Section Sign Research Articles

Validity and Reliability of the Turkish Version of LHB Score.

Long head of biceps (LHB) pathologies are an important cause of pain and dysfunction. As LHB pathologies have specific components from other underlying or related pathologies, the LHB score is designed for an accurate assessment. The aim of this study was to adapt the LHB score into Turkish and to assess its validity and reliability. LHB score was translated and culturally adapted from English to Turkish, and then it was applied to 62 patients with biceps long head pathology. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was computed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient. American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form and modified Constant-Murley score were used to analyze concurrent validity. The Cronbach alpha value of the scale was found as .640. When the subsections of LHB score were computed separately, Cronbach alpha levels of pain/cramps and cosmesis sections were found as .753 and .774, respectively. The intraclass correlation coefficient value of the scale was found to be excellent (.940; P < .001). The total LHB score was determined to have a good positive correlation with the American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form (.527) and Constant-Murley score (.516). But an excellent correlation was revealed between the pain/cramps section of LHB score and other pain sections in American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form (.811) and Constant-Murley score (.816) (P < .001). There was an excellent correlation (.916) between cosmesis section and Popeye sign (P < .001). There was a moderate correlation (.469) between elbow-flexion strength section of LHB score and the digital handheld dynamometer outcomes (P < .001). The Turkish version of the LHB is a valid and reliable tool, especially for biceps pathologies.

CT angiography features of the involved arterial branches of the spontaneous isolated superior mesenteric artery dissection

To explore the CT angiography features of the involved arterial branches of the spontaneous isolated superior mesentery artery dissection(SISMAD). Clinical and CT angiogram data of 6 patients with SISMAD confirmed by dual source energy CT angiography were analyzed retrospectively. The CT angiography features and prognosis of patients were investigated. Average age of 6 patients was(45.83±5.60) years old. Ten branches of jejunoileal artery were involved in 4 patients. All the dissections of the superior mesenteric arteries(SMA) were extended from its proximal to its end. Intramural hematoma was found in all the involved branches, which showed eccentric target sign in the transverse section and sandwich sign in the longitudinal axial section. In 7 branches of 3 patients, the involved branches originated from the false lumina of the SMA. In one patient, the intramural hematoma of the jejunoileal arteries was found to be completely absorbed in a repeated CT angiography one year late. For the SISMAD, the involvement of the branches of the SMA may be associated with the extension of the dissection of the SMA. The inflation of the false lumina of the branches is worse than that of the SMA. With the improvement of the dissection of the SMA, the intramural hematoma of the branches can be absorbed. The conservative treatment may be the first choice for SISMAD without emergency.

Compliance with High-Intensity Radiated Fields Regulations - Emitter's Perspective

NASA's Deep Space Network (DSN) uses high-power transmitters on its large antennas to communicate with spacecraft of NASA and its partner agencies. The prime reflectors of the DSN antennas are parabolic, at 34m and 70m in diameter. The DSN transmitters radiate Continuous Wave (CW) signals at 20 kW - 500 kW at X-band and S-band frequencies. The combination of antenna reflector size and high frequency results in a very narrow beam with extensive oscillating near-field pattern. Another unique feature of the DSN antennas is that they (and the radiated beam) move mostly at very slow sidereal rate, essentially identical in magnitude and at the opposite direction of Earth rotation.The DSN is in the process of revamping its documentation to provide analysis of the High Intensity Radiation Fields (HIRF) environment resulting from radio frequency radiation from DSN antennas for comparison to FAA regulations regarding certification of HIRF protection as outlined in the FAA regulations on HIRF protection for aircraft electrical and electronic systems (Title 14, Code of Federal Regulations (14 CFR) [section sign][section sign] 23.1308, 25.1317, 27.1317, and 29.1317).This paper presents work done at JPL, in consultation with the FAA. The work includes analysis of the radiated field structure created by the unique DSN emitters (combination of transmitters and antennas) and comparing it to the fields defined in the environments in the FAA regulations. The paper identifies areas that required special attention, including the implications of the very narrow beam of the DSN emitters and the sidereal rate motion. The paper derives the maximum emitter power allowed without mitigation and the mitigation zones, where required.Finally, the paper presents summary of the results of the analyses of the DSN emitters and the resulting DSN process documentation.

