Impfhindernisse und ihre Auswirkung auf das Praxismanagement und die Impfquoten in Deutschland

Einleitung Im Jahr 2015 sollten die Masern in Deutschland ausgerottet sein. Es wurden im selben Jahr jedoch 2604 Fälle an das RKI gemeldet. Auch von anderen impfpräventablen Krankheiten gab es immer wieder Ausbrüche. Fragestellung Ziel dieser Arbeit war es Impfhindernisse, die scheinbar einen Einfluss auf die Impfquoten haben, zu identifizieren und nach ihrer Relevanz im Praxisalltag niedergelassener Ärzte zu beurteilen. Methoden Durch eine Literaturrecherche wurden 15 Impfhindernisse identifiziert. Ein Fragebogen wurde an Kassenärztliche Vereinigungen, Berufsverbände, Pharmafirmen und Bundesverbände der Krankenkassen versendet. Danach begannen wir mit einer Online-Umfrage niedergelassene Ärzte (Hausärzte, Gynäkologen und Kinder- und Jugendmediziner) zu befragen, um die Relevanz von 17 Impfhindernissen zu beurteilen. Ergebnisse Der erste Fragebogen zeigte zwei weitere Impfhindernisse, die für niedergelassene Ärzte relevant erschienen. Diese wurden in die Online-Umfrage mit aufgenommen. Von 527 Datensätzen wurden nur die vollständigen berücksichtigt. Es wurden 465 Datensätze analysiert, davon waren 51% von Hausärzten, 34% von Gynäkologen und 13% von Kinder- und Jugendmedizinern. Die Impfhindernisse wurden in zwei Gruppen aufgeteilt: intrinsische Impfhindernisse, die innerhalb des Impfsystems wirken und extrinsische Impfhindernisse, die von außen auf das Impfsystem wirken. Dabei zeigte sich, dass vor allem die ungenügende Bezahlung der Impfung (47% relevant vs. 41% nicht relevant) aber besonders der Impfberatung (66% vs. 25%) einen hohen Stellenwert hat. Außerdem wurde die Diskrepanz zwischen den Impfempfehlungen und der Kostenübernahme (57% vs. 30%), Impfvereinbarungen zwischen Krankenkassen und KVen (53% vs. 33%) und die Verzögerung der Übernahme von Impfempfehlungen durch die Bürokratie (46%vs. 38%) als relevante intrinsische Impfhindernisse eingestuft. Zusätzlich sehen sich die niedergelassenen Ärzte von außen noch mit Impfgegnern unter den Pateinten (78% vs. 21%) und Ärzten (50% vs. 41%) sowie eingeschränkter Verfügbarkeit der Impfstoffe (54% vs. 36%) konfrontiert. Nur ein Teil der Ärzte nutzt die Unterstützung durch Impfsoftware beim Impfmanagement. Schlussfolgerung Mit kurzfristigen Lösungen müssen die wichtigsten Imfhindernisse angegangen werden. Dazu gehört eine Vergütung der Impfberatung sowie Schulung im Umgang mit Impfgegnern. Langfristig muss die Bürokratie abgebaut, sowie die kontinuierliche Versorgung mit Impfstoffen sichergestellt werden. Dazu müssen Politik, Kassen, KVen und Pharmafirmen eng zusammenarbeiten und dürfen dabei die niedergelassenen Ärzte nicht vergessen.Introduction: In 2015 measles should have been eliminated in Germany, but 2604 cases of infection with measles were reported. Moreover, there are outbreaks of other diseases that could be prevented by vaccinations. Aims: The purpose of this study was to investigate the effects of obstacles to vaccination (OV), which prevent resident physicians from high vaccination rates. Methods: In a literature review 15 OVs were identified. A questionnaire was sent to the Associations of Statutory Health Insurance Physicians (ASHIP), professional associations of resident physicians, pharmaceutical companies and associations of health insurance companies. Afterwards we started an online-survey among resident physicians (general practitioners, gynecologists and pediatricians) to assess the relevance of 17 OVs. Results: The questionnaire revealed two more OVs, which seemed to be relevant for resident physicians and were included into the online-survey. Out of 547 participants, 62 were excluded due to missing data. The remaining 465 data sets (51% general practitioners, 34% gynecologists and 13% pediatricians) were analyzed using the software EXCEL. The OVs were divided in two groups: intrinsic OVs, which act inside the vaccination system and extrinsic OVs, which influence the vaccination system from outside. Inadequate payment of vaccination advice (66%relevant vs. 25% not relevant) and inadequate payment of vaccination (47% vs. 41%) have high priorities. Also, the discrepancy between recommendation and assumption of costs (57% vs. 30%), vaccination agreement between ASHIP and health insurance companies (53% vs. 33%) and the delayed takeover of current vaccination recommendations because of bureaucracy (46% vs. 38%) are relevant intrinsic OVs. Additionally, there are opponents of vaccination among patients (78% vs. 21%), procurement problems of vaccines (54% vs. 36%) and opponents of vaccination among colleagues (50% vs. 41%) resident physicians have to deal with as an extrinsic OV. Only a small percentage of the physicianshas adopted vaccination-software in order to simpplify vaccination-management. Conclusion: Short term solutions need to be developed to counteract most important OVs, such as an adequate payment of vaccination advice and training to deal with opponents of vaccination. In the long term unnecessary bureaucracy must be reduced and the procurement of vaccines must be ensured. For this, politics, health insurance companies, ASHIPs and pharmaceutical industry have to cooperate and need to take into account the opinions of resident physicians

