Management and housing factors associated with paratuberculosis-positive herds in small structured alpine cattle husbandry.

Paratuberculosis (Johne´s disease) is a world-wide cattle disease caused by Mycobacterium avium subsp. paratuberculosis (MAP), associated with substantial economic losses. Purchase of subclinically infected animals or contact with animals and equipment of infected farms are known risk factors for disease transmission among herds. The aim of the present study was to identify specific management factors in Austria that triggered a MAP-positive herd status and to evaluate known risk factors for the transmission in cattle in small structured alpine agricultural systems. The agriculture in the Austrian province of Tyrol is characterized by smallholder structures, including shared alpine pastures and traditional barn management techniques. The data from an extensive survey with 50 questions in 2013/2014 and the development of the MAP herd status of 5592 cattle farms by taking feces and blood samples were examined and statistically evaluated. MAP herd status was determined by combining the results of boot swab samples, manure samples, pooled and individual feces samples as well as serological antibody testing by ELISA. The statistical analysis (odds ratio; OR) showed that the use of milk replacers for calf feeding (p = 0.047, OR=0.472) and the use of straw as bedding material for cows (p = 0.032, OR=0.625) were associated with a decreased chance of being a MAP-positive herd. Further, housing cows in deep litter systems (p = 0.028, OR=2.232), the presence of slurry channels (p = 0.028, OR=1.411) and the use of solid manure in young cattle (p = 0.041, OR=1.744) were associated with an increased OR for being MAP-positive. Surprisingly, sharing of lowland pastures (p = 0.564, OR=1.080), alpine pastures (p = 0.419, OR=1.143) or farm equipment (p = 0.733, OR=0.963) and farm size (p = 0.425) had no significant influence on the MAP herd status. The identified differences compared with previously published results in respect of MAP spread in cattle might be attributed to the traditional agricultural structures, including small family-based farms and common pasture during summer in alpine regions. Results of this study contribute to the understanding of the spread of MAP in cattle farming in alpine regions.

[Quality of postoperative pain therapy: evaluation of an established anesthesiology acute pain service]. / Qualität der postoperativen Schmerztherapie : Evaluation eines etablierten anästhesiologischen Akutschmerzdiensts.

BACKGROUND: Despite well-designed concepts of perioperative pain management, recent studies have revealed that a large number of patients still suffer from unacceptable pain after surgery. The purpose of this prospective evaluation was to critically analyze postoperative pain treatment provided by a routinely established, DIN certified acute pain service (APS) at the University Hospital Großhadern in Munich. MATERIALS AND METHODS: A total of 1,000 consecutive patients received one of the following analgesic procedures: continuous epidural analgesia (EA, n = 401), continuous and patient-controlled epidural analgesia (PCEA, n = 305), intravenous patient-controlled analgesia with opioids (PCA, n = 169) or continuous peripheral nerve block (CPNB, n = 125). For EA and PCEA, ropivacaine 0.2 % and sufentanil 0.24 µg/ml were administered while peripheral regional analgesia was performed with infusion of ropivacaine 0.2 % only. Patients with PCEA were allowed a 3 mg bolus once per hour on demand. Standardized intravenous PCA was performed with piritramide 2.5 mg/ml, a bolus of 2.5 mg, a lock-out time of 15 min, a maximum of 25 mg/4 h and no background infusion. During the daily visits the APS assessed pain intensity at rest and during movement on a numerical rating scale from 0 (no pain) to 10 (maximum pain), acceptance of pain, satisfaction with the analgesic procedure, demand of additional non-opioid analgesics, the need for optimization including bolus applications and changes of the infusion rate or retraction of the epidural catheter. The duration of the procedures, side effects and complications were documented. The catheter insertion sites were inspected daily for redness and tenderness on palpation. RESULTS: In general, epidural and peripheral regional analgesic techniques were superior in terms of postoperative analgesia to intravenous opioid PCA and were associated with fewer side effects, such as sedation, nausea, vomiting, obstipation and sensorimotor deficits. A subgroup analysis revealed that in major upper abdominal surgery, EA provided significantly better analgesia at rest and during movement than PCA. In lower abdominal surgery PCEA induced significantly better analgesia than both PCA and EA, especially during movement. Patient satisfaction was generally high and was best with PCEA (95 %) followed by CPNB (94 %), EA (91 %) and PCA (88 %). On the first postoperative day analgesic procedures had to be optimized (e.g. by bolus administration, retraction of catheters or changes to standardized PCA) in 23 % of EA patients, 10 % of PCEA patients, 6 % of PCA patients and 12 % of CPNB patients. Major complications, such as neuraxial hematoma, infections or respiratory depression were not observed. CONCLUSIONS: As described in many prospective studies, this evaluation revealed that for postoperative pain control, regional anesthesia is superior to intravenous patient-controlled analgesia with strong opioids in terms of analgesia and side effects. In the setting of a well-organized acute pain service with frequent education and training of all members involved, postoperative pain management is safe and effective. However, regular re-evaluation of the defined and certified procedures is necessary.

