Hypertension guidelines and their effects on the health system

Introduction: Hypertension guidelines, which have existed for many years and primarily used in the USA, Canada and Great Britain, are now becoming an issue in Germany. Strong efforts are presently underway for a German version comparable to the guidelines developed for the mentioned countries. The development of guidelines is a part of the implementation system of guidelines in Germany. It covers the mode of operation of the AWMF (work community of the scientific medical subject companies) with the clearinghouse for guidelines (CLA) and the cooperation with the centre for medical quality (ÄZQ). In the HTA report the real use of the hypertension guidelines shall be investigated for Germany from the development trends and further possibilities of use according to a medical applicability. Economic issues and an optimisation of use are also discussed. Question: The following questions shall be answered in particular: 1. How much are the guidelines used concerning hypertension? 2. Can effects (or their influence) be established on the medical procedures? 3. Are there statements available about costs and cost effectiveness? 4. Are there recommendations for further use? Methodology: To answer these questions, a comprehensive literature search was done. No empirical investigation was carried out. From this enquiry 206 articles were checked in detail but not all of them were available in full text. Only those publications which directly dealt with high blood pressure guidelines or articles with a direct reference to the topic have been considered in the HTA report. Publications concerning screening or methods of prevention, medical studies of the hypertension syndrome without a direct reference to guidelines and publications concerned with putting guidelines into action were excluded. Results: After an analysis of the selected literature addressing the topic of hypertension guidelines, it was evident that the use of these guidelines cannot be gathered from existing literature at the present time. One can assume from international studies with analogical reasoning that these are confessed and have a high level of acceptance in the medical community. Unfortunately the actual usage is not represented satisfactorily in the scientific literature. The effects of the guidelines on the medical procedures seem to be very strongly individual and the analyses to the compliance show at least an observable effect within the last few years. No publications could be found for the cost effectiveness of the guidelines. The actual compliance with guidelines seems to be in relation with the duration of the professional practice. It seems the shorter the professional practice takes place, the stronger the guidelines are adhered. Discussion: At present, there are only a few notes for the German health service regarding the actual effect of the hypertonus guidelines. However, the reason is not that the effect would not be possibly strong but at the methodical challenge to evaluate the sustaining effects of the application of the hypertonus guidelines. For this reason the literature is very rare regarding this topic. For Germany it can be derived by analogical reasoning from foreign studies that guidelines will facilitate a more and more essential contribution to the design of the health system. Considering that primarily younger physicians accepted guidelines mode, the further construction, update and implementation of guidelines are essential, particularly with regard to the quality assurance. Straight guidelines can express a standard of the quality of a health system as a benchmark. The existence of guidelines or the lack thereof is considered also as a quality indicator of a health system at the organisation for economic cooperation and development (OECD). Conclusion: Guidelines should be evaluated - especially the hypertonus guideline. Also further development and implementation should be emphasised. Methodically oriented work to the approach is pretty recent. It is undeniable that guidelines represent a very essential and important contribution for the successful dealing with significant morbidity problems in a health system. The fact that primarily younger doctors more frequently adopt, employ and adhere to guidelines leads to the assumption that expected sustainability for practical use will increase. Furthermore intensified use of guidelines can be considered in the "mainstream" of the development of the public health system also in an international perspective. Not one single publication contradicts that a further acquirement, update and distribution of guidelines for the use of practices is necessary. The importance of the guideline is also not questioned in any article

Cognitive training for dementia

The aim of the HTA report is to evaluate the effectiveness of cognitive training methods to treat cognitive disorders of dementia and other diseases with cognitive deficits. For this purpose, a systematic literature search was carried out first based on the DIMDI superbase retrieval. The identified publications were judged and selected by two independent, methodically competent experts. 33 publications were included in the report

Voyages Between France and Ireland: Culture, Tourism and Sport

The voyage – the quest, the odyssey, the expedition – is one of the driving forces of civilisation. From ancient times to the present day, human beings have travelled through necessity (wars, persecutions, economic and political pressures), by vocation (religious and humanitarian) and for pleasure (tourism, culture and sport). A voyage intensifies our perception of self, leading us to define and redefine our identity in the liminal space where we are confronted with the Other. This often leads to a change of perspective in our attitudes to culture, identity and politics. The sea is an important feature of the geography of both Ireland and France, so it is perhaps unsurprising that voyages occupy such an important place in the history of both countries. This volume explores aspects of French and Irish society, past and present, through the prism of the voyage. The contributors focus on a wide range of topics, including cultural tourism, literature, gastronomy and sport, in order to trace the ebb and flow of the exchanges between these two countries and their continued influence on one anotherhttps://arrow.tudublin.ie/afisbo/1003/thumbnail.jp

The treatment of Parkinson's disease with dopamine agonists

Parkinson’s disease is a chronic degenerative organic disease with unknown causes. A disappearance of cells with melanin in the substantia nigra is considered as biological artefact of the disease, which causes a degenerative loss of neurons in the corpus striatum of mesencephalon. This structure produces also the transmitter substance dopamine. Due to this disappearance of cells dopamine is not produced in a sufficient quantity which is needed for movement of the body

