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Sulfur plays a vital role in the primary and secondary metabolism of plants, and carries an important function in a large number of different compounds. Despite this importance, compared to other mineral nutrients, relatively little is known about sulfur sensing and signalling, as well as about the mechanisms controlling sulfur metabolism and homeostasis. Sulfur contents in plants vary largely not only among different species, but also among accessions of the same species. We previously used associative transcriptomics to identify several genes potentially controlling variation in sulfate content in the leaves of

Because it is the precursor for various essential cellular components, the amino acid serine is indispensable for every living organism. In plants, serine is synthesized by two major pathways: photorespiration and the phosphorylated pathway of serine biosynthesis (PPSB). However, the importance of these pathways in providing serine for plant development is not fully understood. In this study, we examine the relative contributions of photorespiration and PPSB to providing serine for growth and metabolism in the C3 model plant Arabidopsis thaliana. Our analyses of cell proliferation and elongation reveal that PPSB-derived serine is indispensable for plant growth and its loss cannot be compensated by photorespiratory serine biosynthesis. Using isotope labeling, we show that PPSB-deficiency impairs the synthesis of proteins and purine nucleotides in plants. Furthermore, deficiency in PPSB-mediated serine biosynthesis leads to a strong accumulation of metabolites related to nitrogen metabolism. This result corroborates 15N-isotope labeling in which we observed an increased enrichment in labeled amino acids in PPSB-deficient plants. Expression studies indicate that elevated ammonium uptake and higher glutamine synthetase/glutamine oxoglutarate aminotransferase (GS/GOGAT) activity causes this phenotype. Metabolic analyses further show that elevated nitrogen assimilation and reduced amino acid turnover into proteins and nucleotides are the most likely driving forces for changes in respiratory metabolism and amino acid catabolism in PPSB-deficient plants. Accordingly, we conclude that even though photorespiration generates high amounts of serine in plants, PPSB-derived serine is more important for plant growth and its deficiency triggers the induction of nitrogen assimilation, most likely as an amino acid starvation response.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

The objective was to evaluate the effectiveness of a self-management patient education programme for fibromyalgia syndrome (FMS) as compared with usual care education in inpatient rehabilitation. In a multicentre cluster-randomized controlled trial, 583 inpatients in 3 rehabilitation centres received an advanced self-management patient education programme or usual care education. Patients completed questionnaires at admission, discharge and after 6 and 12 months. Primary outcomes were disease- and treatment-specific knowledge at discharge, and self-management-competencies after 6 months. Secondary outcomes included satisfaction, attitudes, coping competencies, psychological distress and health impairment. We found a medium-sized effect on disease- and treatment-specific knowledge at discharge (P < 0.05, Cohen's d = 0.45, 95% CI = 0.27-0.63), and small effects for subjective knowledge, pain-related control, self-monitoring and insight, communication about disease, action planning for physical activity and treatment satisfaction (all P < 0.05). Only the effect on knowledge persisted for 6 and 12 months. This advanced education programme seemed to be more effective in the short term than usual education. However, intermediate- and long-term effects did not emerge. While superior long-term effects on knowledge as well as short-term effects on self-management skills may suggest implementation, additional long-term effects on other patient-relevant outcomes would be desirable. Trial registration: German Clinical Trials Register, DRKS00008782, Registered 8 July 2015.

A new conceptual framework has enabled the flexible development of rheumatological patient educational programs for different healthcare settings. On this basis, a 5‑h basic training program for patients with rheumatoid arthritis (RA) was developed to be used in specialized centers. Rheumatologists and psychologists were first trained and then the efficacy of the patient training program was evaluated based on the causal model of patient education.The externally randomized waiting control group study with 249 RA patients included 3 measurement points. The impact of the 5‑h basic training on disease and treatment-related knowledge as well as health competence of RA patients was examined. Secondary questions included attitudinal parameters, communication competence, effects on the disease and satisfaction with the educational program. Data were analyzed on an intention to treat basis by means of covariance analyses for the main target variables, adjusted for baseline values.The analyses showed that the training program was effective. Even 3 months after training, participants reported more knowledge and health competence than the waiting control group, with small to medium-sized effects (d = 0.37 and 0.38, respectively). With the exception of disease communication, no other effects of training were observed in the secondary objectives.The basic training program provides a good foundation to develop further interventions to improve attitudinal and disease parameters. It can serve as a central component for rheumatological healthcare for patients with RA at various levels.HINTERGRUND: Ein neues Rahmenkonzept hat die flexible Ableitung und Nutzung von rheumatologischen Schulungsprogrammen für unterschiedliche Versorgungsbereiche ermöglicht. Auf dieser Grundlage wurde eine 5‑stündige Basisschulung für Patienten mit rheumatoider Arthritis (RA) entwickelt, es wurden rheumatologische Fachärzte und Psychologen trainiert, und dann wurde die Wirksamkeit nach dem Wirkmodell der Patientenschulung evaluiert.Mit dem Studiendesign einer extern randomisierten Wartekontrollgruppenstudie mit 3 Messzeitpunkten wurde geprüft, wie sich die 5‑stündige Basisschulung auf das Erkrankungs- und Behandlungswissen sowie auf die Gesundheitskompetenz von RA-Patienten (n = 249) auswirkt. Weitere Fragen betrafen Einstellungsparameter, Kommunikationskompetenz, Erkrankungsauswirkungen und die Zufriedenheit mit der Schulung. Die Auswertungen erfolgten auf Intention-to-treat-Basis mit Kovarianzanalysen für die Hauptzielgrößen unter Berücksichtigung des Ausgangswertes.Die Analysen zeigen, dass die Basisschulung RA wirksam ist. Noch 3 Monate nach der Schulung verfügten die Schulungsteilnehmer über mehr Wissen und Gesundheitskompetenz als die Wartekontrollgruppe mit kleinem bis mittelgroßem Effekt (d = 0,37 bzw. 0,38). In den Nebenzielgrößen zeigten sich mit Ausnahme der Krankheitskommunikation keine weiteren Schulungseffekte.Die Basisschulung bietet eine gute Grundlage, auf der weitere Interventionen zur Verbesserung von Einstellungs- und Erkrankungsparametern aufbauen können. Sie eignet sich damit als zentraler Baustein für die rheumatologische Versorgung auf verschiedenen Ebenen.

