[Novel revision of the training regulations for German physicians-Consequences for trainees and trainers in rheumatology]. / Neue Musterweiterbildungsordnung ­ Konsequenzen für die Weiterzubildenden und die Weiterbilder in der Rheumatologie.

Rheumatology training is reorganized with the implementation of the revision of the training regulations for German physicians (MWBO) to become a specialist in internal medicine and rheumatology. This article focusses on novel aspects including far-reaching waiver of reference numbers, the professionally recommended training plan, the e­logbook, the regulation of specific training periods and the requirement of reapplication for the training authorization in addition to the contents of training. These aspects involve direct consequences for trainees and trainers.

[Implementation of an early geriatric rehabilitation in acute inpatient pneumology]. / Implementierung einer geriatrischen frührehabilitativen Komplexbehandlung (GFK) in der akutstationären Pneumologie.

BACKGROUND: In order to counter the rapidly developing loss of function especially in elderly patients with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) the concept "early geriatric rehabilitation in acute inpatient pneumology" was developed. An essential aspect of the project was a targeted approach making use of multi-professional expertise and standards. METHODS: This 1-year feasibility study included a total of 58 patients with AE-COPD in advanced age (mean: 74.8 ± 6.8 years) with typical geriatric multimorbidity and necessity for acute medical as well as rehabilitation treatment. The results of the early geriatric rehabilitation by a multi-professional rehabilitation team were analyzed in a prospective study approach using standardized assessments. RESULTS: The early geriatric rehabilitation started on median day 3 (range: 1st - 22nd) and lasted in median 16 days (range: 9 - 29). It achieved a significant improvement, particularly in mobility [timed up-and-go, median 19 (range: 10 - 150) vs. 15 (range: 7 - 120) seconds, p < 0.0001], self-help ability [Barthel index, median 73 (range: 5 - 95) vs. 95 (range: 45 - 100) points, p < 0.0001] and social care. CONCLUSIONS: Early geriatric rehabilitation in a cohort of AE-COPD patients is feasible and can be integrated in an acute inpatient pulmonary care system.

[Compliance--(no) topic in pain therapy?]. / Compliance--(k)ein Thema in der Schmerztherapie?

Patients' compliance or adherence to medical therapy recommendations has been identified to be a pivotal element in achievement of treatment success. Nonadherence is a commonly-found phenomenon among patients suffering chronic pain. Its negative impact on the individual health status and on health systems has put forth strategies to improve adherence in the therapy of chronicpain. These include the use of medications with reliable and high efficacy combined with low rate and severity of side effects, limited need of medication to manage breakthrough pain as well as the reduction of application frequency.

[Pharmacological treatment of fibromyalgia syndrome]. / Medikamentöse Therapie des Fibromyalgiesyndroms.

BACKGROUND: An interdisciplinary guideline for the treatment of fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) was developed in cooperation with ten German medical and psychological associations and two patients' self-help organizations. METHODS: Using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/ 2006) a systematic literature search was performed, which included all randomised controlled trials (RCT) evaluating multicomponent therapy in FMS and CWP. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of recommendation was graded according to the German program for disease management guidelines. Consensus was achieved using a multi-step nominal group procedure. RESULTS: The short-term use of amitriptyline is strongly recommended (grade A) and the short-term use of fluoxetine und duloxetine is recommended (grade B). CONCLUSIONS: The recommendations regarding pharmacological treatment of FMS are limited by the short duration of the RCT, the lack of follow-ups and absence of cost-effectiveness studies.

Vitamin D receptor genotypes are not associated with rheumatoid arthritis or biochemical parameters of bone turnover in German RA patients.

OBJECTIVE: Vitamin D is known to exert immunomodulatory effects. An overrepresentation of the b allele of the vitamin D receptor (VDR) has been detected in autoimmune diseases as type-1-diabetes and multiple sclerosis. VDR polymorphisms have been shown to influence bone metabolism and bone density. The aim of the present study was to examine the distribution of VDR alleles in German rheumatoid arthritis (RA) patients and their relation to bone turnover parameters. METHODS: 62 German RA patients were included and compared to 40 controls. Three VDR alleles were examined (Bsm I, Taq I and Fok I). In addition, serum intact osteocalcin (OC), parathyroid hormone, bone specific alkaline phosphatase (B-ALP), the carboxyterminal extension peptide of type I procollagen, 25-OH-vitamin D and urinary deoxypyridinoline (DPD) excretion were measured. Furthermore, C-reactive protein, erythrocyte sedimentation rate and rheumatoid factor were measured. RESULTS: We found a slightly higher frequency of the bB and tT-genotype in RA patients compared to controls, which was not statistically significant. OC and B-ALP were found to be significantly higher in RA patients with positive correlations between bone formation and resorption parameters indicating higher bone turnover in RA patients with maintained coupling. CRP in RA patients correlated with DPD and inversely with PTH. VDR genotype showed no association with bone turnover, family history or the presence of rheumatoid factor. CONCLUSIONS: Our results suggest that VDR polymorphisms do not play a major role in RA predisposition in Germans.