Development of a Software Tool Using Deterministic Logic for the Optimization of Cochlear Implant Processor Programming

An intelligent agent, Fitting to Outcomes eXpert, was developed to optimize and automate Cochlear implant (CI) programming. The current article describes the rationale, development, and features of this tool. Cochlear implant fitting is a time-consuming procedure to define the value of a subset of the available electric parameters based primarily on behavioral responses. It is comfort-driven with high intraindividual and interindividual variability both with respect to the patient and to the clinician. Its validity in terms of process control can be questioned. Good clinical practice would require an outcome-driven approach. An intelligent agent may help solve the complexity of addressing more electric parameters based on a range of outcome measures. A software application was developed that consists of deterministic rules that analyze the map settings in the processor together with psychoacoustic test results (audiogram, A(section sign)E phoneme discrimination, A(section sign)E loudness scaling, speech audiogram) obtained with that map. The rules were based on the daily clinical practice and the expertise of the CI programmers. The data transfer to and from this agent is either manual or through seamless digital communication with the CI fitting database and the psychoacoustic test suite. It recommends and executes modifications to the map settings to improve the outcome. Fitting to Outcomes eXpert is an operational intelligent agent, the principles of which are described. Its development and modes of operation are outlined, and a case example is given. Fitting to Outcomes eXpert is in use for more than a year now and seems to be capable to improve the measured outcome. It is argued that this novel tool allows a systematic approach focusing on outcome, reducing the fitting time, and improving the quality of fitting. It introduces principles of artificial intelligence in the process of CI fitting.

Analyse der Erlössituation bei der ambulanten Behandlung nach § 116 b SGB V am Beispiel des Marfan-Syndroms

The Marfan syndrome is a typical rare disease with multiorgan involvement and the need for specialized interdisciplinary medical care. A novel German legal directive according to section sign 116 b of the Social Statutes Book V (116 b SGB V) improves options for reimbursement and thus encourages specialized hospitals to provide ambulatory care for rare diseases such as Marfan syndrome. The authors provide the first economic analysis of section sign 116 b in a German Marfan center. The costs were assessed in 184 cases with Marfan syndrome receiving medical care in the Hamburg Marfan Clinic. The authors assessed the financial profit both according to payments received from invoices established according to the 116 b directive [reimbursement (116b)] and from calculations according to section sign 117 SGB V [reimbursement (117)]. A total of 117 patients traveled to the Marfan clinic (64%) < 50 km, 27 patients (15%) between >or= 50 and <or= 100 km, and 40 patients (22%) > 100 km. The total costs for ambulatory care were 71,606.28 Euro. The reimbursement (116b) was 55,549.87 Euro and the reimbursement (117) was 11,776.00 Euro. Many patients accept long distances of traveling to receive specialized ambulatory medical care. However, for optimal patient management specialized centers need to cooperate intensively with local health care providers. The novel legal directive according to section sign 116 b has significantly improved reimbursement for Marfan centers and allows for improving the quality of medical care.

Erfolgsfaktoren integrierter Versorgungsprozesse in der Endoprothetik: Ergebnisse einer qualitativen Prozessanalyse