[The International Classification of Functioning, Disability and Health (ICF) - update of the problem based inventory]. / Die Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) - Aktualisierung der problemorientierten Bestandsaufnahme.

The review continues the work of the article pub-lished in 2006. The core issue is the use and implementation of the ICF in Germany. Nevertheless, it includes also international resources as well as developments. The review is based on on public resources like several kinds of documents, congress abstracts, publications. The aim of the non-systematic review is to show the spectrum and modes of application of the ICF in Germany. Therefore, the review may serve as a guide to the ICF implementation. However, more detailed analyses focusing on specific aspects of the ICF and its use are preferable, especially in health services and whenever the bio-psycho-social model is used as a reference.

[Instrumentality of the International Classification of Functioning, Disability and Health (ICF) in classification of long-term consequences of diseases]. / Die Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) als Klassifikationshilfe der langfristigen Krankheitsfolgen.

The ICF (International Classification of Functioning, Disability and Health) is an international classification of disease consequences and phenomena associated with health conditions. It is complementary to the already established classification of diseases (ICD). The ICF provides both a framework and a classification that comprehensively cover relevant domains of functioning to describe long-term consequences of diseases. The classification can be used as a universal language understood by medical doctors, health professionals, researchers, patients and other groups. The ICF is based on an integrative biopsychosocial model of functioning. Functioning is used as an umbrella term for all non-problematic body functions, body structures, activities and participation. Based on the biopsychosocial model the ICF comprises a hierarchical classification to describe functioning as well as environmental factors. Problems of long-term survivors as well as persons suffering from chronic diseases, relevant findings, treatment goals and treatment concepts can be managed by applying the ICF to the patients.

Factors explaining limitations in activities and restrictions in participation in rheumatoid arthritis.

AIM: The objectives of this study were to examine which factors, according to the International Classification of Functioning, Disability and Health (ICF) framework contribute to the explanation of activity limitations measured by the Health Assessment Questionnaire (HAQ - model I) and which factors contribute to the explanation of participation restrictions measured by the Social Function Scale of SF-36 (model II) in patients with rheumatoid arthritis (RA). METHODS: Cross-sectional data collection of variables concerning the health status of 239 consecutively included patients with RA at the outpatient Departments of Physical Medicine and Rehabilitation of the University Hospital of Zurich and of the University Hospital of Munich was conducted. Measures included: disease activity score (DAS-28), Rheumatoid Arthritis Disease Activity Index (RADAI), HAQ, Short-form-36 (SF-36), Sociodemo-graphy Questionnaire, Comorbidity Questionnaire (SCQ), Muscle Strength Index (MSI), range of motion (EPM-ROM), grip strength, Sequentional Occupational and Dexterity Assessment (SODA), radiologic score (Ratingen Score). Multivariate regression analyses were conducted building models of explanation. RESULTS: Model I included vitality, RADAI, DAS, SODA PAIN Score, MSI and EPM-ROM as explaining variables with a globally explained variance of 53%. Model II included vitality, mental health, the HAQ and living alone as explaining variables with a globally explained variance of 42.4%. CONCLUSION: Activity limitations in RA were mainly explained by vitality and disease activity factors. Restrictions in participation in RA were mainly explained by vitality and mental health.

Identification of similarities and differences in functioning in persons with rheumatoid arthritis and ankylosing spondylitis using the International Classification of Functioning, Disability and Health (ICF).

