Biomedical subjects

M Schnabel

Publications and source records attributed to M Schnabel.

At least 19 recordsLinked to original sources

PubMed2006

Improving pathway compliance and clinician performance by using information technology.

To deliver patient-specific advice at the time and place of a consultation is an important contribution to improving clinician performance. Using computer-based decision support on the basis of clinical pathways is a promising strategy to achieve this goal. Thereby integration of IT applications into the clinical workflow is a core precondition for success. User acceptance and usability play a critical role: additional effort has to be balanced with enough benefit for the users and interaction design and evaluation should be handled as an intertwined, continuous process. Experiences from routine use of an online surgical pathway at Marburg University Medical Center show that it is possible to successfully address this issue by seamlessly integrating patient-specific pathway recommendations with documentation tasks which have to be done anyway, by substantially reusing entered data to accelerate routine tasks (e.g. by automatically generating orders and reports), and by continuously and systematically monitoring pathway conformance and documentation quality.

Academic Medical Centers↗

PubMed2006

[Development of a clinical guideline on medical rehabilitation of patients after lumbar disc surgery].

In cooperation with the Federation of German Pension Insurance Institutes (VDR) and with the VfR Norderney e. V., the university of Witten/Herdecke has developed a clinical guideline on medical rehabilitation for patients after lumbar disc surgery. Methodically, development of this guideline was based on the following three steps: (1) consideration of recent scientific literature, (2) analyses of structures and processes employed in rehab clinics, using consultations with clinic managers, with occupational groups involved in rehabilitation and analysis of patient files, as well as (3) the consensus process. One central result was the statement of substantial paucity of research on evidence for many therapeutic interventions used in orthopaedic rehabilitation of patients after lumbar disc surgery. Analyses and investigations in rehabilitation clinics showed a wide range of therapeutic interventions, used to very different extents. Development of the guideline therefore took place on the basis of consensus-based processes. Using formal consensus techniques according to recommendations of the Association of the scientific medical societies in Germany (AWMF), the guideline presented was developed in cooperation with the occupational groups involved in the rehabilitation process. Its structure focuses on the therapeutic targets, and it includes a clinical algorithm illustrating the orthopaedic rehabilitation process in a simple and understandable manner. The guideline presented is based on recent knowledge and corresponds to stage S2 of development. A further implementation project will evaluate practicability and acceptance of this guideline.

Germany↗

PubMed2006

IT support for clinical pathways--lessons learned.

Clinical pathways are an effective instrument to decrease undesired practice variability and improve clinician performance. IT applications embedded into clinical routine work can help to increase pathway compliance. Successfully implementing such applications requires both a responsive IT infrastructure and a participatory and iterative design process aimed at achieving user acceptance and usability. Experiences from the implementation and iterative improvement of an online surgical pathway at Marburg University Medical Centre have shown that pathway conformance actually could be improved by the use of IT. An analysis of the iterative design process has shown that future pathway projects can benefit from the lessons learned during this project. Based on these lessons a method for developing well adapted interaction mechanisms is presented, which is aimed at improving process alignment. Our goal is to build up a library of tested reusable components to reduce the number of iterations for pathway implementation.

Academic Medical Centers↗

PubMed2005

[Bone mineral density in postmenopausal women with proximal femoral fractures--comparative study between quantitative ultrasonometry and gold standard DXA].