Concentric Scanning Strategies for Laser Powder Bed Fusion: Porosity Distribution in Practical Geometries

Besides the optimisation of process parameters such as laser power or scan speed, the choice of the scan path represents a possibility to optimise the laser powder bed fusion process even further. The usual hatching strategy creates a homogeneous microstructure but makes it necessary to switch the laser off and on after each scan vector, which can slow down the fabrication. Moreover, the end of each scan vector is a location susceptible to the creation of keyhole pores. In this work, these disadvantages were meant to be avoided by using scan strategies that consist of longer paths and thus less end of track points. To this end, an open-source tool to tailor the LPBF G-code to geometric part features and advanced path configurations was developed and embedded into a co-visualization platform. With this tool, specimens built with four different types of paths were fabricated and the effect of these alternative scan strategies on pore distributions and path neighbourhood was investigated using micro-computed tomography. In the examined example geometry, a spiral scan pattern reduced the distance the laser had to jump between scanning by 78%. However, with the alternative path patterns, the defect architecture was strongly dependant on the part geometry and increased the overall porosity to 0.42%. Respective alleviation approaches are therefore necessary and are discussed in the remainder of this work

Semi-solid wire-feed additive manufacturing of AlSi7Mg by direct induction heating

In this study, a novel process is presented in which direct induction heating with frequencies in the MHz range is used for the wire-feed additive manufacturing of the alloy AlSi7Mg. The high frequency of 1.5 MHz enables processing of 1.2 mm diameter wires without the need for indirect heating via a nozzle. The feasibility of the process is proven by the experimental identification of a proper process window regarding the influential parameters such as the distance between inductor and substrate, induction power and wire feed rate for the fabrication of single layers. Furthermore, a strategy for the successful fabrication of multi-layered cubes is developed. The microstructure of the cubes exhibits a characteristic variation along the build direction. Micro-computed tomography is used to reveal defects like lack of fusion and spherical pores in test cubes. The presented results are used to derive possible process improvements, which will allow the novel process to be used as a fast and powder-free alternative metal additive manufacturing route in future