OBJECTIVE: The objective of this study is to identify similarities and differences in functioning in AS and RA using the ICF as the framework for the description of functioning. METHODS: The Comprehensive ICF Core Sets for RA and AS were compared qualitatively regarding their content. A comparison study of common second-level ICF categories from both ICF Core Sets collected in two different cross-sectional studies in the Netherlands was performed. Significant differences regarding the level of impairments, limitations or restrictions were analyzed within the Mann-Whitney U-Test. To study whether the common ICF categories have different meaning for the two populations the Rasch model for dichotomous response option was used. RESULTS: The Comprehensive ICF Core Set for AS includes 74 ICF categories in 19 chapters and the Comprehensive ICF Core Set for RA includes 96 ICF categories in 22 chapters. Interviews among 87 patients with AS and 143 patients with RA on 24 of the common ICF categories revealed significant differences regarding the extent of problems. DIF analyses reflect that the meaning of some ICF categories, such as 'd410 Changing basic body positions' is different in relation to functioning depending on the health condition. CONCLUSION: This study was the first to compare functioning in AS and RA based on the ICF. The results confirmed to a large extend the experiences well known from other studies and thereby showed that the ICF is useful to describe and compare functioning. Some aspects could be identified which are not easy to understand with existing evidence and need to be explained in the future.

[Use of ICF Core Sets for medical reports concerning patients with low back pain and chronic widespread pain syndrome]. / Anwendung der ICF Core Sets in der Begutachtung von Patienten mit lumbalen Rückenschmerzen und generalisiertem Schmerzsyndrom.

BACKGROUND: Medical reports of the national pension insurance are essential for the national pension regulatory authority to decide on granting services regarding participation as well as retirement pensions due to inability to work. There are guidelines regarding the content of medical reports. It is also generally accepted that the evaluation of functioning is an essential component of them. However, it is still an open question to what extent the standardisation and the objectiveness of medical reports can be improved. The ICF (International Classification of Functioning, Disability and Health) is a framework as well as a common language for describing functioning and disability. ICF Core Sets are lists of disease-specific relevant ICF categories and can be a useful practicable tool for medical reports for national pension insurance. They could support the standardization of the medical reports. The aim of this planned project is to examine whether the ICF Core Sets for low back pain and chronic widespread pain could serve as a useful basis for medical reports for national pension insurance regarding the patients suffering low back pain or chronic widespread pain. METHOD: Six hundred medical reports from patients with low back pain or chronic widespread pain, respectively, will be translated into the language of the ICF using a retrospective qualitative study design. For this translation ('linking') process specialised physicians from the national pension insurance and members of the Institute for Health and Rehabilitations Science will be trained to use established linking rules. STATE OF THE PROJECT: Currently, a total of 244 medical reports from the national pension insurance with the health conditions low back pain or chronic widespread pain were selected by members of the national pension insurance. The medical reports are anonymised in different federal states according to the appropriate requirements. The first 10 medical reports have already being analysed. OUTLOOK: First analyses show that the structure of medical reports varies enormously. Therefore a comparison of the content without having a common basis is hardly possible. This demonstrates the importance of the project and the possible usefulness of the ICF and the ICF Core Sets for structuring the content of medical reports for the national pension insurance.

Towards an ICF Core Set for chronic musculoskeletal conditions: commonalities across ICF Core Sets for osteoarthritis, rheumatoid arthritis, osteoporosis, low back pain and chronic widespread pain.

The objective of the study was to identify commonalities among the International Classification of Functioning, Disability and Health (ICF) Core Sets of osteoarthritis (OA), osteoporosis (OP), low back pain (LBP), rheumatoid arthritis (RA) and chronic widespread pain (CWP). The aim is to identify relevant categories for the development of a tentative ICF Core Set for musculoskeletal and pain conditions. The ICF categories common to the five musculoskeletal and pain conditions in the Brief and Comprehensive ICF Core Sets were identified in three steps. In a first step, the commonalities across the Brief and Comprehensive ICF Core Sets for these conditions were examined. In a second and third step, we analysed the increase in commonalities when iteratively excluding one or two of the five conditions. In the first step, 29 common categories out of the total number of 120 categories were identified across the Comprehensive ICF Core Sets of all musculoskeletal and pain conditions, primarily in the component activities and participation. In the second and third step, we found that the exclusion of CWP across the Comprehensive ICF Core Sets increased the commonalities of the remaining four musculoskeletal conditions in a maximum of ten additional categories. The Brief ICF Core Sets of all musculoskeletal and pain conditions contain four common categories out of a total number of 62 categories. The iterative exclusion of a singular condition did not significantly increase the commonalities in the remaining. Based on our analysis, it seems possible to develop a tentative Comprehensive ICF Core Set across a number of musculoskeletal conditions including LBP, OA, OP and RA. However, the profile of functioning in people with CWP differs considerably and should not be further considered for a common ICF Core Set.