INTRODUCTION: Osteoporosis associated proximal femoral fracture is a major public health problem. Diagnostic assessment includes patients history, laboratory testings and bone mineral density measurements. Hereby, dual X-ray absorptiometry (DXA) is regarded as the "Goldstandard". Quantitative ultrasonometry (QUS) of bone is a safe, simple, free of radiation, portable, cost-effective and therefore powerful diagnostic tool. QUS should be taken in account for primary assessment in patients with supposed osteoporosis in clinical practice. AIM OF THE STUDY: We performed this cross sectional pilot study to evaluate the ability of two different QUS-devices (os calcis) in comparison to DXA (lumbar spine and femoral neck) to discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls. PATIENTS AND METHODS: All together, 44 postmenopausal women were included. Of these, 22 suffered a proximal femoral fracture and were compared with 22 healthy, age- and BMI-matched controls. Bone assessments were performed by DXA (femoral neck and lumbar spine) and QUS of the heel using Achilles and Insight. RESULTS: T- and Z-Score of DXA (femoral neck) were significantly lower in women with hip fracture compared to controls (p < 0.008 and p < 0.01). QUS-Insight also revealed significantly lower values of T- and Z-Score in women with hip fracture compared to controls (p < 0.01 and p < 0.005). QUS-Achilles measurement results also comprised significant differences between the groups (T-Score und Z-Score: p < 0.02). In accordance to the T-Score (femoral neck), all three devices (DXA femoral neck, Achilles and Insight) showed an equal significant correlation (p < 0.001). The correlation in between both QUS-devices was higher (0.956; p < 0.0001) than in between DXA-results (femoral neck vs. lumbar spine, 0.577; p < 0.01). The Z-Score also showed a significant correlation. DXA (lumbar spine) didn't show any significant differences in T- and Z-Score. CONCLUSION: In comparison to the gold standard DXA (femoral neck), both QUS-devices showed an equal ability to significantly discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls. If our results are confirmed by more cross-sectional and longitudinal studies, QUS could be a helpful and valuable technique in clinical practice. Finally, all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment must be instituted.

Absorptiometry, Photon↗

PubMed2005

[Further development of the diagnosis-related groups system--fact or fiction? Differentiation of case severities in patients with proximal femoral fractures 2003-2005].

BACKGROUND: The previous system of hospital financing based on the returns (consisting of payments received minus cost of patient treatment) is undergoing considerable changes on the basis of learning to apply the new Diagnosis-Related Groups (G-DRG) system which differentiates the financial returns according to the individual severity of each case. AIM OF THE STUDY: 1. What are the differences in cost and returns when applying the G-DRG systems 2003, 2004 and 2005 to well-defined groups of patients (for example, surgery of proximal femoral fractures)? 2. The influence exercised by secondary (supplementary) diagnosis on the grouping of the patients. 3. Has the G-DRG system been appropriately developed further in respect of improved differentiation according to severity of the cases and homogenisation of the patient groups? PATIENTS AND METHODS: The study was based on comprehensive clinical data of 169 proximal femur fracture patients. We assessed the Case-Mix index, relative weights and returns, basic DRG, DRG, the number and weight of secondary diagnoses relevant for complexity and comorbidity levels (CCL), the summands of the CCL's and the resulting PCCL values (Patient Clinical Complexity Levels). The data were subjected to analysis of variance and graphically descriptive analysis. RESULTS: The effective Case Mix index decreases in the 2004 and 2005 systems compared to 2003. This is due to a significant drop in returns based on an unchanged rate of receipts of 3000 . The progressive development of the systems was partly associated with major changes in grouping without significant intra-group homogenisation or improved inter-group discrimination of indications. The differentiation process does not fully utilise the differentiation potential of the basic data. CONCLUSIONS: No definite improvement of the differentiation potential of the G-DRG systems seems to have been achieved by the 2004 and 2005 systems compared to 2003 using the data of the relevant group of patients with proximal femoral fractures. From 2005 onward the financial lumpsum receipts and returns will definitely affect hospital budgets. Hence, a substantial improvement of the the basis of calculation is imperative for 2005 as well as complete publication of the relevant data. It is indeed doubtful whether the extension of the convergence phase to 5 years presently under discussion would provide sufficient time for an adequate solution of the financial and system problems.

Aged↗

PubMed2005

Improving pathway compliance and clinician performance by using information technology.

To deliver patient-specific advice at the time and place of a consultation, to improve clinician performance and compliance by using computer-based decision support, and to integrate such IT solutions with the clinical workflow are important strategies for the implementation of clinical pathways. User acceptance plays a critical role: additional effort has to be balanced with enough benefit for the users. Experiences from routine use of an online surgical pathway at Marburg University Medical Center show that it is possible to successfully address this issue by seamlessly integrating patient-specific pat documentation tasks which have to be done anyway and by substantially reusing entered data to accelerate routine tasks (e.g. by automatically generating orders and reports).

