Spatial competition between health care providers: effects of standardization

In the international health care literature there is a broad discussion on impacts of competition in health care markets. But aspects of standardization in regional health care markets with no price competition received comparatively little attention. We use a typical Hotelling-framework (reference case) to analyze a regional health care market with two health care providers competing in (vertical) quality after the scope of medical treatment is set (horizontal quality). We conclude, that in the reference case both health care provider will use vertical quality to separate from each other. In the next step (standardization case) we introduce one health care provider to be the standard leader in vertical quality. In the standardization case a more homogeneous supply can be expected. But, there is a higher possibility that the standard follower has to leave the regional health care market. --

Wettbewerbliche Auswirkungen eines nichtneutralen Internets

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Spatial competition between health care providers: effects of standardization

In the international health care literature there is a broaddiscussion on impacts of competition in health care markets. But aspects of standardization in regional health care markets with no price competition received comparatively little attention. We use a typical Hotelling-framework (reference case) to analyze a regional health care market with two health care providers competing in (vertical) quality after the scope of medical treatment is set (horizontal quality). We conclude, that in the reference case both health care provider will use vertical quality to separate from each other. In the next step (standardization case) we introduce one health care provider to be the standard leader in vertical quality. In the standardization case a more homogeneous supply can be expected. But, there is a higher possibility that the standard follower has to leave the regional health care market

Functional results after chest wall stabilization with a new screwless fixation device

OBJECTIVES This is the experience with the Stratos system in two surgical centres for the management of two types of rib fractures: flail chest and multiple dislocated rib fractures with significant chest wall deformity. METHODS From January 2009 to May 2012, 94 consecutive patients were included. Selected indications were extended anterolateral flail chest (n = 68) and dislocated painful rib fractures (n = 26). The open reduction internal fixation (ORIF) system consists of flexible titanium rib clamps and connecting plates. The postoperative course was assessed. Clinical and functional outcomes were evaluated at 6 months. Functional assessment consisted of measurement of the functional vital capacity (FVC) and magnetic resonance imaging (MRI) examination with determination of the radiological vital capacity (rVC) in patients with a flail chest. RESULTS The median operation time and length of hospital stay were 122 min and 19 days, respectively, in patients with a flail chest, and 67 min and 11 days, respectively, in patients with dislocated painful rib fractures. The morbidity rate was 6.4% and the overall 30-day mortality rate was 1.1%. Clinical evaluation and pulmonary function testing at 6 months revealed no deformity of the chest wall, symmetrical shoulder girdle mobility in 88% and a feeling of stiffness on the operated side in 19% of the patients operated for a flail chest. Median ratio of FVC was 88%, not suggesting any restriction after stabilization. MRI was performed in 53% (36 of 68) of the patients with a flail chest. The analysis of the rVC showed, on average, no clinically relevant restriction related to the operation, with a mean rVC of the operated relative to the non-operated side of 92% (95% confidence interval: 83, 100). Stabilization of more than four ribs was associated with a lower median rVC than stabilization of four or less ribs. CONCLUSIONS Our results suggest that stabilization of the chest wall with this screwless rib fixation device can be performed with a low morbidity and lead to early restoration of chest wall integrity and respiratory pump function, without clinically relevant functional restriction. Owing to the simplicity of the fixation technique, indications for stabilization can be safely enlarged to selected patients with dislocated and painful rib fracture

Smad7 in T cells drives T helper 1 responses in multiple sclerosis and experimental autoimmune encephalomyelitis

Autoreactive CD4+ T lymphocytes play a vital role in the pathogenesis of multiple sclerosis and its animal model, experimental autoimmune encephalomyelitis. Since the discovery of T helper 17 cells, there is an ongoing debate whether T helper 1, T helper 17 or both subtypes of T lymphocytes are important for the initiation of autoimmune neuroinflammation. We examined peripheral blood CD4+ cells from patients with active and stable relapsing–remitting multiple sclerosis, and used mice with conditional deletion or over-expression of the transforming growth factor-β inhibitor Smad7, to delineate the role of Smad7 in T cell differentiation and autoimmune neuroinflammation. We found that Smad7 is up-regulated in peripheral CD4+ cells from patients with multiple sclerosis during relapse but not remission, and that expression of Smad7 strongly correlates with T-bet, a transcription factor defining T helper 1 responses. Concordantly, mice with transgenic over-expression of Smad7 in T cells developed an enhanced disease course during experimental autoimmune encephalomyelitis, accompanied by elevated infiltration of inflammatory cells and T helper 1 responses in the central nervous system. On the contrary, mice with a T cell-specific deletion of Smad7 had reduced disease and central nervous system inflammation. Lack of Smad7 in T cells blunted T cell proliferation and T helper 1 responses in the periphery but left T helper 17 responses unaltered. Furthermore, frequencies of regulatory T cells were increased in the central nervous system of mice with a T cell-specific deletion and reduced in mice with a T cell-specific over-expression of Smad7. Downstream effects of transforming growth factor-β on in vitro differentiation of naïve T cells to T helper 1, T helper 17 and regulatory T cell phenotypes were enhanced in T cells lacking Smad7. Finally, Smad7 was induced during T helper 1 differentiation and inhibited during T helper 17 differentiation. Taken together, the level of Smad7 in T cells determines T helper 1 polarization and regulates inflammatory cellular responses. Since a Smad7 deletion in T cells leads to immunosuppression, Smad7 may be a potential new therapeutic target in multiple sclerosis

Erhöhung der Stickstoff-Effizienz in Maisfruchtfolgen mit Hilfe des Gülle-Strip-Till-Verfahrens

Das Gülle-Strip-Till-Verfahren kombiniert die Streifenbearbeitung mit der platzierten Gülle-Depot-Düngung. Im vorliegenden Projekt wird das Potential des Verfahrens hinsichtlich einer Erhöhung der N-Effizienz in Maisfruchtfolgen untersucht. Vorgestellt werden die methodische Vorgehensweise und Ergebnisse der Voruntersuchungen. Bisherige Ergebnisse zeigten die höchsten NO3--Auswaschungen über den Pfad des Dränabflusses bei konventioneller Bewirt-schaftung in der vegetationsfreien Zeit. Bewirtschaftungsmaßnahmen, wie die intensive Bodenbearbeitung führten zu steigenden NO3--Konzentrationen im Dränabfluss. Demgegenüber war der Einfluss von Düngungsmaßnahmen in Zeiten erhöhter Pflanzenaufnahme nicht sichtbar. Ungewöhnlich hohe NO2--Gehalte im Dränabfluss deuten auf eine Akkumulation von NO2- im Zusammenhang mit Mineralisati-onsereignissen und der Ausbringung von NH4+-haltigen Düngern hin