The evolution of C4 photosynthesis led to an increase in carbon assimilation rates and plant growth compared to C3 photosynthetic plants. This enhanced plant growth, in turn, affects the requirement for soil-derived mineral nutrients. However, mineral plant nutrition has scarcely been considered in connection with C4 photosynthesis. Sulfur is crucial for plant growth and development, and preliminary studies in the genus Flaveria suggested metabolic differences in sulfate assimilation along the C4 evolutionary trajectory. Here, we show that in controlled conditions, foliar accumulation of the reduced sulfur compounds Cys and glutathione (GSH) increased with progressing establishment of the C4 photosynthetic cycle in different Flaveria species. An enhanced demand for reduced sulfur in C4Flaveria species is reflected in high rates of [35S]sulfate incorporation into GSH upon sulfate deprivation and increased GSH turnover as a reaction to the inhibition of GSH synthesis. Expression analyses indicate that the γ-glutamyl cycle is crucial for the recycling of GSH in C4 species. Sulfate reduction and GSH synthesis seems to be preferentially localized in the roots of C4 species, which might be linked to its colocalization with the phosphorylated pathway of Ser biosynthesis. Interspecies grafting experiments of F. robusta (C3) and F. bidentis (C4) revealed that the root system primarily controls sulfate acquisition, GSH synthesis, and sulfate and metabolite allocation in C3 and C4 plants. This study thus shows that evolution of C4 photosynthesis resulted in a wide range of adaptations of sulfur metabolism and points out the need for broader studies on importance of mineral nutrition for C4 plants.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

ObjectivesSince 2014, the Federal German Pension Insurance has approved several departments to implement work-related medical rehabilitation programmes across Germany. Our cohort study was launched to assess the effects of work-related medical rehabilitation under real-life conditions.MethodsParticipants received either a common or a work-related medical rehabilitation programme. Propensity score matching was used to identify controls that were comparable to work-related medical rehabilitation patients. The effects were assessed by patient-reported outcome measures 10 months after completing the rehabilitation programme.ResultsWe compared 641 patients who were treated in work-related medical rehabilitation with 641 matched controls. Only half of the treated patients had high initial work disability risk scores and were intended to be reached by the new programmes. The dose of work-related components was on average in accordance with the guideline; however, the heterogeneity was high. Work-related medical rehabilitation increased the proportion of patients returning to work by 5.8 percentage points (95% CI 0.005 to 0.110), decreased the median time to return to work by 9.46 days (95% CI -18.14 to -0.79), and improved self-rated work ability by 0.38 points (95% CI 0.05 to 0.72) compared with common medical rehabilitation. A per-protocol analysis revealed that work-related medical rehabilitation was more effective if patients were assigned according to the guideline and the minimal mandatory treatment dose was actually delivered.ConclusionsThe implementation of work-related medical rehabilitation in German rehabilitation centres affected work participation outcomes. Improving guideline fidelity (reach and dose delivered) will probably improve the outcomes in real-world care.Trial Registration NumberDRKS00009780

Sulfur is present in plants in a large range of essential primary metabolites, as well as in numerous natural products. Many of these secondary metabolites contain sulfur in the oxidized form of organic sulfate. However, except of glucosinolates, very little is known about other classes of such sulfated metabolites, mainly because of lack of specific and quantitative analytical methods. We developed an LC-MS method to analyze sulfated flavonoids, a group of sulfated secondary metabolites prominent, e.g., in plants of the genus Flaveria. The method uses a linear gradient of methanol/formic acid in water on a Restek Raptor C18 Core-Shell column for separation of the compounds. The sulfated flavonoids are detected by mass spectrometry (MS) in a negative mode, using a neutral loss of 80 Da after a collision induced dissociation. With this method we were also able to quantify the sulfated flavonoids. We could detect all (mono)sulfated flavonoids described before in Flaveria plus a number of new ones, such as isorhamnetin-sulfate-glycoside. In addition, we showed that sulfated flavonoids represent a substantial sulfur pool in Flaveria, larger than the thiols glutathione and cysteine. The individual species possess different sulfated flavonoids, but there is no correlation between the qualitative pattern and type of photosynthesis. Similar to other sulfur-containing secondary compounds, the concentration of sulfated flavonoids in leaves is reduced by sulfur starvation. The new LC-MS method will enable qualitative and quantitative detection of these secondary metabolites in plants as a pre-requisite to addressing their functions.

Background Self-report questionnaires are widely used to assess changes in quality of life (QoL) during the course of cancer treatment. However, comparing baseline scores to follow-up scores is only justified if patients' internal measurement standards have not changed over time, that is, no response shift occurred. We aimed to examine response shift in terms of reconceptualization, reprioritization and recalibration among prostate cancer patients. Material and methods We included 402 newly diagnosed patients (mean age 65 years) and assessed QoL at the beginning of cancer treatment and three months later. QoL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). We employed structural equation modeling testing measurement invariance between occasions to disentangle 'true' change and change in the measurement model (response shift). Results We found reprioritization effects for both the Physical Functioning and Role Functioning subscales of the EORTC QLQ-C30, indicating that both had gained importance for representing the latent construct of QoL at follow-up. These effects added to the worsening effect evident in the latent construct, thus rendering observed changes even more pronounced. In addition, we found recalibration effects for both the Emotional Functioning and Cognitive Functioning subscales indicating judgments becoming more lenient over time. These effects counteracted 'true' negative changes thus obscuring any substantial changes on the observed level. Conclusion Our results suggest that changes observed in some subscales of the EORTC QLQ-C30 should not be taken at face value as they may be affected by patients' changed measurement standards.