Academic Medical Centers↗

PubMed2004

[Quality management and strategic consequences of assessing documentation and coding under the German Diagnostic Related Groups system].

INTRODUCTION: The introduction of the German Diagnostic Related Groups (D-DRG) system requires redesigning administrative patient management strategies. Wrong coding leads to inaccurate grouping and endangers the reimbursement of treatment costs. This situation emphasizes the roles of documentation and coding as factors of economical success. PURPOSE: The aims of this study were to assess the quantity and quality of initial documentation and coding (ICD-10 and OPS-301) and find operative strategies to improve efficiency and strategic means to ensure optimal documentation and coding quality. METHODS: In a prospective study, documentation and coding quality were evaluated in a standardized way by weekly assessment. RESULTS: Clinical data from 1385 inpatients were processed for initial correctness and quality of documentation and coding. Principal diagnoses were found to be accurate in 82.7% of cases, inexact in 7.1%, and wrong in 10.1%. Effects on financial returns occurred in 16%. Based on these findings, an optimized, interdisciplinary, and multiprofessional workflow on medical documentation, coding, and data control was developed. CONCLUSIONS: Workflow incorporating regular assessment of documentation and coding quality is required by the DRG system to ensure efficient accounting of hospital services. Interdisciplinary and multiprofessional cooperation is recognized to be an important factor in establishing an efficient workflow in medical documentation and coding.

Diagnosis-Related Groups↗

PubMed2004

[Diagnosis and therapy of acute complaints after "whiplash injury" in Germany. Results of a representative survey at surgical and trauma departments in Germany].

Whiplash injury of the cervical spine is a relevant medical and socioeconomic problem, which is still the subject of controversy. We performed a survey to evaluate the current status of diagnostics, classification, treatment, and doctors' subjective opinions at surgical and trauma departments in Germany. A total of 1568 hospitals were addressed to answer a standardized questionnaire on their proceedings and opinions concerning whiplash injury. We received 540 (34.44%) completed questionnaires. There was overall agreement concerning the need for physical examination. The radiological assessment included an a.p. and a lateral plain X-ray of the cervical spine in 82.6%. The indication for functional X-rays in flexion/extension was inconsistent. On average they were performed in 39.1% of all patients. In most cases (68.9%) whiplash injury was not classified; 13.2% of doctors used the classification according to the Quebec Task Force and 13.9% according to Erdmann. A cervical collar was prescribed in 85%. While 30% of patients received only a cervical collar, 55.6% underwent additional physiotherapy. Only 8.3% were treated by physiotherapy without immobilization. The doctors' subjective opinions indicated psychological factors to be important for long-lasting problems, but not for the acute period of complaints. There is no homogeneous concept for diagnostics, classification, and treatment of patients who suffered a whiplash injury in Germany. This situation reflects the current problems in management of this condition. Scientific evidence for functional treatment to avoid adverse influence of immobilization by cervical collars has not yet been transferred to our daily routine in Germany.

Germany↗

PubMed2004

[False aneurysm and bleeding caused by a secondary dislocated lesser trochanter fragment].

A 92-year-old woman incurred an unstable pertrochanteric hip fracture with avulsion of the lesser trochanter (type 31-A2 according to the AO classification). The fracture was treated by gliding nail osteosynthesis, without fixing the minimally displaced lesser trochanter. No intra- or postoperative complications were detected. Suddenly, after 30 days, a swelling of the proximal femoral region, accompanied by signs of haemorrhage, occurred.CT-scans showed a false aneurysm of the deep femoral artery and a dorsal laceration of the artery proximal to the aneurysm. X-rays showed a further dislocation with rotation of the lesser trochanter fragment. Intraoperatively, the tip of the lesser trochanter fragment was identified to be responsible for the laceration of the artery. The false aneurysm was resected and the defect bridged by a vascular prosthesis while the fragment was removed. Follow-up showed no further complications. According to case reports from the literature, false aneurysms and laceration of the deep femoral artery caused by dislocated lesser trochanter fracture fragments are rare.

Aged↗

PubMed2004

[Marburg shoulder radiography splint (MSR splint) for standardized and high quality plain film radiography in fractures of the proximal humerus].

