Validity and reliability of a locomotor stage-based functional rating scale in spinal cord injury.

STUDY DESIGN: This is a prospective observational cohort study. OBJECTIVES: The objectives of this study were to apply and adapt a rating scale based on locomotor stages (LSs) derived from cerebral palsy (CP) to spinal cord injury (SCI) and to quantify its inter-rater reliability and construct validity. METHODS: The inter-rater reliability of LSs originally developed for children with CP was tested in a chronic SCI cohort. On the basis of the distribution of the LSs for CP, Locomotor Stages in Spinal Cord Injury (LOSSCI) were defined. Their validity was then tested with the Spinal Cord Independence Measure (SCIM) in another acute SCI cohort. RESULTS: The 10-point LSs for CP were assessed by two raters in 65 chronic patients. Weighted Cohen's kappa (WCk) was 0.985 (P<0.0001). Only four mismatches were found, resulting in an accuracy of 93.4%. On the basis of the distribution of the LSs for CP in SCI, the five-point LOSSCI grading scale was developed. WCk of LOSSCI was 0.976 (P<0.0001). Only three mismatches between raters were found, resulting in an overall accuracy of 95.1%. The validity data sets consisted of 448 SCIM records from 161 patients obtained within the first year after injury. Spearman's correlation coefficients were the highest between LOSSCI and SCIM indoor mobility (room and toilet; R=0.82) and the lowest between LOSSCI and SCIM respiration and sphincter management (R=0.68). CONCLUSION: LOSSCI provides a reliable and valid clinical tool to assess locomotor function in SCI. LOSSCI not only reflects bipedal walking but also covers a wide range of key motor skills.

Uncertainties in landscape analysis and ecosystem service assessment.

Landscape analysis and ecosystem service assessment have drawn increasing concern from research and application at the landscape scale. Thanks to the continuously emerging assessments as well as studies aiming at evaluation method improvement, policy makers and landscape managers have an increasing interest in integrating ecosystem services into their decisions. However, the plausible assessments carry numerous sources of uncertainties, which regrettably tend to be ignored or disregarded by the actors or researchers. In order to cope with uncertainties and make them more transparent for landscape managers, we demonstrate them by reviewing literature, describing an example and proposing approaches for uncertainty analysis. Additionally, we conclude with potential actions to reduce the insecurities accompanying landscape analysis and ecosystem service assessments. As for landscape analysis, the fundamental uncertainty origins are landscape complexity and methodological uncertainties. Concerning the uncertainty sources of ecosystem service assessments, the complexity of the natural system, respondents' preferences and technical problems play essential roles. By analyzing the assessment process, we find that initial data uncertainty pervades the whole assessment and argue that the limited knowledge about the complexity of ecosystems is the focal origin of uncertainties. For analyzing uncertainties in assessments, we propose systems analysis, scenario simulation and the comparison method as promising strategies. To reduce uncertainties, we assume that actions should integrate continuous learning, expanding respondent numbers and sources, considering representativeness, improving and standardizing assessment methods and optimizing spatial and geobiophysical data.

[Visualisation methods for etheric formative forces]. / Die "bildschaffenden" Methoden der anthroposophischen Medizin (I). Eine kritische Analyse.

UNLABELLED: Rudolf Steiner, the founder of anthroposophy, suggested the development of visualisation methods for "etheric formative forces". The essential methods, their "spiritual scientific" basis and indications are described and their claims critically tested. SUMMARY: The methods are not validated, the key criteria for diagnostic tests (reproducibility, sensitivity, specifity) are not given.

["For the welfare of patients"--is this really the case?]. / "Patientenwohl hat Vorrang" - stimmt das wirklich?

According to a decision by the German Federal Constitution Court (1 BvR 347/98), it is illegal to refuse compulsorily insured persons therapy if they suffering from a lifethreatening disease against which there is no effective therapy on the basis of current medical science. The chosen method of treatment should offer a not entirely remote chance of healing. What counts is the effect treatment has in each individual case. Serious objections to the the Court's criteria have been expressed by medical and legal experts, who contend that the Court has disregarded patients' protection against unknown risks and "quackery" as well as the incalculable financial effects on the community of insureds.

[Significance of environmental medicine from the viewpoint of the medical review board of the social health insurance program]. / Die Bedeutung der Umweltmedizin aus der Sicht des Medizinischen Dienstes der Krankenversicherung (MDK).

Tasks concerning environmental medicine are a significant aspect of the expert work done by the medical review board of the social health insurance fund. Thus far there are no commonly accepted theories and/or criteria with regard to the cause of environmental incompatibilities, nor are there generally accepted criteria/standards for clinical diagnostic procedures and therapy. Problems arise from the fact that the field of environmental medicine not only offers scientifically accepted and verified diagnostic and therapeutic methods, but also numerous unconventional procedures without verified validity. The decision of the scientific expert has to be based on the legal principles of social legislation and jurisdiction. His/her opinion must be competent, objective and independent. Further research is urgently needed to improve the scientific data pool. With it, well-grounded methods and standards can be offered.