Objectives Work-related components are an essential part of rehabilitation programs to support return to work of patients with musculoskeletal disorders. In Germany, a guideline for work-related medical rehabilitation was developed to increase work-related treatment components. In addition, new departments were approved to implement work-related medical rehabilitation programs. The aim of our study was to explore the state of implementation of the guideline’s recommendations by describing the change in the delivered dose of work-related treatments. Design Nonrandomized controlled trial (cohort study). Setting Fifty-nine German rehabilitation centers. Participants Patients (N=9046) with musculoskeletal disorders were treated in work-related medical rehabilitation or common medical rehabilitation. Patients were matched one-to-one by propensity scores. Interventions Work-related medical rehabilitation in 2014 and medical rehabilitation in 2011. Main Outcome Measures Treatment dose of work-related therapies. Results The mean dose of work-related therapies increased from 2.2 hours (95% confidence interval [CI], 1.6-2.8) to 8.9 hours (95% CI, 7.7-10.1). The mean dose of social counseling increased from 51 to 84 minutes, the mean dose of psychosocial work-related groups from 39 to 216 minutes, and the mean dose of functional capacity training from 39 to 234 minutes. The intraclass correlation of 0.67 (95% CI, 0.58-0.75) for the total dose of work-related therapies indicated that the variance explained by centers was high. Conclusions The delivered dose of work-related components was increased. However, there were discrepancies between the guideline’s recommendations and the actual dose delivered in at least half of the centers. It is very likely that this will affect the effectiveness of work-related medical rehabilitation in practice.

Zusammenfassung Einleitung: Auf Initiative der Kommission zur Weiterentwicklung der Sozialmedizin in der gesetzlichen Rentenversicherung wurde in den letzten Jahren ein Qualitätssicherungskonzept für die sozialmedizinische Begutachtung bei Anträgen auf Erwerbsminderungsrenten entwickelt, dem ein Peer Review-Verfahren zugrunde liegt. Die Qualitätsbewertung in diesem Verfahren vollzieht sich mithilfe eines hierarchisch aufgebauten Prüffragenkatalogs, der in diesem Pilotprojekt auf seine Güte hin evaluiert wurde. Methoden: Datengrundlage bildeten 260 Erstgutachten zur Erwerbsminderungsrente von 12 teilnehmenden Rentenversicherungsträgern, zu denen insgesamt 771 Reviews von 19 Peers erstellt wurden. Zur Beurteilung der Reliabilität wurde in erster Linie Kendalls Konkordanzkoeffizient W herangezogen. Ergebnisse: Für das Verfahren konnten je nach Prüffrage sehr heterogene Reliabilitätswerte identifiziert werden. Der Range für Kendells W erstreckte sich dabei von 0,09 bis 0,88. Das übergeordnete Kriterium, welches gleichzeitig das Hauptzielkriterium ist, erreicht einen Wert von 0,37. Schlussfolgerung: Die Interrater-Reliabilität des Peer Reviews der sozialmedizinischen Begutachtung mithilfe des vorliegenden Manuals erweist sich im Kontext vergleichbarer Studienergebnisse aus anderen Peer Review-Kontexten als akzeptabel. Ansatzpunkte für eine Verbesserung können in einer systematischen Schulung und regelmäßigen Anwendertreffen der Peers gesehen werden.

Im Rahmen zweier Projekte wurden Instrumente zur externen Qualitatssicherung in stationaren Einrichtungen der Vorsorge und Rehabilitation fur Mutter und Vater entwickelt. Fur den Bereich der Prozessqualitat sollte dabei als Alternative zum Peer-Review-Verfahren ein Ansatz erprobt werden, bei dem die Patientinnenperspektive im Vordergrund steht. Ziel war es, einen „idealen Prozess“ als Standard zu definieren, messbare Kriterien zu entwickeln und eine multimethodale Erfassung unter Einbezug verschiedener Ebenen zu erproben. Auf der Grundlage verschiedener Quellen wurden im Rahmen eines Konsensprozesses mit einer projektbegleitenden Expertengruppe der „ideale Prozess“ fur Mutter-Vater-Kind-Reha/Vorsorge und die zugehorigen Kriterien definiert. Die Kriterien wurden dann uber verschiedene Ebenen erfasst – auf Klinikebene uber eine Strukturerhebung prozessrelevanter Strukturmerkmale, auf Patientinnenebene einerseits uber einen vom Klinikpersonal auszufullenden Dokumentationsbogen und andererseits uber eine ereignisorientierte Patientinnenbefragung. Die Daten wurden in Zusammenarbeit mit 37 Piloteinrichtungen erhoben (davon 19 Vorsorge-einrichtungen, 11 Rehabilitationseinrichtungen und 7 Einrichtungen mit beiden Zulassungen). Die Auswertung der patientenbezogenen prozessrelevanten Daten bezieht sich auf eine Stichprobe von 1 513 Patientinnen in der Vorsorge und 286 Patientinnen in der Rehabilitation. Der resultierende „ideale Prozess“ umfasst die Phasen „Vorbereitung der Masnahme“, „Anreisesituation“, „Planung der Behandlung“, „Durchfuhrung der Behandlung“, „Abschluss der Behandlung“ und „Organisation der Behandlung“, welche jeweils spezifische Kriterien beinhalten. Beispielhaft werden die Ergebnisse der Phasen „Planung der Behandlung“ und „Durchfuhrung der Behandlung“ dargestellt. Es zeigt sich eine Variabilitat im Erfullungsgrad sowohl zwischen verschiedenen Merkmalen als auch zwischen den Einrichtungen. Die Mehrheit der Patientinnen sieht die Kriterien als erfullt an, aus der Dokumentation der Einrichtungen ergeben sich mittlere bis hohe Erfullungsgrade, die in der Strukturerhebung erfassten Kriterien werden nach Klinikangaben zumeist erfullt. Ubereinstimmungen zwischen den 3 Datenebenen konnen beobachtet werden. Auf der Grundlage des definierten „idealen Prozesses“ scheint die erprobte Methode geeignet, prozessrelevante Merkmale aus verschiedenen Perspektiven abzubilden, wobei das Gesamtbild uber die verschiedenen Ebenen und Methoden betrachtet werden muss. Die exemplarisch erfasste Prozessqualitat der Piloteinrichtungen kann als uberwiegend gut beurteilt werden, einzelne Defizite der Prozessqualitat sowie Limitationen des gewahlten Vorgehens werden diskutiert.