To ensure safe, quick, pain-relieving, standardized, and reproducible high quality plain film radiography in fractures of the proximal humerus, the MSR splint was introduced into clinical practice. With the rectangular and completely radiolucent splint the shoulder radiographs are obtained in supine position by a sole radiographer. Two radiographs are taken in projection at 90 degrees to one another: the true anteroposterior and axillary views, the most important views for fracture visualization and assessment. The smooth flat bottom part of the splint glides easily across the X-ray table below the injured shoulder. The arm lying on the chest is carefully rotated externally up to the neutral position and placed in the splint, then fixed with Velcro fastening with the forearm supinated. The splint is adjusted to the patient for the anteroposterior view which is taken with the central ray directed at the coracoid process and perpendicularly on the film cassette. For the axillary view the MSR splint holding the upper extremity is carefully swiveled into a 80-90 degrees abduction position. Even in cases of comminuted fractures this maneuver is not painful for the patients. The X-ray tube is put into a horizontal position with the central ray pointing to the humeral head in an angle about 25 degrees to the long body axis. The cassette is placed upright in touch with the shoulder girdle. In our institution the MSR splint is not only routinely used for diagnosing fractures of the proximal humerus but also for radiological follow-up controls.

Equipment Design↗

PubMed2004

Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury.

OBJECTIVES: Standard therapy in Germany for acute whiplash injury has traditionally included a soft collar (cervical orthosis), an approach that is passive compared with early exercise and mobilisation. The purpose of this study is to examine the recovery in the first six weeks of groups of acute whiplash injury patients subjected to two different treatment approaches, the traditional approach of a collar compared with active, early mobilisation. METHODS: Between August 1997 and February 2000 a randomised clinical trial with a total of 200 patients was performed. A total of 97 were randomly assigned to a collar therapy group, and 103 to the exercise group, treated by a physiotherapist. Study participants recorded average pain and disability twice (baseline and six week follow up) during a one week period by diary, using numeric visual analogue (VAS) rating scales ranging from 0 to 10. RESULTS: The initial mean VAS pain intensity and VAS disability reported by the collar therapy group and the exercise group showed no statistical difference. The mean VAS pain rating reported by the collar therapy group after six weeks was 1.60 and mean VAS disability rating was 1.56. The mean VAS pain intensity of the exercise group was 1.04 and mean VAS disability was 0.92. These differences between the groups were both significant, as was the reduction in the prevalence of symptoms in the exercise therapy group compared with the collar group at six weeks. CONCLUSIONS: Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury.

Accidents, Traffic↗

PubMed2003

[From clinical guidelines to clinical pathways: development of a management-oriented algorithm for the treatment of polytraumatized patients in the acute period].

INTRODUCTION: The treatment of polytraumatized patients in the acute period is an exemplary model of multidisciplinary cooperation in a very critical timeframe. Implementing standards formulated in the clinical guidelines of the German Association of Traumatology requires a detailed description of "how to do it." METHODS: Based on the guidelines and validated quality indictors, the optimal standard of care as the goal was defined. A clinical algorithm was developed and personal responsibilities and time limits were clearly assigned to each decision step and action. Checklists, documentation charts, and a full text supplement the algorithm. The complete pathway was adopted by representatives of all occupational groups involved in early trauma care in a consensus process. RESULTS: Improvement potentials were identified in those areas for which the guidelines did not provide explicit recommendations. These represent the key elements of the algorithm. Pathway-specific review criteria (quality indicators) were defined for scheduled reevaluation. CONCLUSIONS: Implementing clinical guidelines at the local level requires a problem-oriented and management-oriented elaboration towards a clinical pathway as the basis for a quantitative process and cost analysis.

Algorithms↗

PubMed2003

[Results of elastic stable intramedullary nailing (ESIN) in forearm fractures in childhood].