Bypass operation at the beating heart in comparison to the operation with support of the heart-lung machine

The coronary Bypass operation at the beating heart ("off-pump surgery") is a new procedure which promises advantages in comparison to the established procedure with uses a heart-lung machine ("on-pump-surgery")

Beschäftigungsbeitrag des Mittelstands 2007 in Deutschland: Ergebnisse einer Sonderauswertung der Beschäftigtenstatistik der Bundesagentur für Arbeit

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Therapy of unspecific tinnitus without organic cause

Introduction: There is a variety of medical and non-medical therapies in practice, which were not evaluated regarding its effectiveness by any systematic evidence oriented investigation. A number of therapies of medical and non-medical type try to treat the different types of tinnitus. The evidence in the scientific literature also had to be cleared in the field of diagnosis and classification as well as medical/psychiatric/psychological procedures of existing medical therapy. Question: The HTA report had to investigate the following questions: * Which evidence do diagnostic methods in recognition of tinnitus have? * Which types of therapy show medical effectiveness at the acute or chronic tinnitus without an organic cause? * Which consequences (need for further research, future procedures) can be drawn? Methodology: In the following databases "tinnitus" was searched according to the search string:HTA97; INAHTA; CDAR94; CDSR93; CCTR93; ME66; ME0A; HT83; SM78; CA66; CB85; BA70; BA93; EM74; IS74; ET80; EB94; IA70; AZ72; CV72; GE79; EU93; HN69; ED93; EA08 Result: 1932 studies, unsorted after assessment in accordance with EBM criterions, selection: 409 studies. Due to the completely heterogeneous representation modes of the therapeutic approaches at the treatment of the chronic tinnitus no quantitative synthesis method could be performed. Therefore the methodology of a qualitative overview has been carried out. Results: The diagnostic confirmation of the non-specific tinnitus without organic cause meets with the problem of the assurance of the diagnosis tinnitus. According to the current opinion the stepwise diagnostics is carried out also in the case of the so called subjective tinnitus. Nothing can be said about the evidence of these procedures since no publication was found about that. A study concerning the evidence of the diagnostic questionnaires from Goebel and Hiller [1] comes to the end that the tinnitus questionnaire frequently used (TF) [2] is the best evaluated procedure. The number of therapies which treat tinnitus is exceptionally high and makes clear, that the search for "the" tinnitus therapy is still going on. According to the current knowledge tinnitus genesis is multifactorial and therefore there can’t be any standard therapy for tinnitus. The following seven categories can be distinguished: Ad 1: Machine-aided acoustic therapies: From many studies regarding machine-aided acoustic therapy of tinnitus only two showed an evidence degree that allows scientifically correct statements about the effectiveness of these procedures. Selectively significant improvements could be shown in the comparison with a placebo (apparatus switched off) a superiority of tinnitus-maskers. Ad 2: Electrostimulation: In an application study of electro-stimulation the results were not evaluated statistically, but it was described descriptively that a successful medical treatment can be expected in about 50% of the cases. Ad 3: Psychological therapy procedures: Hypnosis did not show positive effectiveness. With regard to biofeedback it can be concluded that this method can be effective in individual cases, however regarded as unreliable from missing reproducibility. Neurobiofeedback could prove that it had a positive therapeutic effect. From eight controlled studies to relaxation techniques and cognitive behaviour therapy four studies showed a therapeutic effectiveness and four failed. Combined therapies proved generally to be more effective than individual types. The behaviour medical psychotherapy could show a positive therapy effect. In a study with cognitive therapy and relaxation (three groups, a passive relaxation, an active relaxation and a cognitive therapy) short-term successes could be stated (for one month), however, the parameters of success returned on the initial value after four months. Also only coincidental and short-term successes could be achieved with cognitive behaviour therapy training, autogenic training and structured group psychotherapy. Ad 4: Tinnitus Retraining Therapy (TRT): Unfortunately, the published results of the TRT are methodically frequently bad and scientific of a poor value. Many of the studies presented until now regarding tinnitus retraining therapy are not informative in their scientific context. In a study with 95 patients with a chronic tinnitus TRT could show a significant, more than six months lasting stable success by comparison to a combination of TET with group behaviour therapy (improvement be achieved around at least ten points in the tinnitus questionnaire (TF)). Ad 5: Pharmacological therapies: Rheological drugs (medicines for hemodilution) could not show any statistically significant effect in the treatment of tinnitus. Studies to the medical treatment with tocainides (lidocaine) showed repeatable positive effects on tinnitus in higher dosages (as of 1.2 mg/day). Lamotrigine as a medicine had an effect positively only at with a small fraction of patients. Two studies with GABA receptor agonists could not prove therapeutic effects for tinnitus. Undesired side-effects were observed. Injections with Carvoverine (a glutamate antagonist) achieved significantly successes with a special form of tinnitus, the “Cochlear-synaptic tinnitus (CST)". A tricyclic antidepressant (Amitriptilin) could prove superiority against placebo. This effect could be confirmed in another study. However Clonazepame (a benzodiazepine), could not achieve any improvement. Short-term improvements were achieved with other benzodiazepines (Clonazepame, Diazepam, Flurazepame, Oxacepame and Alprazolame). A German retrospective study suggests a graded pharmacological therapy by means of rheological infusion therapy, applications of neurotransmitters, and injections of lidocaine. This method achieved a disappearance or a recovery of the complaints at 95.3% of the acute and 26.7% of the chronic cases. Ad 6: Surgical procedures: The effects of the operative excision of the stapes (stapedectomy) showed significant effects concerning tinnitus. This method is a routine operation to recover hearing, effects on tinnitus were observed only coincidently. There are generally high frequencies of improvements of tinnitus after cochlea implantations; however the risk of deterioration is present with this method. Ad 7: Other and alternative therapy procedures: The hyperbaric oxygen therapy can be considered successful after acute events with tinnitus. The therapy should be started in the first month after appearance of the tinnitus. The methods transcranial-, electromagnetic and transcutaneous nerve stimulations did not show any significant effects on tinnitus. Also low laser medical treatment showed disappointing effects. The “pneumatic external contra-pulsation” is described as an unproblematic usable procedure by the authors of the examination, but 10% of the patients had to stop the medical treatment because of complications associated with the medical treatment .Acupuncture showed significant improvements in comparison to medical treatment. The effectiveness of this therapy could not be reproduced in another study. Five other studies between 1993 and 1999 also did not show any therapeutic effect of this method. Gingko-Biloba preparations did not show any positive effects in large-scale studies on tinnitus. Discussion: Neither the diagnostic procedures nor the therapeutic methods or the individual therapies reach a usual scientific level in medicine. Unsolved problems concerning insurance, economic as well as legal problems have resulted for the patients and for caring stuff from this unsatisfactory situation. Numerous competitive tinnitus emergence models led to an incredible creativity in trying out different therapy approaches. No convergence of the therapy procedures can be seen within the last decades of tinnitus research, contrariwise there is always more and more “creativity” of new approaches. Priority has to be given to find the cause of tinnitus since therapies are a consequence of a better understanding of these symptoms that evidence oriented investigations on an usual scientific level can be started. Conclusion: The innumerable therapeutic approaches, seeming completely incoherent to their effects should be coordinated on the meaningfulness, on the success parameters and with patient safety in light of the most plausible explanation models for non-specific chronic Tinnitus. To this the facilities of competence centres or related science- directing facilities are recommendable. Examinations which are carried out also with small numbers show often methodical insufficiencies. It is necessary that minimal requirements on a scientifically clinical experiment, such as design, case number calculation, analytic statistics, control group, are fulfilled. It is recommendable, that further research has to be promoted regarding tinnitus causes that a coordinated evidence-orientated treatment will be developed