Synthetic studies toward phorboxazole A. stereoselective synthesis of the C(28)-C(46) side chain fragment.

A stereoselective synthesis of the C(28)-C(46) fragment (3) of phorboxazole A is described. Key advances include an enantioselective allylation to establish the stereochemistry of the tetrahydropyran unit and a useful SmI(2)-mediated modification of the Barbier reaction of iodomethyloxazole 15 with aldehyde 14.

[Thermotherapy in rheumatic diseases]. / Thermotherapie bei rheumatischen Erkrankungen.

Heat and cold treatment are often used in the physical therapy of rheumatic diseases. Thermotherapy influences perfusion, muscular tone, pain, and inflamed arthritic joints. Cold applications are preferable in treating active arthritis. Heat treatment is advantageous in the management of less active arthritis and non-inflammatory rheumatic disorders. Current investigations demonstrate that thermotherapy influences the endocrine--an immune systems.

Ankylosing spondylitis and infections of the female urogenital tract.

Thirty-two female patients with confirmed ankylosing spondylitis (AS) and 33 women of similar age with pure ileitis terminalis Crohn were examined for genitourinary infection. Urethral syndrome was found in 15 out of 32 patients with AS: 11 of them had urethritis and 4 urethritis associated with vaginitis. Five women of the control group suffered from urethritis. In all cases with genitourinary infection, Chlamydia trachomatis was isolated. By comparing the AS-patients (urogenital infection group and the non-infected group) with regard to other present clinical parameters, it was found, as expected, that the erythrocyte sedimentation rate in the 1st hour was significantly higher in the infected group. In addition, the infected patients had a significantly higher incidence of enthesopathy, involvement of the spinal column, and higher C-reactive protein values (CRP > or = 5 mg/l). A family history of AS was equally present. Other clinical parameters, such as inflammatory involvement of the joints and HLA-B27 correlation, did not differ significantly between infected and non-infected patients.

Moderate beer consumption and positive biochemical changes in patients with coronary atherosclerosis.

OBJECTIVES: The aim of this study was to evaluate the influence of moderate beer consumption on lipid metabolism and antioxidant activity in patients (pts) with coronary artery disease (CAD). SUBJECTS: Forty-eight male pts with CAD not alcohol beverages consumers were randomly divided into experimental (EG) and control (CG) groups, 24 pts each. SETTING: Rehovot University Hospital, Israel. INTERVENTION: Every patient of the EG during a period of 30 consecutive days consumed 330 ml of Maccabee beer (> 20 g of alcohol). The pts of the CG did not consume alcohol during the trial period. METHODS: A wide range of tests including total cholesterol, LDL-C, HDL-C, total tocopherol and alpha-tocopherol. RESULTS: Only in the pts of the EG were found a tendency to an increase of the level of HDL-C and a statistically significant rise in the level of total tocopherol (P < 0.025) and alpha-tocopherol (P < 0.025). CONCLUSIONS: Even a short period of moderate beer consumption leads to some favourable biochemical changes in blood of pts with CAD which are widely regarded as indicators of CAD prevention.

Skin microcirculation during tapwater iontophoresis in humans: cathode stimulates more than anode.

The aim of this controlled study was to evaluate the influence of anode and cathode on skin blood flow by using direct current. Skin microcirculation and skin temperature of 26 healthy subjects (17 men and 9 women, 20-64 years of age) without any vascular diseases were registered when a tapwater iontophoresis was applied. Thermoindifferent water temperature was used to prevent thermic effects on microcirculation. The blood flow measurement was conducted by laser-Doppler flowmetry on the proximal forearm and on the back of the wrist. The skin temperature was measured before and after treatment by an infrared thermometer. In 19 persons there was an intense erythema on the side of the cathode and an only modest one on the side of the anode, while 7 persons showed meager reactions on both sides. The erythema rose strongly from the distal (back of the hand) to the proximal forearm. The comparison of the microcirculation of the arms showed an increase of 120% at the anode and of 700% at the cathode. The differences between the two sides were significant (P < 0.001). After the end of tapwater iontophoresis the skin temperature increased more on the side of the cathode than on the anode side (P < 0.001). The frequency of vasomotion did not change. The vasomotion amplitude increased 67% at the anode (P < 0.05) and 175% at the cathode (P < 0.001). The increased blood flow effect was not age or sex dependent. Although the increased blood flow effect was six times larger on the cathode side, the subjects did not perceive any subjective difference.

Reduced skin hyperemia during tap water iontophoresis after intake of acetylsalicylic acid.

