trials that the treatment is likely to be effective but provided little relevant additional information on long-term effects, prognostic factors, and adverse effects.

Opera features medicine more than many may recognize—not surprising, given the emotional intensity and extremes associated with illness and death. Physicians’ great voices beguile when emotional abysses crack open; consider, for example, the roles of doctors Dulcamara (Donizetti’s L’Elisir d’Amore), Malatesta (Donizetti’s Don Pasquale), Grenvil (Verdi’s La Traviata), and Miracle (Offenbach’s The Tales of Hoffmann) in the canon. Psychiatric symptoms especially are associated with a distorted sense of objective reality, touching on dimensions that may be expressed hauntingly in music, such as the unfolding psychotic symptoms leading to murder and suicide in Berg’s Wozzeck and to hospital admission of a military general in Hans Werner Henze’s We Come to the River.

Die Pravalenz von Adipositas (Body Mass Index ≥30 kg/m2) liegt in Deutschland fur Manner bei 19,9% und fur Frauen bei 21,6%, im Osten jeweils hoher als im Westen. Medizinische Risiken bei Ubergewicht sind vor allem die erhohte Inzidenz von Risikofaktoren und Manifestationen der Herz-Kreislauf-Erkrankungen. Epidemiologische Untersuchungen zeigen zudem eine kontinuierliche Zunahme der Gesamtmortalitat bereits ab Body Mass Index 25. In multivariaten Analysen erwies sich Adipositas unter Berucksichtigung von Hyperlipoproteinamie, Hypertonie und Diabetes als ein unabhangiger signifikanter Risikofaktor fur koronare Herzkrankheit, Herzinsuffizienz, Schlaganfall und plotzlichen Herztod. Genetische Aspekte spielen bei der Entwicklung von Adipositas eine wichtige Rolle. Die Ergebnisse bisheriger Interventionsstudien sind weitgehend enttauschend. Nach wie vor gilt: “Most obese persons will not stay in treatment, most will not lose weight, and of those who lose weight, most will regain it”. (“Die meisten adiposen Personen bleiben nicht in Behandlung, die meisten verlieren kein Gewicht und von denen, die Gewicht verlieren, nehmen die meisten wieder zu”.) Die Akzeptanz von Adipositas als ernst zu nehmende Erkrankung wird zur Entwicklung wirksamer und dauerhafter Therapie- und Praventionsstrategien beitragen.

The variety of existing definitions of sudden cardiac death makes the assessment of trends and the comparison of study results difficult. In 1995/97, the rates of sudden cardiac death were 209 per 100000 for men and 80 per 100000 for women in the age group of 25–74 years according to the data of the WHO MONICA/KORA Augsburg Coronary Event Register in Germany. In the USA, about 225000 sudden cardiac deaths occur per annum. Sudden cardiac death is more likely to occur in older patients and men than in younger patients and women. Similarly to myocardial infarction, a circadian, weekly, and seasonal variation in the incidence of sudden cardiac death can be observed. Triggers of sudden cardiac death include physical activity, emotional stress, and environmental factors. Successful preventive measures combine behaviour modification, pharmacological interventions, and the implanted cardioverter defibrillator in high-risk patients to protect patients during vulnerable periods.

Systematic data are sparse on clinical outcome after acute coronary disease followed by cardiac rehabilitation therapy. Therefore, our objective was to determine the long-term development of cardiac risk factors, recurrent clinical events, and cardiac medication in patients undergoing routine in hospital cardiac rehabilitation therapy.In the prospective PIN Study (Post Infarct Care), 2441 consecutive patients (78% men, 60+/-10 years, 22% women, 65+/-10 years) were enrolled in 18 inpatient rehabilitation centres in Germany following myocardial infarction (56%), coronary artery bypass graft (38%) or percutaneous transluminal coronary angioplasty (6%). Cardiac risk factors, pre-specified clinical end-points, and the prescription of cardiac medication were prospectively documented on admission to and at discharge from rehabilitation therapy, and 3, 6 and 12 months later by obtaining information with standardized questionnaires from the patients and their physicians. The cardiac risk factors improved initially during cardiac rehabilitation therapy, but deteriorated within the following 12 months: 39% patients smoked at the beginning vs 5% at the end of in hospital rehabilitation vs 10% at 12 months follow-up (P0.001). The respective numbers for patients with blood pressure140 and/or 90 mmHg were 24 vs 8 vs 25% (P0.01) and with plasma cholesterol200 mg. dl(-1)57 vs 29 vs 51% (P0.01). A total of 886 patients experienced one or more recurrent clinical events during the first year, 69% of those within the initial 6 months. At 12 months follow-up, 77% of patients received aspirin, 70% beta-blockers, 62% lipid lowering medication, and 53% angiotensin converting enzyme inhibitors.The present results indicate that the benefit of cardiac rehabilitation therapy following acute coronary events is only partially maintained during the following year. Continuous strategies of medical care need to be developed to improve the long-term outcome in coronary patients.