In Germany, introduction of the law on Integrated Health Care (IC) (section sign 140a-d SGB V) opened up the possibility of cross-sectoral health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. However, cross-institutional and interdisciplinary work contexts demand new organizational structures in order to assure the coordination of different competences, resources and interests. This study aims at identifying factors of successful integrated care settings for total hip and knee arthroplasty. Using the example of an integrated care setting between an orthopaedic hospital and a rehabilitation clinic it will be examined which factors lead to successful implementation of the services and measures designed. A qualitative research design was developed comprising different methods of data assessment (participant observation, guided expert interviews, document analyses) enabling a comprehensive exploration. Overall, data were derived from six consultations with patients, two integrated care information sessions and various documents (17 patient files, information material, patient lists, etc.). First of all, the different phases of development and implementation of integrated care settings were described. In this context, clearly defined aims, structures and appropriate measures seem to be crucial for an ideal long-term cooperation. Furthermore, the staff perspective on the effects of the IC programme on their daily routines proved an essential basis for process reconstruction. The staff members pointed out four main aspects regarding IC settings, i. e., improved image, increased knowledge, intensity of relationship, and less and more work effort. Against this background, factors of successful IC settings could be generated such as the need for central coordination, a regular staff information systems as well as accompanying process monitoring. Several key factors of successful integrated care settings in arthroplasty could be generated which provide important clues for shaping future interdisciplinary and cross-sectoral cooperation settings in health care services in general.

Evaluation of clinical trials by Ethics Committees in Germany: experience of applicants with the review of requests for opinion of the Ethics Committees - results of a survey among members of the German Association of Research-Based Pharmaceutical Companies (VFA).

The review of requests for a positive opinion of the ethics committees (application procedure) as a requirement to start a clinical trial in Germany has been completely redesigned with the transposition of EU Directive 2001/20/EC in the 12th Amendment of the German Medicines Act in August 2004. The experience of applicants (sponsors, legal representatives of sponsors in the EU and persons or organizations authorized by the sponsors to make the application, respectively) in terms of interactions with the ethics committees in Germany has been positive overall, especially with respect to ethics committee adherence to the statutory timelines applicable for review of requests. However, inconsistencies between ethics committees exist in terms of the form and content of the requirements for application documents and their evaluation.With the objective of further improving both the quality of applications and the evaluation of those applications by ethics committees, a survey among members of the German Association of Research-Based Pharmaceutical Companies (VFA) was conducted from January to April 2008. Based on reasoned opinions issued by the respective ethics committee in charge of the coordinating principal investigator (coordinating ethics committee), the type and frequency of formal and content-related objections to applications according to § 7 of the German Good Clinical Practice (GCP) Regulation were systematically documented, and qualitative and quantitative analyses performed. 21 out of 44 members of the VFA participated in the survey. 288 applications for Phase I–IV studies submitted between January and December 2007 to 40 ethics committees were evaluated.This survey shows that about one in six applications is incomplete and has formal and/or content objections, respectively, especially those that pertain to documents demonstrating the qualification of the investigator and/or suitability of the facilities. These objections are attributable to some extent to the differing and/or unclear requirements of the individual ethics committees on the content and comprehension of the submission documents. However, applicants also need to pay more attention to the completeness and validity of the submission documents. The majority of content-related objections apply to the patient information and consent documents and study protocols submitted. Applicants on average acted upon only 3 out of 4 objections, for various reasons: the relevant information was already given in the submitted documents, but had not been taken into consideration by the ethics committees; objections were not applicable; objections lacked a legal basis. In such cases the applicants made reference to the specific information already submitted or gave reasons for not acting on the objection. This course of action was accepted by the ethics committees, with few exceptions. The survey sheds light on the existing inconsistencies in the evaluations of applications by the various ethics committees and suggests ways in which the existing constructive dialogue between applicants and ethics committees may provide a basis to further harmonize both the requirements regarding form and content of application documents, and the criteria for evaluation of applications by ethics committees within the legal framework.