Автономное устройство освещения на базе микроконтроллера ATmega

Объектом исследования является автономное устройство освещения, на основе 8-битного микроконтроллера AVR типа ATmega16. Цель данной работы: Создать устройство, включающее на непродолжительное время светодиод с повышенной яркостью. Устройство предназначено для кратковременного освещения, гаражей, лестничных клеток, частных квартир, замочных скважин, путей выхода и т.п. Включение устройства происходит бесконтактно в момент, когда перемещение объекта фиксируется датчиком движения (ДД). Для обеспечения автономности устройство должно быть с батарейным, либо аккумуляторным питанием. Основное требование к разработанной схеме – обеспечить минимальное потребление в режиме покоя.The object of study is an Autonomous lighting device based on an 8-bit microcontroller AVR type ATmega16. The purpose of this work: to Create a device, including for a short time, the led with increased brightness. The device is intended for short-term lighting, garages, stairwells, private apartments, keyholes, ways out, etc. enabling the contactless device occurs at a time when the moving object is recorded by a motion sensor (DD). To ensure the autonomy of the device must be battery-or battery-powered. The main requirement for the developed scheme to ensure a minimum consumption in rest mode

Об актуальности создания конфедеративного государства на постсоветском пространстве

Затяжной системный кризис на постсоветском пространстве, санкции против России заставляют искать выход из сложившейся ситуации. Мы предположили, что экономические предпосылки и сформировавшееся мнение большинства способствует созданию нового конфедеративного государства, включающего в себя большинство стран бывшего СССР и, возможно, другие союзные страны. В ходе проведенного исследования и состоявшегося социального опроса данное предположение было подтверждено

Hybrid material additive manufacturing: interlocking interfaces for fused filament fabrication on laser powder bed fusion substrates

The fabrication of polymer–metal hybrids in an additive process makes it possible to further improve the geometrical and material adaption in a multi-material design. In this work, PLA is fabricated through a fused filament fabrication process on AlSi10Mg structures manufactured by laser powder bed fusion. The mechanical connection is realised by form fit, for which different geometries are examined through tensile tests. Deep penetration of the PLA into the metallic structures is achieved by optimisation of the process parameters. The penetration depth is assessed through the use of micro-computed tomography. Finally, the interplay of mechanisms leading to a firm connection is discussed

Dynamics of M-Theory Cosmology

A complete global analysis of spatially-flat, four-dimensional cosmologies derived from the type IIA string and M-theory effective actions is presented. A non--trivial Ramond-Ramond sector is included. The governing equations are written as a dynamical system. Asymptotically, the form fields are dynamically negligible, but play a crucial role in determining the possible intermediate behaviour of the solutions (i.e. the nature of the equilibrium points). The only past-attracting solution (source in the system) may be interpreted in the eleven-dimensional setting in terms of flat space. This source is unstable to the introduction of spatial curvature.Comment: 13 pages, 4 Postscript figures, uses graphics.sty, submitted to Phys. Rev.

Bent Domain Walls as Braneworlds

We consider domain walls embedded in curved backgrounds as an approximation for braneworld scenarios. We give a large class of new exact solutions, exhausting the possibilities for describing one and two walls for the cases where the curvature of both the bulk and the wall is locally constant. In the case of two walls, we find solutions where each wall has positive tension. An interesting property of these solutions is that the curvature of the walls can be much smaller than the tension, leading to a significant cancellation of the effective cosmological constant, which however is still much larger than the observational limits. We further discuss some aspects of inflation in models based on wall solutions.Comment: 26 pages, latex, no figures, corrected few typos, as accepted for publication in Phys. Rev.

Mechanisms of cardiac arrhythmias.

This is the final version of the article. It was first available from Elsevier via http://dx.doi.org/10.1016/j.joa.2015.11.003Blood circulation is the result of the beating of the heart, which provides the mechanical force to pump oxygenated blood to, and deoxygenated blood away from, the peripheral tissues. This depends critically on the preceding electrical activation. Disruptions in the orderly pattern of this propagating cardiac excitation wave can lead to arrhythmias. Understanding of the mechanisms underlying their generation and maintenance requires knowledge of the ionic contributions to the cardiac action potential, which is discussed in the first part of this review. A brief outline of the different classification systems for arrhythmogenesis is then provided, followed by a detailed discussion for each mechanism in turn, highlighting recent advances in this area.The author received a BBSRC Doctoral CASE Studentship at the Department of Biochemistry, University of Cambridge, in conjunction with Xention Discovery, for his PhD studies