Skin microcirculation and skin temperature of 10 healthy subjects (6 men and 4 women, 20-44 yr of age) without any vascular diseases were registered when a thermoindifferent tap water iontophoresis was applied. The aim of this controlled study was to evaluate the development of skin hyperemia after the intake of 500 mg of acetylsalicylic acid (ASA). The measurement was conducted by laser-Doppler flowmetry on the proximal forearm. The skin temperature was measured before and after the treatment by an infrared thermometer. In all persons there was an intense erythema on the side of the cathode and only a modest one on the side of the anode. Without ASA preliminary treatment, the cutaneous flow showed an increase of 106% at the anodal side and that of 834% at the cathodal side (P < 0.001). After ending tap water iontophoresis, the skin temperature increased more on the cathode side than on the anode side (P < 0.001). After the intake of 500 mg ASA, the increase of the flow was 78% at the anode and 88% at the cathode. The comparison of the skin microcirculation did not show any differences at the anodal side when acetylsalicylic acid was taken before, but a strong suppression of the galvanic erythema at the cathodal side was observed after the intake of ASA. There is a direct influence of acetylsalicylic acid on the induction of the neurogenic inflammation caused by a galvanic erythema. The intensity of the induced erythema correlates with the analgesic effects of constant current treatment. An attenuation of the electrotherapeutic analgesia is possible.

[Ankylosing spondylitis and urogenital infection: diagnosis of urologic infection and correlation with rheumatologic findings]. / Ankylosierende Spondylitis und Urogenitalinfektion: Urologische Infektionsdiagnostik und Korrelation mit rheumatologischen Befunden.

We examined 134 male patients with confirmed ankylosing spondylitis. The study protocol included a medical-rheumatological examination and thorough exploration for infections of the urinogential tract. An urethroadnexitis was found in 37 of 134 patients (27.6%): Two patients suffered from balanitis, 17 patients from urethritis, 18 patients from prostatitis, and two patients from epididymitis. Only four patients gave a history of urethritis and eight patients of prostatitis. The microorganisms isolated most frequently from patients with urogenital infection were Chlamydia trachomatis and, in few cases, Ureaplasma urealyticum. By comparing the urethroadnexitis group and the non-infected group with regard to other clinical parameters, we found a significantly increased C-reactive protein in the infected group. Other clinical parameters like involvement of the free spinal column, inflammatory involvement of the joints, and HLA-B27 correlation did not differ significantly.

Chlorophyll fluorescence measurements to assess the competition of substituted anthraquinones for the QB binding site.

As analogs of the Photosystem II plastoquinone electron acceptor, QB, substituted quinones compete with QB for a common binding domain and thereby inhibit QB function. Substituted quinones interact with the QB binding niche via hydrogen bonds, and the extent of hydrogen bond formation is determined by quinone structure. We have previously shown that the quinone inhibitory activity can be quantitated using measurements of chlorophyll fluorescence quenching. To assess competition for the QB binding site, we report here measurements of the action of various pairs of substituted anthraquinones on the chlorophyll fluorescence emission of barley chloroplasts. The degree of competition between quinones for the QB binding site is classified as competition, partial competition, or no competition. Two quinones were classified as undergoing competition, i.e., interacting for the same or overlapping sites, if the chlorophyll fluorescence level in the presence of the two quinones was not as low as that achieved in the presence of either one of the quinones individually. Non-competitive quinones with different binding sites quenched chlorophyll fluorescence to the level expected if the quenching effects of the individual quinones were additive. Partial competition, or some interaction for the same or overlapping sites, was characterized by an extent of fluorescence quenching in the presence of two quinones that was more effective than either quinone alone but not as sizable as that expected when the two quinones act independently. These results reflect an interesting situation whereby substitution patterns can alter the binding characteristics within a single class of inhibitors. In an accompanying manuscript we report the results of CNDO molecular orbital calculations to demonstrate that the pi charge distribution in substituted quinones governs their binding properties.

Analysis of pi charge distribution in substituted anthraquinones to assess affinity for the QB binding site.

In the accompanying paper (Biochim. Biophys. Acta (1990) 1020, 163-168), we have determined the degree of competition between substituted 9,10-anthraquinones for the QB binding niche through measurements of the additivity of quinone-quenching effects on chlorophyll fluorescence. Quinones inhibit QB function by competitively displacing QB through hydrogen-bond formation with the QB binding protein. The sign of the net pi-charge density on atoms adjacent to the carbonyl moieties is believed to determine the particular hydrogen-bond(s) that result(s). In this study we report CNDO molecular orbital calculations of pi electronic charge distribution in substituted 9,10-anthraquinones to explore the relationship of inhibitor activity and competition to sign of net pi-charge density. We find that the substitution patterns of 9,10-anthraquinones alter the signs of the net pi-charge densities on the carbon atoms adjacent to the carbonyl moieties and thus determine the binding properties of the anthraquinones in the QB niche. While most experimentally studied 9,10-anthraquinones use both carbonyl oxygens to hydrogen bond to the histidine-215 and serine-264 regions of the D-1 QB binding protein, some quinones appear to hydrogen-bond to only one site. Thus, 9,10-anthraquinones constitute a class of QB inhibitors that function as either members of the histidine or serine family of QB inhibitors or as simultaneous representatives of both inhibitor groups.