Entscheidungsanalytische Modellierung von Kosten pro QALY im Kontext des deutschen Sozialrechts

In 2007, a legal reform introduced formal health economic evaluation for selected reimbursement decisions by the statutory health insurance in Germany. The methods of evaluation are currently under discussion. This study assesses whether an approach based on decision-analytic cost per QALY modelling fits with the legal requirements set by Book Five of the German Social Code (SGB V). It is based on a review of legal documents and the relevant literature. Key specifications for economic evaluation in Germany are the differential interpretations of "benefit" in the relevant legislation as well as the requirement that the methods follow "international standards of evidence-based medicine and health economics" ( section sign section sign 35b, 139a SGB V). In German reimbursement decision practice, new interventions have undergone an assessment of (1) benefit, (2) necessity and (3) cost-effectiveness (prior to the legal reform only exclusion of dominated alternatives). While the establishment of benefit in step (1) is preferably based on clinical trials in current practice, also two different interpretations of "benefit" in steps (1) and (3) would be in accord with SGB V. Methods for establishing QALYs measure and evaluate different dimensions of health benefit based on transparent and theoretically justified methods. They also capture the dimensions specifically stated by section sign 35b SGB V, e. g., extension of life or improvement in quality of life. Compared to ad-hoc synthesis of the different measures of patient benefit from clinical trials, this is more consistent with the standards of evidence-based medicine and health economics. Decision analytical modelling provides a practical and theoretically sound method to integrate the condition-specific evidence for estimating the costs and benefits associated with a medical treatment in health care practice. Both the establishment of health effects in terms of QALYs and decision-analytical models for evidence synthesis meet the requirements of SGB V. Further methodological issues that need to be addressed include guidelines for QALY measures, and the choice of analytical perspective that fits best with German law. This notwithstanding, it remains an open question how the appropriateness of a cost-benefit ratio should be appraised and what role cost-effectiveness should play in health care decision making, compared with other principles potentially relevant to the decision.

A Spherical Molecule with a Carbon‐Free Ih‐C80 Topological Framework

The complete encapsulation of ortho-carborane by a fullerene-like building-block system consisting of pentaphosphaferrocene and Cu(I)Cl leads to the formation of the spherical supermolecule C(2)B(10)H(12) section sign[{Cp*Fe(eta(5)-P(5))}(12)(CuCl)(20)]. This product of template-controlled aggregation represents the first example of a carbon-free C(80) analogue possessing icosahedral symmetry.

Vergleich zweier automatischer Verfahren zur Auswertung von CDMAM-Prüfkörperaufnahmen

To test the sensitivity of automatic methods for evaluating CDMAM test images with respect to noise. CDMAM test images were analyzed with two computer programs. The images were made with different tube loads [mAs]. The other exposure conditions remained constant. They were analyzed with the CDCOM program, which is offered by the EUREF as a free download, and with the CDMAM Image Checker (CDIC), which was developed by the authors. The determination of the sensitivity in one image always delivers the same result when the same type of computer program is used. This means that the precision of both programs is sufficient. The dose sensitivity of CDIC is two times higher than the sensitivity of CDCOM. However, the required entrance dose (ESAK) for a faultless evaluation with the CDIC program is in the range of 10 mGy. The nominal sensitivity values for the CDCOM program attain a higher level. Differences in dose of more than 5 % should be detectable by both programs. Methods that dispense with visual inspections to determine the performance of X-ray units for mammography can be applied in the acceptance test or the yearly constancy tests according to the German X-ray directive ( section sign 16). The CDCOM program cannot be characterized fully because the data is not complete. Finally the detection methods are not clear. Therefore, the CDCOM program can be called a black box method, while the CDIC has to be called an open source method (general public license).

Wirksamkeit und Kosteneffektivität von Raucherentwöhnungskursen in der GKV: eine Literaturübersicht