Sorptive removal of short‑chain perfluoroalkyl substances (PFAS) during drinking water treatment using activated carbon and anion exchanger

Laboratory tests and column tests were carried out in a waterwoks to investigate the removal of short- and longchain PFAS using activated carbon filtration and ion exchange treatment. For all adsorbents, the sorption affinity of short-chain per- and polyfluoroalkyl carboxylic acids (PFCA) was significantly lower than that of long-chain PFAS or short-chain per- and polyfluoroalkyl sulfonic acids (PFSA). In the PFAS-polluted groundwater matrix, the short-chain PFCA PFBA and PFPeA could only be sufficiently removed with activated carbon over short run times of 6000 and 11,000 bed volumes (BV), respectively. Longer PFCA with a chain length of C6 or more were removed over longer run times. The removal of short-chain PFCA using ion exchange media could also only be achieved over relatively short run times of 5000 BV for PFBA, 10,000BV for PFPeA and 18,000 BV for PFHxA. These are sometimes significantly longer than those of activated carbon. Due to the higher material costs for ion exchange media, there are nevertheless no lower operating costs when the ion exchangers are used in single-use mode. However, ion exchangers can be regenerated and then reused which can result in economic advantages compared to activated carbon filtration. However, for the extensive regeneration, especially for the elution of the long-chain PFAS, the additional use of ethanol is needed in the process. In contrast, the short-chain PFBA and PFPeA can be extracted without organic solvent from a weakly basic ion exchanger

Explicit Substitutions for Contextual Type Theory

In this paper, we present an explicit substitution calculus which distinguishes between ordinary bound variables and meta-variables. Its typing discipline is derived from contextual modal type theory. We first present a dependently typed lambda calculus with explicit substitutions for ordinary variables and explicit meta-substitutions for meta-variables. We then present a weak head normalization procedure which performs both substitutions lazily and in a single pass thereby combining substitution walks for the two different classes of variables. Finally, we describe a bidirectional type checking algorithm which uses weak head normalization and prove soundness.Comment: In Proceedings LFMTP 2010, arXiv:1009.218