Einrichtungen, die Masnahmen der stationaren Vorsorge und Rehabilitation fur Mutter, Vater und Kinder durchfuhren, sind nach § 137d SGB V zur externen Qualitatssicherung verpflichtet. Im Auftrag der Verbande der Krankenkassen auf Bundesebene wurden in 2 Pilotprojekten Verfahren zur externen Qualitatssicherung in der stationaren Vorsorge und Rehabilitation fur Mutter und Vater entwickelt. Zielsetzung war es, ein Instrumentarium zur Erhebung von Strukturmerkmalen in diesem Versorgungsbereich zu entwickeln und dessen Angemessenheit zu erproben. Bezuglich der Strukturqualitat umfassten die Projektauftrage a) die Konzeption und Erprobung eines Erhebungsbogens, b) die Definition von Bewertungskriterien fur spatere einrichtungsvergleichende Datenanalysen und c) die dazu notwendige Beschreibung der aktuellen Versorgungssituation im Bereich der Mutter-/Vater-Kind-Rehabilitation und -Vorsorge. Um die Strukturqualitat umfassend zu dokumentieren, wurde ein modular aufgebauter Strukturerhebungsbogen konzipiert und im Rahmen einer Querschnittserhebung in 115 Mutter-Vater-Kind-Einrichtungen erprobt. Um aussagefahige Qualitatsmessungen hinsichtlich der Strukturmerkmale zu gewahrleisten, erfolgte eine expertengestutzte Definition von vorlaufigen Basis- und Zuweisungskriterien. Die meisten Einrichtungen geben Versorgungsvertrage sowohl fur Vorsorge als auch fur Rehabilitation an, wobei Masnahmen fur Mutter/Vater mit Kindern uberwiegen; nur 7 Einrichtungen fuhren ausschlieslich Mutter-/Vater-Masnahmen durch. Die Einrichtungsgrosen variieren stark; Behandlungsschwerpunkte/Indikationen beziehen sich vor allem auf die Bereiche Psychosomatik, Dermatologie und Pneumologie. Insgesamt zeigt sich bei den strukturellen Voraussetzungen ein hohes Niveau. In der hier prasentierten Auswertung der vorlaufigen Basiskriterien (BK) werden die Erfullungsgrade der vorlaufig definierten BK bezuglich der Strukturdimensionen dargestellt. Der modulare Strukturerhebungsbogen hat sich in seinem ersten Einsatz bewahrt, damit wurde ein Instrumentarium zur Erfassung der Strukturqualitat fur einen routinemasigen Einsatz in der Praxis entwickelt. Daruber hinaus konnen die gewonnenen Daten zur Festlegung des endgultigen Kriterienkatalogs genutzt werden.

Fur die stationare Rehabilitation und Vorsorge fur Mutter, Vater und Kinder liegen bislang keine Programme zur externen Qualitatssicherung vor. Daher wurden Verfahren zur Dokumentation der Ergebnisqualitat mit dem Ziel erprobt, Aussagen uber die Abbildung qualitatsrelevanter Unterschiede zwischen Einrichtungen treffen zu konnen. Bezugnehmend auf das biopsychosoziale Modell der ICF wurden nach Spezifizierung relevanter Outcome-Parameter und deren Operationalisierung uber validierte Assessments einrichtungsvergleichende Analysen in 45 stationaren Vorsorge- und Rehabilitationseinrichtungen fur Mutter, Vater und Kinder durchgefuhrt. Es wurden Mehrebenenmodelle mit Risikoadjustierung berechnet. Uber Intraklassenkorrelationen wurde bestimmt, in welchen Parametern Unterschiede zwischen Einrichtungen abbildbar waren und bei Kontrolle relevanter Confounder fur jeden Parameter der durch Patienten- bzw. Einrichtungsmerkmale erklarte Varianzanteil ermittelt. Fur Vorsorgeeinrichtungen zeigten sich bei 9 von 15 Parametern substanzielle Variationen auf der Einrichtungsebene. Fast alle Einrichtungen wichen nicht signifikant vom Gesamtmittelwert im jeweiligen Parameter ab. Bei Rehabilitationseinrichtungen fand sich in 2 von 10 Parametern eine bedeutsame Variation. Die Differenzen zwischen den meisten Einrichtungen lagen in einem Bereich zu erwartender Variabilitat. Die Ergebnisse implizieren, dass klinikvergleichende Analysen der Ergebnisqualitat eher geeignet scheinen, Einrichtungen mit niedriger Qualitat herauszufiltern als qualitatsbezogene Rangreihen von Einrichtungen zu erstellen.