Most of German health insurance funds provide and reimburse cognitive-behavioural group-based courses for smoking cessation according to section sign 20 Abs. 1 SGB V or section sign 20 a SGB V. The main goal of this study is to conduct a review of the efficacy and cost-effectiveness of these smoking cessation courses and their methodical approaches. A literature search for available systematic reviews, meta-analyses, health technology assessments (HTA), and guidelines was conducted in relevant databases. Overall, six publications were included. Two sources confirm the long-term efficacy of group-based smoking cessation approach [OR (odds ratio)=1.3 and OR=2.17] with meta-analyses. The majority of available reviews or national guidelines are based on the results of these two researches. Two further reviews estimate the behaviour-based group therapy as effective. The efficacy estimation of single behavioural intervention components (skill training, problem solv-ing, relapse prevention) varies from OR=0.91 to OR=1.5. The evidence is insufficient for the internationally widespread course "Allen Carr's Easyway". No relevant publications on economic issues could be included for the courses currently made available by the statutory health insurance. The methodical approaches of smoking cessation courses offered by health insurance funds are effective and recommendable according to the available secondary literature. The efficacy of these interventions is not very high and solely covers general methodical approaches or programme components. Evaluations of current smoking cessation courses are rare and do not meet internationally accepted standards. Further research should be aimed to evaluate the established programmes with high-quality health economic studies.

Regionalanästhesie als Wettbewerbsvorteil im Krankenhaus

The German Social Act V section sign 12 is aimed towards competition, efficiency and quality in healthcare. Because surgical departments are billing standard diagnosis-related group (DRG) case costs to health insurance companies, they claim best value for money for internal services. Thus, anaesthesia concepts are being closely scrutinized. The present analysis was performed to gain economic arguments for the strategic positioning of regional anaesthesia procedures into clinical pathways.Surgical procedures, which in 2005 had a relevant caseload in Germany, were chosen in which regional anaesthesia procedures (alone or in combination with general anaesthesia) could routinely be used. The structure of costs and earnings for hospital services, split by types and centres of cost, as well as by underlying procedures are contained in the annually updated public accessible dataset (DRG browser) of the German Hospital Reimbursement Institute (InEK). For the year 2005 besides own data, national anaesthesia staffing costs are available from the German Society of Anaesthesiology (DGAI). The curve of earnings per DRG can be calculated from the 2005 InEK browser. This curve intersects by the cost curve at the point of national mean length of stay. The cost curve was calculated by process-oriented distribution of cost centres over the length of stay and allows benchmarking within the national competitive environment. For comparison of process times data from our local database were used. While the InEK browser lacks process times, the cost positions 5.1-5.3 (staffing costs anaesthesia) and the national structure adjusted anaesthesia staffing costs 2005 as published by the DGAI, were used to calculate nationwide mean available anaesthesia times which were compared with own process times.Within the portfolio diagram of lengths of stay for each DRG and process times most procedures are located in the economic lower left, in particular those with high case mix (length of stay and anaesthesia times below reimbursement relevant national mean). The driver of increased earnings is shortening length of stay. Our use of regional anaesthesia is 5 to 10-fold higher than national benchmarks and may contribute to our advantageous position in national competition. The annual increases in profit per DRG range between EUR 1,706 and EUR 467,359 and compensate by far the investment of regional anaesthesia derived pain management, besides the advantage of increased patient satisfaction and avoidance of complications.Regional anaesthesia is a considerable value driver in clinical pathways by shortening length of stay. The present analysis further demonstrates that time for regional block performance is covered by anaesthesia reimbursement within the DRG costing schedule.

Cuff occlusion on the left upper arm increases flow of the left internal mammary artery and bypass flow to the left anterior descending artery

Changes in vascular resistance in the left forearm may affect the flow of left internal mammary artery (LIMA)- to left anterior descending artery (LADA) bypass, because the LIMA is a major branch of the subclavian artery. We studied the effects of occlusion of the left upper arm on blood flow of LIMA-to-LADA bypass in patients undergoing coronary artery bypass grafting (CABG). In ten patients, the blood volume shed from LIMA with the distal end open (LIMA free flow) was stored for 1 min before and during cuff inflation in CABG surgery. LIMA-LADA bypass flow was measured with ultrasonic flow-metry before and after cuff inflation on the left upper arm in an other ten patients. Mean arterial blood pressure (MAP), heart rate (HR), and electrocardiograms (ECGs) were monitored throughout the studies. LIMA free flow (ml x min(-1)) increased from 50.3 +/- 7.1 to 60.9 +/- 8.4 (P < 0.01) at the end of 1-min cuff inflation. LIMA-LADA bypass flow (ml x min(-1)) increased from 31.4 +/- 3.7 to 39.7 +/- 4.0 (P section sign 0.05) at 1 min after cuff inflation. MAP, HR, and ST segments on ECGs did not show any significant changes related to measurement times. LIMA-LADA bypass flow increased after cuff inflation on the left upper arm and returned to the baseline values after cuff deflation. Anesthesiologists should be aware of this relationship between local vascular resistance and bypass flow for the evaluation of LIMA-LADA anastomosis.