Cardiac rotation and relaxation in patients with aortic valve stenosis.

BACKGROUND: Diastolic dysfunction with delayed relaxation and abnormal passive elastic properties has been described in patients with severe pressure overload hypertrophy. The purpose of this study was to evaluate the time course of rotational motion of the left ventricle in patients with aortic valve stenosis using myocardial tagging. METHODS: Myocardial tagging is a non-invasive method based on magnetic resonance which makes it possible to label ('tag') specific myocardial regions. From the motion of the tag's cardiac rotation, radial displacement and translational motion can be determined. In 12 controls and 13 patients with severe aortic valve stenosis systolic and diastolic wall motion was assessed in an apical and basal short axis plane. RESULTS: The normal left ventricle performs a systolic wringing motion around the ventricular long axis with clockwise rotation at the base (-4.4+/-1.6 degrees) and counter-clockwise rotation at the apex (+6.8+/-2.5 degrees) when viewed from the apex. During early diastole an untwisting motion can be observed which precedes diastolic filling. In patients with aortic valve stenosis systolic rotation is reduced at the base (-2.4+/-2.0 degrees; P<0.01) but increased at the apex (+12.0+/-6.0 degrees; P<0.05). Diastolic untwisting is delayed and prolonged with a decrease in normalized rotation velocity (-6.9+/-1.1 s(-1)) when compared to controls (-10.7+/-2.2 s(-1); P<0.001). Maximal systolic torsion is 8.0+/-2.1 degrees in controls and 14.1+/-6.4 degrees (P<0.01) in patients with aortic valve stenosis. CONCLUSIONS: Left ventricular pressure overload hypertrophy is associated with a reduction in basal and an increase in apical rotation resulting in increased torsion of the ventricle. Diastolic untwisting is delayed and prolonged. This may explain the occurrence of diastolic dysfunction in patients with severe pressure overload hypertrophy.

Clinical course and symptomatic prediagnostic period of patients with Wegener's granulomatosis and microscopic polyangiitis.

The clinical course of 15 patients with Wegener's granulomatosis (WG) and eight patients with microscopic polyangiitis (MPA) from one nephrological clinical center is presented for the period from 1984 to 1993, when testing for antineutrophil cytoplasmic antibodies (ANCA) was gradually introduced into routine clinical practice. We found a high degree of prolonged time periods with symptoms attributable to WG or MPA until the specific diagnosis was made. Nine patients with WG and one patient with MPA had symptomatic prediagnostic periods of more than three years, which extended in one case up to twenty years. In these prediagnostic periods, often even severe flares of vasculitic activity resulted in spontaneous remission without immunosuppressive therapy. One patient on chronic dialysis for four months because of rapidly progressive glomerulonephritis, experienced sufficient spontaneous regain of residual renal function to stay off dialysis for 6 years. Despite a high amount of spontaneous recovery, recurrent flares of disease eventually led to death in those cases without sufficient immunosuppressive therapy. Contrary to long courses of disease, one patient with WG had a fulminate exacerbation of disease with lethal hemoptysis after a prediagnostic period of only three months. Renal disease, respiratory and other symptoms did not occur sequentially, but each could precede the other. We conclude in agreement with published former experience, that WG and MPA show a highly variable spontaneous disease course, that requires extended observational periods for evaluating maintenance therapies.

Functional hand development in tetraplegia.

The development of the 'functional hand' in tetraplegics has been historically facilitated through specialized hand positioning schemes. However, clinical experience at the University Hospital Heidelberg demonstrates no direct relationship between various hand positioning techniques and the probability of functional hand development. The aim of this study was to document the various methods of hand positioning and the resulting functional outcome. In a multi-center study, the paralysed thumb and finger positioning of 64 tetraplegics and the resultant functional outcome was evaluated with a specially developed survey form. Results indicated that the functional outcome of the tetraplegic hand was highly dependent on the level of the spinal cord injury and only to a minor degree dependent upon the different methods of hand positioning employed. The conclusion drawn is that remaining neurologic function after injury determines the final functional outcome of the tetraplegic hand.

[Unconventional concepts in environmental medicine]. / Unkonventionelle Konzepte in der Umweltmedizin.

More and more people are convinced to be afflicted with diseases caused by ill-defined environmental factors. Until now it has also not been possible to delineate unambiguously common features to describe a syndrome-like pattern which is the essential requirement for rational prophylactic and therapeutic intervention. Despite of this scientific status a wide variety of supposedly diagnostic and therapeutic methods of unproven efficacy is currently advertised and often applied in a polypragmatic manner. Besides providing a description of the different techniques their clinical relevance is critically evaluated.

[Cost development in health care with special reference to unconventional procedures]. / Kostenentwicklung im Gesundheitswesen unter besonderer Berücksichtigung unkonventioneller Verfahren.