Fur die medizinische Vorsorge und Rehabilitation fur Mutter und Vater einschlieslich Mutter-/Vater-Kind-Masnahmen existierte bislang kein standardisiertes bundesweites Qualitatssicherungsprogramm. Im Auftrag der Verbande der Krankenkassen auf Bundesebene wurden darum Instrumente und Verfahrensweisen der externen Qualitatssicherung entwickelt und erprobt. Auf Ebene der Strukturqualitat wurden ein modularer Strukturerhebungsbogen konzipiert, vorlaufige Basis- bzw. Zuweisungskriterien definiert und eine Visitationscheckliste erstellt. Strukturdaten wurden bundesweit erfasst. Die klinikvergleichende Auswertung der Strukturerhebung (n=115 Bogen) erfolgte anhand des prozentualen Erfullungsgrads von Basis- und Zuweisungskriterien. Die Erprobung der Instrumente zur Messung der Prozess- und der Ergebnisqualitat erfolgte in Zusammenarbeit mit 38 Piloteinrichtungen. Die Prozessqualitat wurde multimethodal uber prozessnahe Strukturmerkmale, fallbezogene Routinedokumentationen sowie eine ereignisorientierte Patientenbefragung erfasst. Die Ergebnisqualitat wurde auf der Datengrundlage von N=1 799 Patienten mittels Mehrebenenmodellen unter Adjustierung relevanter Confounder gepruft. Es wurden Verfahrensweisen, Instrumente und Auswertungsroutinen zur externen Qualitatssicherung entwickelt, erprobt und mit den Akteuren des Leistungsbereichs abgestimmt. Zu jedem Qualitatssicherungsbaustein werden Ergebnisse anhand ausgewahlter Beispiele dargestellt. Auf den meisten der risikoadjustierten Outcome-Parameter konnten keine signifikanten Klinikunterschiede festgestellt werden. Es steht ein bundesweit einheitliches Instrumentarium zur vergleichenden Qualitatsmessung in Mutter-Vater-Kind-Einrichtungen zur Verfugung. Da jedoch die Komplexitat des familienorientierten Leistungsbereichs nicht vollstandig abgebildet wird, muss das Instrumentarium weiter adaptiert werden und fur neue Entwicklungen offen sein.

Background: Patients with inflammatory bowel disease (IBD) suffer from various physical as well as psychological impairments, and patient education may help improve their well-being. Therefore, we developed a manualized education program for IBD patients addressing medical and psychological issues. This study aimed to evaluate it in a large controlled trial. Methods: A total of 181 IBD outpatients participated in a prospective, randomized, waitlist-controlled trial; assessments were made before as well as 2 weeks and 3 months after intervention. Analysis of covariance was used to assess intervention effects on disease-related worries and concerns (primary outcome), fear of progression, coping with anxiety, health competencies, health-related quality of life (HRQoL), perceived disease activity, symptoms of depression and anxiety, disease-related knowledge, and coping strategies. Participants' satisfaction with the program was also evaluated. Results: At 2 weeks and 3 months after intervention, we found significant large effects of our education program on skill and technique acquisition, knowledge, and coping with IBD. Moreover, we found significant medium effects on disease-related worries and concerns, fear of progression, coping with anxiety, constructive attitudes and approaches, as well as coping with disease-related negative emotions. The number of coping strategies used was significantly higher at 3 months. We did not find any effects on perceived disease activity, HRQoL, positive and active engagement in life, or symptoms of anxiety and depression. The program was rated very favorably by the attendees. Conclusion: Our education program contributed to improvements in psychological distress, self-management skills, and coping and was appreciated by its attendees.

Although inflammatory bowel disease (IBD) affects patients' psychological well-being, previous educational programs have failed to demonstrate effects on psychosocial outcomes and quality of life. Therefore, we developed a group-based psychoeducational program that combined provision of both medical information and psychological self-management skills, delivered in an interactive manner, and evaluated it in a large, cluster-randomized trial. We assigned 540 rehabilitation inpatients suffering from IBD (mean age 43 years, 66% female) to either the new intervention or a control group comprising the same overall intensity and the same medical information, but only general psychosocial information. The primary outcome was patient-reported IBD-related concerns. Secondary outcomes included disease knowledge, coping, self-management skills, fear of progression, anxiety, depression and quality of life. Assessments took place at baseline, end of rehabilitation and after 3 and 12 months.The psychoeducational self-management program did not prove superior to the control group regarding primary and secondary outcomes. However, positive changes over time occurred in both groups regarding most outcomes. The superior effectiveness of the newly developed psychoeducational program could not be demonstrated. Since the intervention and control groups may have been too similar, this trial may have been too conservative to produce between-group effects.

Vocational orientation in medical rehabilitation has become an important issue in rehabilitation science and practice in Germany. Although a variety of vocationally oriented interventions has been developed in recent years, there is still a lack of consensus with regard to the definition of specific types of interventions as well as relevant criteria (e. g., methods; instruments; duration/frequency; patient groups). Building on preliminary definitions, basic types of vocationally oriented measures/interventions were conceptually modified and refined in the context of a consensual process. 39 experts of various professions were contacted during a 2-stage Delphi survey to evaluate existing definitions of vocationally oriented interventions using key questions. Standardized descriptions of 5 vocationally oriented basic interventions were specified in cooperation with an interdisciplinary panel of experts. Descriptions were published in a workbook and a homepage for researchers and clinicians, which also contain information on the implementation of measures into rehabilitative care as well as good practice examples. The media developed in this project may contribute to the transfer of research results on vocationally oriented rehabilitation into health care practice.

In the context of medical rehabilitation quality assurance, the use of screening procedures aims at specifically screening for rehabilitative cases that might be affected by quality problems. These may then be subjected to more elaborate quality management procedures. In the study presented, a criteria-based screening checklist designed to tap potential quality problems among rehabilitative cases in the German statutory accident insurance medical rehabilitation system was evaluated regarding its validity and suitability for routine use. Checklists were filled out by accident insurance administrators in three regional insurance funds who were instructed to evaluate all current rehabilitation cases (n=189) with regard to potential quality problems. For validation of the instrument, case reviews by physicians familiar with medical and administrative features of the accident insurance rehabilitation system were used. About a fifth of all cases reviewed using the screening checklist (22%) were classified as potentially problematic in terms of quality. Absence of relevant documents, delays in document receipt, and complications during treatment were cited as the most frequent problems. Concordance between the screening checklist and physicians' ratings concerning the quality of rehabilitative cases was moderate. Sensitivity and specificity were insufficient when using physicians' ratings as a validation criterion (0.53 and 0.56, respectively). Accident insurance administrators rated the screening checklist as a useful and practical quality management instrument. Concerning its insufficient validity using physicians' ratings as a validation criterion, the suitability of the checklist as a screening instrument is questionable. The instrument's potential of introducing the accident insurance administrators' expertise and knowledge into medical rehabilitation quality management strategies is highlighted. Further research on methodological aspects of the instrument as well as its content features is warranted. Starting points for modifications are outlined.