Verfahrensweisen und Methoden zur Nutzenbewertung von Arzneimitteln in Deutschland

Verfahrensweisen und Methoden zur Nutzenbewertung von Arzneimitteln in Deutschland

Zur Messung und Darstellung von medizinischer Ergebnisqualität mit administrativen Routinedaten in Deutschland

While internationally low-effort reporting and quality assurance systems based on routine data for hospitals were implemented a long time ago, the evaluation of the treatment quality in hospitals according to section sign 137 SGB V in Germany still relies on special data collection, which demands considerable extra time and effort for the healthcare providers. The current article starts by addressing the question whether quality analyses using primary data sources should be preferred to analyses using secondary data analyses. Subsequently, current possibilities of measuring outcome quality, using administrative routine data, will be illustrated, referring to the large collaborative project Quality Assurance of Hospital Care with Routine Data (QSR). This project was carried out in order to examine possibilities of measuring quality based on routine administrative data in Germany from 2002-2007. The objectives of this article are to present a summary of the project's current status as well as to provide perspectives of future quality assurance with routine data in Germany. In addition, some general problems in measurement of outcome quality, the volume-prevalence problem and the problem of risk adjustment are presented, and possible solutions are proposed.

Differences in the Inflammatory Response between Patients with and Those without Diabetes Mellitus after Coronary Stenting

Patients with diabetes mellitus who undergo coronary stenting are at increased risk of restenosis. It is known that inflammation plays a crucial role in restenosis. We assessed the inflammatory response to elective coronary stent implantation (CSI) in stable diabetic and nondiabetic patients. C-reactive protein (CRP), soluble (s) P-selectin, and soluble intercellular adhesion molecule (sICAM)-1 plasma levels were determined in diabetic (n = 51) and nondiabetic (n = 56) patients before and 48 hours and 4 weeks after bare metal stenting (BMS). Diabetic patients presented significantly higher inflammatory marker levels before and after CSI. Nonetheless, diabetic and nondiabetic patients had postintervention peak of markers attained within 48 hours. At baseline, diabetic and nondiabetic patients presented CRP levels of 5.0 +/- 20.1 (P < or = 0.04) and 3.8 +/- 9.4 microg/ml and, at 48 hours postintervention, 22.0 +/- 20.2 (P = 0.001; P = 0.002) and 12.6 +/- 11.3 (P < or = 0.0001) microg/ml. Regarding sP-selectin, diabetic and nondiabetic patients obtained levels of, at baseline, 182 +/- 118 (P < or = 0.04) and 105 +/- 48 ng/ml and, at 48 hours, 455 +/- 290 (P = 0.001; P < or = 0.01) and 215 +/- 120 (P < or = 0.04) ng/ml. For diabetic and nondiabetic patients, sICAM-1 levels were, at baseline, 248 +/- 98 (P < or = 0.04) and 199 +/- 94 ng/ml and, at 48 hours, 601 +/- 201 (P = 0.001; P < or = 0.01) and 283 +/- 220 (P = 0.001) ng/ml. At 4 weeks, for all patients, markers returned to preprocedural levels: versus before PCI: *P = 0.001, (section sign)P < or = 0.0001; versus nondiabetic patients: (#)P < or = 0.04, (paragraph sign)P = 0.002, (Upsilon)P < or = 0.01. Diabetic and nondiabetic patients exhibited a temporal inflammatory response after an elective BMS. However, diabetic patients present higher preprocedural levels of CRP, sP-selectin, and sICAM-1 and reveal a further exacerbated inflammatory response after intervention. The differences in inflammatory response may have implications in restenosis within these two sets of patients.