The cost of healthcare continues to escalate. At the same time alternative medicine is becoming more popular. Therefore it seems necessary to consider the price of unconventional therapies: they are more expensive than generally supposed. The reasons are distinct modes of therapy, polypragmasy, long term therapies, and consecutive costs. Finally there is the question, whether it is ethical to ask for the cost efficiency ratio in the treatment of seriously ill.

[Diagnosis of space-occupying renal processes: sonography and aimed fine-needle biopsy]. / Diagnostik raumfordernder renaler Prozesse: Sonographie und gezielte Feinnadel-Biopsie.

It is reported on 3 cases in which by sonographic examination a tumorous process could be established. In all cases the additional investigation by fine needle biopsy and cytological examination proved the presence of malignant cells. This local renal process proved by sonography could be verified neither by i.v. pyelographic nor arteriographic methods. For two patients the diagnosis based on sonography, fine needle puncture and cytological test could be verified by operation. The third patient was not operated in spite of malignant cells in the cytogram because of negative computer tomography provided by an external hospital.

[The normal pancreas. Demonstration in the sonogram in relation to age]. / Das normale Pankreas. Darstellung im Sonogramm in Abhängigkeit zum Lebensalter.

For 191 patients without any clinically or anamnestically traceable disease of pancreas sonographic inspection was performed, a real time-equipment type Aloka, SSD 240 was used. The age of the patients, divided into 5 groups ranged from 15 to 90 years. The measurements of the pancreas sonographic inspection was performed, a real time-equipment type Aloka, SSD 240 was used. The age of the patients, divided into 5 groups ranged from 15 to 90 years. The measurements of the pancreas were established for head, neck, corpus and tail respectively. The following mean values for the thickness were found: Head: 2,41 +/- 0,41 cm; neck: 1,53 +/- 0,34 cm; corpus: 1,90 +/- 0,37 cm; tail: 1,67 +/- 0,37 cm. The width of the organ was in the area of the head: 1,3 to 3,5 cm, neck 1,0 to 2,7 cm, corpus 1,1 to 3,0 cm, tail 0,8 to 2,6 cm. A comparison between normal weight- and overweight-patients showed no significant differences at all. The echostructure of the pancreas showed a clear increase of intensity with progress in age. The reason for this more detailed echostructure is seen in an infiltration of fat as well as collagenous and fibrous elements. No change in organ size was found in this connection.

[Oncocytoma of the thyroid gland]. / Das Onkozytom der Schilddrüse.

The Huerthle cell tumor is quite frequent in southern Germany; this is shown by examinations of patients from our field hospital for nuclear medicine. Our findings conclude with data presented by Galvan (Salzburg). The certainly quite short observation period shows that Huerthle cell adenomas occur much more frequent than carcinomas, when a Huerthle cell neoplasm is diagnosed cytologically. Our investigations show, that Huerthle cell tumors of the thyroid gland are a not wellknown and rare disease, which necessitates a clear decision as result of the cytological finding as far as necessary surgical measures are concerned. This is probably the only way to improve the efficiency of measures for early diagnosis and treatment of tumors of the thyroid gland. Considering the want of clearness which still exists referring to the dignity of Huerthle cell tumors in our opinion even cases which had been diagnosed as adenomas histologically should be controlled regularly once a year during an observation period of ten years.

[Duodenal ulcer in the aged. Diagnosis, therapy and disease course]. / Ulcus duodeni beim alten Menschen. Diagnose, Therapie, Verlauf.

In 68 of 1152 patients older than 65 years an acute ulcus duodeni could be stated by endoscopy. This is 5,9% of the examined patients. Among this group there was a remarkably great number of patients who belonged to the age group between 70 and 80 years. The anamnesis of 42 patients indicated complaints for several years, whereas 26 patients showed symptoms only for a few weeks. The size of the acute ulceration was mostly below 1,0 cm. A determined relation between the size of the ulceration, the patients age and the duration of their anamnesis could not be found. In 12 patients an acute ulcus ventriculi could be proved simultaneously. In 15 cases acute bleeding was the initial symptom of the ulceration. Healing of the ulcera took between 4 weeks and 3 months. The conservative therapeutical steps were not standardized. Stationary and ambulant patients did not show any difference in the time of healing. It was remarkable that the consumption of alcohol and especially of cigarettes was relatively high.

[Hyperthyroidism in the elderly]. / Hyperthyreose im Alter.

In patients older than 60 years it is more difficult to establish the diagnosis of thyrotoxicosis because 1. the classical symptoms are either less pronounced or totally absent, 2. complaints of symptoms of the digestive system are more striking and suspicious of a carcinoma (diminished appetite, weight loss, constipation), 3. symptoms like hypertension and cardiac arrhythmia are often to be found in elderly people and therefore not of great diagnostic significance, 4. in a high percentage of cases a selective T3-thyrotoxicosis is to be found.