In accident patient care, there is a substantial overlap between the scope of duties of hospital social services and tasks fulfilled by the German statutory accident insurances' visiting staff that regularly takes care of accident patients. Therefore, a project on the integration of hospital social services into the organizational structures of the German statutory accident insurance was initiated which aimed at optimising communication and realising synergy effects. A formative evaluation of the project was conducted that provided process- and outcome-related data for a comprehensive evaluation of the strengths and potentials of the project. Report forms containing patient-related information were completed by hospital social services. Forms were evaluated in terms of their utility for case management by accident insurance administrators using a checklist. Project implementation and procedures were documented and evaluated using semi-structured interviews with social services staff and accident insurance employees. Through the model, a comprehensive care for accident patients could be reached. In one third of all cases reviewed, rehabilitation management could be improved by including hospital social services. Moreover, in one third of all cases, care-related activities initiated by accident insurance funds could be reduced by involving local hospital social services. The report form used by hospital social services was evaluated as a useful tool in the context of patient care and rehabilitation management. The model was evaluated by interview participants as a highly targeted approach in accident patients' care management. Implications of the study for improving health care are discussed.

Objective To evaluate a newly developed education programme for Parkinson's disease (PD) patients. Methods The programme consisted of eight sessions and aimed at improving knowledge and skills related to self-monitoring, health promotion, stress management, depression, anxiety, social competence, and social support, all with special reference to PD. The programme was formatively evaluated in seven European countries (Spain, Finland, Italy, The Netherlands, United Kingdom, Estonia, Germany) with 151 patients diagnosed with idiopathic PD. The evaluation included patients’ ratings of the comprehensibility and feasibility of the programme as well as mood ratings before and after each session. Patients also completed questionnaires at the beginning and end of the programme to explore possible changes in disease-related psychosocial problems, quality of life, and depression. Results The programme was feasible to run, and patients were able to understand its elements. Patients reported mood elevations following individual sessions and reduced disease-related psychosocial problems after completing the programme. There were no substantial differences in results between cultures. Conclusion Patient education appears to have potential as a useful and feasible intervention, complementing medical treatment in PD. Practice implications The present programme will soon be available in seven European languages and can be tested in different health care systems.

A search for a narrow baryonic resonance decaying to K(s)(0)p or K-s(0)(p) over bar is carried out in deep inelastic ep scattering with the H1 detector at HERA. ss Such a resonance could be a strange pentaquark Theta(+), evidence for which has been reported by several experiments. The K(s)(0)p and K-s(0)(p) over bar invariant ss mass distributions presented here do not show any significant peak in the mass range from threshold up to 1.7 GeV. Mass dependent upper limits on sigma(ep -> e Theta X+) x BR(Theta(+) -> K(0)p) are obtained at the 95% confidence level.

Measurements are presented of inclusive charm and beauty cross sections in e^+p collisions at HERA for values of photon virtuality 12 \le Q^2 \le 60 GeV^2 and of the Bjorken scaling variable 0.0002 \le x \le 0.005. The fractions of events containing charm and beauty quarks are determined using a method based on the impact parameter, in the transverse plane, of tracks to the primary vertex, as measured by the H1 vertex detector. Values for the structure functions F_2^{c\bar{c}} and F_2^{b\bar{b}} are obtained. This is the first measurement of F_2^{b\bar{b}} in this kinematic range. The results are found to be compatible with the predictions of perturbative quantum chromodynamics and withprevious measurements of F_2^{c\bar{c}}.

The sociomedical evaluation by the German Pension Insurance serves the purpose of determining entitlement to disability pensions. A quality assurance concept for the sociomedical evaluation was developed, which is based on a peer Review process. Peer review is an established process of external quality assurance in health care. The review is based on a hierarchically constructed manual that was evaluated in this pilot project.The database consists of 260 medical reports for disability pension of 12 pension insurance agencies. 771 reviews from 19 peers were included in the evaluation of the inter-rater reliability. Kendall's coefficient of concordance W for more than 2 raters is used as primary measure of inter-rater reliability.Reliability appeared to be heterogeneous. Kendalls W varies for the particular criteria from 0.09 to 0.88 and reached for primary criterion reproducibility a value of 0.37.The reliability of the manual seemed acceptable in the context of existing research data and is in line with existing peer review research outcomes. Nevertheless, the concordance is limited and requires optimisation. Starting points for improvement can be seen in a systematic training and regular user meetings of the peers involved.

A search for gravitinos produced in e±p collisions is performed using the H1 detector at HERA. The data were taken at a centre-of-mass energy of 319 GeV and correspond to an integrated luminosity of 64.3 pb -1 for e+p collisions and 13.5 pb-1 for e -p collisions. If R-parity is not conserved, the t-channel exchange of a selectron can produce a neutralino, which, in models where the gravitino is the lightest supersymmetric particle, subsequently decays into a photon and a light gravitino. The resulting event signature, which involves an isolated photon, a jet and missing transverse energy, is analysed for the first time at HERA. No deviation from the Standard Model is found. Exclusion limits on the cross section and on R-parity-violating Yukawa couplings are derived in a Gauge Mediated Supersymmetry Breaking scenario. The results are independent of the squark sector. Neutralinos and supersymmetric partners of the left-handed electron with masses up to 112 GeV and 164 GeV, respectively, can be ruled out at the 95% confidence level for R-parity-violating couplings λ′ equal to 1, in some parts of the parameter space of the considered model. © 2005 Elsevier B.V. All rights reserved., 0, DESY-04-227 / hep-ex/0501030, SCOPUS: ar.j, H1 Collaboration., info:eu-repo/semantics/published

Measurements are presented of inclusive charm and beauty cross sections in e$^+$p collisions at HERA for values of photon virtuality Q$^2$ > 150 GeV$^2$ and of inelasticity 0.1 < y < 0.7. The charm and beauty fractions are determined using a method based on the impact parameter, in the transverse plane, of tracks to the primary vertex, as measured by the H1 vertex detector. The data are divided into four regions in Q$^2$ and Bjorken x, and values for the structure functions $F_2^{c\overline{c}}$ and $F_2^{b\overline{b}}$ are obtained. The results are found to be compatible with the predictions of perturbative quantum chromodynamics.