Conservative treatment of unstable forearm fractures in childhood leads to disappointing results in up to 50%. Therefore the indication for a primary operative treatment is given. In the early 1990s the ORIF (open reduction and internal fixation) Procedure was the commonly practiced treatment. Nowadays elastic stable intramedullary nailing (ESIN) is increasingly recommended. Aim of our prospective investigation was to evaluate difficulties, early results and complications of the elastic stable intramedullary nailing of forearm fractures in children. From January 1998 to December 2000 fifty-four children (23 female, 31 male) with an average age of 8 years (8-16) were treated operatively with ESIN. 48 patients had a single forearm-fracture,6 were multiple injured (ISS<16). Open reduction was necessary in 7,4% cases. Clinically and radiologically a good consolidation was found in all fractures. In one case a large callus formation induced a reduced range of motion. As complications seven superficial infections,which required neither pharmacological nor surgical intervention,were treated. In two cases a temporary paraesthesia of the N. radialis superficialis occurred. In one patient a progressive lesion of the N. ulnaris was observed, due to a constriction of scar-tissue. All fractures healed, in all cases with full range of motion. No relevant difference of length or deviation of the axis was observed. Good clinical results, the low risk of complications and the positive biological impact make the ESIN to the standard procedure in the treatment of unstable forearm fractures in childhood.

Adolescent↗

PubMed2002

[Results of early mobilisation of acute whiplash injuries].

BACKGROUND: Diagnostic evaluation and therapeutic management of acute neck pain after whiplash is a frequent but unsolved clinical problem. Long-lasting symptoms and disability are common. Former studies proposed beneficial effects of physiotherapy in the early management of whiplash injury. The purpose of this study was to assess the effects of early active mobilization versus standard treatment with a soft cervical collar. METHODS: Between August 1997 and February 2000 a prospective randomized clinical trial with a total of 168 patients was performed. Of these patients 81 (31 male, 50 female; average age 28,78 years) were randomly assigned to the standard therapy group, which received a soft cervical collar, and 87 (31 male, 56 female; average age 29,62 years) to the early mobilization group, treated by physiotherapy. Study participants documented pain and disability twice (baseline and six week follow-up) during a one week period by diary, using numeric rating scales ranging from 0 to 10. RESULTS: The initial mean pain intensity (4,75) reported by the standard therapy group was similar to disability (4,76). There were no significant differences to initial pain (4,50) and disability (4,39) reported by the early mobilization group. The mean pain intensity reported by the standard therapy group after 6 weeks was 2,66 and disability was 2,40. The mean pain intensity indicated by physiotherapy group was 1,44 and mean disability was 1,29. The differences between the groups were both significant. CONCLUSIONS: Early mobilization is superior to the standard therapy regarding pain intensity and disability. We conclude that mobilization should be recommended as the new adequate standard-therapy in the acute management of whiplash injury.

Adult↗

PubMed2002

Dedifferentiation-associated changes in morphology and gene expression in primary human articular chondrocytes in cell culture.

OBJECTIVE: The aim of the present study was the investigation of differential gene expression in primary human articular chondrocytes (HACs) and in cultivated cells derived from HACs. DESIGN: Primary human articular chondrocytes (HACs) isolated from non-arthritic human articular cartilage and monolayer cultures of HACs were investigated by immunohistochemistry, Northern analysis, RT-PCR and cDNA arrays. RESULTS: By immunohistochemistry we detected expression of collagen II, protein S-100, chondroitin-4-sulphate and vimentin in freshly isolated HACs. Cultivated HACs, however, showed only collagen I and vimentin expression. These data were corroborated by the results of Northern analysis using specifc cDNA probes for collagens I, II and III and chondromodulin, respectively, demonstrating collagen II and chondromodulin expression in primary HACs but not in cultivated cells. Hybridization of mRNA from primary HACs and cultivated cells to cDNA arrays revealed additional transcriptional changes associated with dedifferentiation during propagation of chondrocytes in vitro. We found a more complex hybridization pattern for primary HACs than for cultivated cells. Of the genes expressed in primary HACs the early growth response (EGR1) transcription factor showed the strongest expression whereas D-type cyclin was expressed in proliferating cells. Other factors associated with differentiated HACs were the adhesion molecules ICAM-1 and VCAM-1, VEGF, TGFbeta2, and the monocyte chemotactic protein receptor. CONCLUSIONS: Our data support the hypothesis that HACs dedifferentiate when grown in monolayer cultures. Moreover, the expression patterns also show that proliferation and differentiation are exclusive features of human chondrocytes.