Späte Schwangerschaftsabbrüche als Problem des Gesetzgebers

Based on the coalition agreement of 2005 aimed at improving the situation regarding late-term abortions, the author examines to what extent the current legislation on abortion requires amendment. In an historical overview, he explores the long tradition of the step-wise protection of life commensurate with the gradual "animation" of the fetus, the abortion of which by "human hand" was a punishable crime. Having been observed in civil codes of modern times for centuries, this tradition finally perished in section sign 218 of 1871. With the embryopathic indication of 1974, a comparatively late deadline of 22 weeks came back into force. However, since the German Bundestag overruled this indication in 1995, only the unlimited (until birth) medico-social indication (section sign 218 par. 2 of the German criminal code) applies to late terminations, according to which even late terminations of fetuses of extrauterine viability are "not unlawful". While examining both decisions of the German Federal Constitutional Court and the literature, the author makes the case for restricting section sign 281 a par. 2 with extrauterine viability of the child--according to the constitutional preservation of life and our legal tradition--strictly to those cases where the pregnant woman's life is in danger.

Das Berufskrankheitenverfahren bei urologischen Erkrankungen

According to section sign 202 of the German Social Security Code VII, individuals diagnosed with bladder cancer or renal cell cancer who had been occupationally exposed to carcinogens known to induce cancer in these human tissues must be reported to the statutory accident insurance. In this paper, the course of the administrative procedure, particularly considering the reporting procedure and screening for occupational risk factors by a CD-based tool, developed by the authors, is described.

Der Anspruch auf medizinische Rehabilitation nach dem GKV-Wettbewerbsstärkungsgesetz 2007

Since April 1, 2007 medical rehabilitation is a standard insurance benefit of the statutory health insurance scheme (covered by the SGB V, book 5 of the German social code), with the right of the beneficiary to comply especially with the intentions, the principles and the preconditions of the benefits as stipulated in the SGB IX (book 9 of the German social code covering rehabilitation and participation of persons with disabilities). In claiming benefits the applicable rules primarily are those of the SGB IX, as long as the SGB V does not contain different rules. In light of the demands of the SGB IX, the prevailing case law of the Federal Social Court concerning technical aids and assistive devices cannot persist any longer. The so-called "basic-compensation" is contradictory to the specifications of the SGB IX. Medical rehabilitation does not only consist of complex benefits, but every single benefit pursuant to section sign 26 Abs. 2, Abs. 3 SGB IX is a medical rehabilitation benefit if its priority intention is to achieve the beneficiary's participation in society.

Comprehensive Care Center und § 116b SGB V

Through the GMG (modified law of health system) the section sign 116b "out-patients department" was newly introduced into the SGB V (5(th) social welfare legislation) in 2004. Thus, the health insurance companies had the possibility to come to an agreement with hospitals concerning rare illnesses such as haemophilia. On this basis a care agreement was agreed upon in 2005 between the University Hospital Eppendorf (Hamburg) and three big health insurance companies. The result leads to positive changes for all concerned: The patients were offered an optimal care through the link to the CCC and this with an adequate compensation for the coagulation section for out-patients. As the therapy programme became more clarified, the communication between the parties involved became more constructive. With the law to strengthen competition (WSG) for the insurance companies, a change of section sign 116b of the SGB V (5(th) social welfare legislation) came into force in 2007. Thus the legal basis for the a. m. agreement was withdrawn. It is now the task of the a. m. parties to find a way to secure the advantages obtained through this agreement, to the benefit of the patients, the coagulation sections for out-patients and the cost bearers.