A search for scalar top quarks in R-parity violating supersymmetry is performed in e(+)p collisions at HERA using the H1 detector. The data, taken at roots = 319 GeV and 301 GeV, correspond to an integrated luminosity of 106 pb(-1). The resonant production of scalar top quarks t in positron quark fusion via an R-parity violating Yukawa coupling lambda' is considered with the subsequent bosonic stop decay t --> BW. The R-parity violating decay of the sbottom quark b --> dv(e) and leptonic and hadronic W decays are considered. No evidence for stop production is found in the search for bosonic stop decays nor in a search for the direct R-parity violating decay t --> eq. Mass dependent limits on lambda' are obtained in the framework of the minimal supersymmetric Standard Model. Stop quarks with masses up to 275 GeV can be excluded at the 95% confidence level for a Yukawa coupling of electromagnetic strength. (C) 2004 Elsevier B.V. All rights reserved.

The proton structure function F-2(x, Q(2)) is measured in inelastic QED Compton scattering using data collected with the H1 detector at HERA. QED Compton events are used to access the kinematic range of very low virtualities of the exchanged photon, Q(2), down to 0.5 GeV2, and Bjorken x up to similar to 0.06, a region which has not been covered previously by inclusive measurements at HERA. The results are in agreement with the measurements from fixed target lepton-nucleon scattering experiments. (C) 2004 Published by Elsevier B.V.

Deep-inelastic positron-proton interactions at low values of Bjorken-x down to x \approx 4.10^-5 which give rise to high transverse momentum pi^0 mesons are studied with the H1 experiment at HERA. The inclusive cross section for pi^0 mesons produced at small angles with respect to the proton remnant (the forward region) is presented as a function of the transverse momentum and energy of the pi^0 and of the four-momentum transfer Q^2 and Bjorken-x. Measurements are also presented of the transverse energy flow in events containing a forward pi^0 meson. Hadronic final state calculations based on QCD models implementing different parton evolution schemes are confronted with the data.

Cross sections for the production of two isolated muons up to high di-muon masses are measured in ep collisions at HERA with the H1 detector in a data sample corresponding to an integrated luminosity of 71 pb-1 at a centre of mass energy of √s=319 GeV. The results are in good agreement with Standard Model predictions, the dominant process being photon-photon interactions. Additional muons or electrons are searched for in events with two high transverse momentum muons using the full data sample corresponding to 114 pb-1, where data at √s=301 GeV and √s=319 GeV are combined. Both the di-lepton sample and the tri-lepton sample agree well with the predictions. © 2004 Published by Elsevier B.V., 0, DESY-03-159 / hep-ex/0311015, SCOPUS: ar.j, info:eu-repo/semantics/published

Deep-inelastic e^\pm p scattering at high squared momentum transfer Q^2 up to 30000 GeV^2 is used to search for eq contact interactions associated to scales far beyond the HERA centre of mass energy. The neutral current cross section measurements d sigma / d Q^2, corresponding to integrated luminosities of 16.4 pb^-1 of e^- p data and 100.8 pb^-1 of e^+ p data, are well described by the Standard Model and are analysed to set constraints on new phenomena. For conventional contact interactions lower limits are set on compositeness scales Lambda ranging between 1.6 - 5.5 TeV. Couplings and masses of leptoquarks and squarks in R-parity violating supersymmetry are constrained to M / lambda > 0.3 - 1.4 TeV. A search for low scale quantum gravity effects in models with large extra dimensions provides limits on the effective Planck scale of M_S > 0.8 TeV. A form factor analysis yields a bound on the radius of light quarks of R_q < 1.0 x 10^-18 m., 15 pages, 5 figures and 5 tables

As required by German law, inpatient institutions offering prevention and rehabilitation measures for mothers, fathers and children are obliged to implement external quality assurance measures. In 2 pilot projects funded by the German federal association of health insurance funds, external quality assurance procedures for in-hospital prevention and rehabilitation of mothers and fathers were analyzed with the aim of developing a set of instruments for the description of structural characteristics in this area of health care and to evaluate its appropriateness. Concerning structure-related quality, the project included a) designing and evaluating a questionnaire, b) the definition of assessment criteria for subsequent comparative data analyses, and c) the description and documentation of the current state in the field of rehabilitation and prevention for mothers, fathers and children.To document structural quality comprehensively, a modular questionnaire was developed and tested in a survey of 115 inpatient prevention and rehabilitation institutions for mothers, fathers and children. Involving an expert panel, preliminary basic and selection criteria were defined in order to assure a conducive assessment with regard to structural attributes.The majority of institutions had provider agreements for both prevention and rehabilitation. Measures for mothers/fathers with children were predominant; only 7 institutions exclusively treated mothers and fathers. Institution sizes varied strongly. Major indications included psychosomatics, dermatology, and pneumology. Overall, structural conditions of the institutions showed a high standard. Potential for development was found with regard to some aspects of the conceptual framework of institutional practice and the implementation of the International Classification of Functioning, Disability and Health (ICF) in diagnostics. In this article, the degrees of fulfillment with relation to the structural dimensions are presented, referring to the analysis of the preliminary basic criteria.The developed modular questionnaire tapping structural features of inpatient mother/father-child institutions has proven to be a useful instrument to describe the structural quality in future routine practice of quality assurance. In addition, the data can be used for the definition of the final set of criteria.