Aged↗

PubMed2002

[Evaluation and results of the gliding nail in the elderly patient].

Evaluation of the gliding nail in the elderly patient with unstable fracture of the proximal femur. Primary aims of the study were the description of surgical procedure, the specific complications, postoperative pain, recovered mobility and social status after nailing procedure. The observation period of this prospective non-randomized observational cohort study was from 10/97 to 07/00. 121 patients (90 female, 31 male) with unstable femoral fracture were included. Data evaluation included type of fracture, surgical data, procedure specific complications and pre and post surgical development (pain, mobility and social status). The evaluation of the outcome was performed at least 3 months (median 10.4 months) after surgical intervention by telephone-interview. A subgroup of 20 patients was re-examined. 24 A1-, 65 A2-, 16 A3-, 11 subtrochanteric and 5 other fractures were stabilized with a gliding nail. The mean time of surgery was 77 minutes. In 15 out of 121 patients complications lead to a second surgical intervention. In the follow-up examination we were able to obtain following findings: 33.9 % vs. 56.2 % (preoperative) of patients were self-contained. The need for professional care was unchanged. 23.5 % vs. 58.7 % (preoperative) showed unlimited mobility. 20.3 % vs. 12.8 % complained light or moderate pain. According to our experience the gliding nail is a safe and minimal invasive system with a low complication rate. In consideration of patient based outcome the gliding nail shows good results compared to other treatment options. For the given reasons the authors prefer the gliding nail as treatment of choice for proximal femoral fractures.

Aged↗

PubMed2002

Representing and processing medical knowledge using formal concept analysis.

OBJECTIVES: The aim is to show the flexibility, adequateness, and generality of formal concept analysis (FCA) applied to expert systems in medicine. METHODS: The basic idea of formal concept analysis is to look at a set of objects together with their attributes (formal context) under a definite mathematical view. This view leads to a mathematical structure, a complete lattice, which can be represented graphically. RESULTS: Some examples show that this method is very general and can be used to describe diseases, relationships between diseases and findings, the inference process, and among others, types of uncertainty. For many applications, the adequateness of this method, concerning the underlying semantics, can easily be made plausible. CONCLUSIONS: FCA can be used to analyze data that can be described by objects and attributes of any kind. The selected examples (diseases, patient cases, therapeutic decisions, rules) show the usefulness of this method. Although it is not difficult to transform the relevant semantics into a formal context in many cases, much more experience is necessary.

Algorithms↗

PubMed2001

[A holder for standardized radiological detection of ulnar capsule-ligament lesions of the thumb base joint].

AIM OF THE STUDY: To evaluate the usefulness of a self-constructed holding device for standardized, investigator-independent radiodiagnostics for ulnar capsulo-ligamentous lesions of the thumb metacarpophalangeal joint compared to the uninjured side. MATERIAL AND METHODS: A holding device for stress roentgenograms was constructed. Normal abduction arcs were evaluated in 20 degrees flexion in 28 healthy volunteers. The investigator-dependent variance was assessed. The study group comprised 123 consecutive patients (68 male, 55 female, aged 7 to 68 years, mean age 30 years). RESULTS: The normal arc of abduction was calculated to be 12 degrees (range 3 degrees to 24 degrees), while the mean individual difference in side by side comparison in volunteers was 0.3 degree (SD 2.69 degrees, range 0 degree-8 degrees). A rupture was diagnosed in 47 patients; 41 were operated. The preoperative diagnoses confirmed correct in all operated patients. A difference of greater than 6 degrees is indicative of a rupture with a sensitivity of 66.7% and a specificity of 96.9%. CONCLUSIONS: In summary, the holding device is useful for the practical work. Individual differences of less than 4 degrees are negative, between 4 degrees and 7 degrees questionable positive, between 7 degrees and 12 degrees are positive and over 12 degrees proof indicator of a rupture of the ulnar collateral ligament of the thumb metacarpophalangeal joint.

Adolescent↗