To date, there are no programs for external quality assurance for inpatient prevention and rehabilitation programs for mothers, fathers and children. Instruments for outcome quality assessment were evaluated with the goal of determining their ability to document differences between prevention/rehabilitation centers in quality-relevant outcome parameters. Referring to the ICF, relevant outcome variables were specified and operationalized using established questionnaires. Data from 45 inpatient prevention and rehabilitation centers for mothers, fathers and children were analyzed using multilevel modeling with risk adjustment. Intra-class correlations were computed to determine in which parameters differences between institutions could be found. The percentage of variability accounted for by patient vs. institution characteristics was computed while statistically controlling for relevant confounders. For prevention centers, substantial variation on the institutional level was found in 9 out of 15 parameters. Almost all institutions did not deviate significantly from the grand mean of the respective parameter. For rehabilitation centers, significant variability was found in 2 out of 10 parameters. The differences between most institutions remained within a range of expectable variability. The results imply that comparative analyses across hospitals are better suited to identify institutions with low quality rather than establish quality-based rankings of institutions.

There so far is no standardized program for external quality assurance in inpatient parent-child prevention and rehabilitation in Germany. Therefore, instruments and methods of external quality assurance were developed and evaluated on behalf of the federal-level health insurance institutions.On the level of structure quality, a modular questionnaire for assessing structural features of rehabilitation/prevention centers, basic and allocation criteria as well as a checklist for visitations were developed. Structural data were collected in a nationwide survey of parent-child prevention and rehabilitation centers. Process and outcome quality data were collected in n=38 centers. Process quality was assessed using multiple methods (process-related structural features, case-related routine documentation, and incident-related patient questionnaires). Outcome quality was measured via patient questionnaires (n=1 799 patients). We used a multi-level modelling approach by adjusting relevant confounders on institutional and patient levels.The methods, instruments and analyzing procedures developed for measuring quality on the level of structure, processes and outcomes were adjusted in cooperation with all relevant stakeholders. Results are exemplarily presented for all quality assurance tools. For most of the risk-adjusted outcome parameters, we found no significant differences between institutions.For the first time, a comprehensive, standardized and generally applicable set of methods and instruments for routine use in comparative quality measurement of inpatient parent-child prevention and rehabilitation is available. However, it should be considered that the very heterogeneous field of family-oriented measures can not be covered entirely by an external quality assurance program. Therefore, methods and instruments have to be adapted continuously to the specifics of this area of health care and to new developments.

Vocational orientation in medical rehabilitation has become an important issue in rehabilitation science and practice in Germany. Although a variety of vocationally oriented interventions has been developed in recent years, there is still a lack of consensus with regard to the definition of specific types of interventions as well as relevant criteria (e. g., methods; instruments; duration/frequency; patient groups). Building on preliminary definitions, basic types of vocationally oriented measures/interventions were conceptually modified and refined in the context of a consensual process. 39 experts of various professions were contacted during a 2-stage Delphi survey to evaluate existing definitions of vocationally oriented interventions using key questions. Standardized descriptions of 5 vocationally oriented basic interventions were specified in cooperation with an interdisciplinary panel of experts. Descriptions were published in a workbook and a homepage for researchers and clinicians, which also contain information on the implementation of measures into rehabilitative care as well as good practice examples. The media developed in this project may contribute to the transfer of research results on vocationally oriented rehabilitation into health care practice.

The aim of this paper is to outline a current trend in inpatient medical rehabilitation in Germany, i.e. vocationally oriented medical rehabilitation (VOMR). Since employment-related demands and challenges pose a potential source of strain regarding employees' health and work ability, rehabilitative treatment in Germany is increasingly geared towards including work-related issues in diagnostics and therapy. To date, German rehabilitation research and practice have focussed primarily on the development of screening instruments for identifying vocational problems, interface management and inter-sectoral cooperation and the specification and standardisation of vocationally oriented interventions and programmes (e.g. work hardening, group interventions). Further developments in VOMR should examine the varying needs of patients for work-related interventions as well as the neglect of specific subgroups of patients (e.g. long-term unemployed) and topics (e.g. interference between work and other life domains).

In the context of medical rehabilitation quality assurance, the use of screening procedures aims at specifically screening for rehabilitative cases that might be affected by quality problems. These may then be subjected to more elaborate quality management procedures. In the study presented, a criteria-based screening checklist designed to tap potential quality problems among rehabilitative cases in the German statutory accident insurance medical rehabilitation system was evaluated regarding its validity and suitability for routine use. Checklists were filled out by accident insurance administrators in three regional insurance funds who were instructed to evaluate all current rehabilitation cases (n=189) with regard to potential quality problems. For validation of the instrument, case reviews by physicians familiar with medical and administrative features of the accident insurance rehabilitation system were used. About a fifth of all cases reviewed using the screening checklist (22%) were classified as potentially problematic in terms of quality. Absence of relevant documents, delays in document receipt, and complications during treatment were cited as the most frequent problems. Concordance between the screening checklist and physicians' ratings concerning the quality of rehabilitative cases was moderate. Sensitivity and specificity were insufficient when using physicians' ratings as a validation criterion (0.53 and 0.56, respectively). Accident insurance administrators rated the screening checklist as a useful and practical quality management instrument. Concerning its insufficient validity using physicians' ratings as a validation criterion, the suitability of the checklist as a screening instrument is questionable. The instrument's potential of introducing the accident insurance administrators' expertise and knowledge into medical rehabilitation quality management strategies is highlighted. Further research on methodological aspects of the instrument as well as its content features is warranted. Starting points for modifications are outlined.