Post-infarct cardiac sympathetic hyperactivity regulates galanin expression.

The neuropeptide galanin is elevated in the cardiac sympathetic innervation after myocardial infarction (MI). Galanin inhibits vagal transmission and may support the regeneration of sympathetic nerves, thereby contributing to the development of arrhythmia and sudden cardiac death after MI. The reason for increased galanin production in sympathetic neurons after myocardial infarction is not known. Cardiac sympathetic neurons are activated chronically after cardiac ischemia-reperfusion, and activation of sympathetic neurons in culture stimulates galanin expression. Therefore, we tested the hypothesis that increased sympathetic nerve activity stimulates galanin expression in cardiac sympathetic neurons after myocardial infarction. To test this hypothesis we used TGR(ASrAOGEN) transgenic rats, which lack brain angiotensinogen and do not exhibit post-infarct sympathetic hyperactivity. Hearts and stellate ganglia were collected 1 week after ischemia-reperfusion. Galanin mRNA was quantified by real-time PCR and peptide content was assayed by enzyme-linked immunosorbent assay. Galanin mRNA increased approximately 3-fold after MI in cardiac sympathetic neurons of both genotypes compared to unoperated and sham controls. Left ventricular galanin content, however, increased after MI only in Sprague-Dawley rats and not in AOGEN rats. These data suggest that post-infarct cardiac sympathetic hyperactivity stimulates galanin peptide production but is not required for increased galanin mRNA expression.

Effectiveness of a community-based 3-year advisory program after acquired brain injury.

Objective of this study was to examine the effectiveness of a coordinated, community based 3-year advisory program in 1534 patients with acquired brain injury. Patients and caregivers were offered a coordinated advisory program after discharge from rehabilitation. Patients in the historical control group received standard aftercare. The main outcomes were functional status [Functional Independence Measure (FIM)], and days spent in the acute hospital. The secondary outcome was survival. Patients were comparable for sex (intervention: 41.3% female, control: 38.0%), and younger in the control group (mean age intervention: 55.3, control: 49.6). Functional status at discharge was lower in the intervention group (mean FIM intervention: 66.2, control: 80.3). Patients in the intervention group experienced a moderate gain in FIM. Rate of days in hospital was 15.4 per 1000 person days (intervention) and 15.5 per 1000 person days (control). Patients of the intervention group had an increased rate of days in hospital. A total of 16.0% of patients in the intervention group and 19.3% in the control group died during follow-up. Patients in the intervention had a significant lower mortality risk depending on follow-up period and discharge FIM. The advisory program may be effective for all patients with acquired brain injury.

Practicability of segmental stabilizing exercises in the context of a group program for the secondary prevention of low back pain. An explorative pilot study.

AIM: Segmental stabilizing exercises (SSE) for specific dysfunction of local muscles (m. transversus abdominis, m. multifidus, pelvic floor muscles and diaphragm pelvis) have been advocated in patients with low back pain (LBP). The specific aims of this study were to examine: 1) whether participants of a group program learn SSE; 2) whether they respond to SSE with a reduction in present LBP and 3) to what extent people report using SSE in daily living. METHODS: One-hundred nurses participated in this explorative pilot study. Data from a 12-week multimodal program including SSE as intervention for the prevention of LBP were analysed. The prone test was taken as an indicator for the participants' ability to perform SSE correctly. Present back pain was assessed on a numerical rating scale (0-10). A compliance questionnaire and a transfer questionnaire assessed compliance and transfer of SSE into daily living. RESULTS: After the intervention, 72% of participants were able to perform SSE correctly as measured by the prone test. Between 48% and 78% of the participants with present LBP experienced a minimal, clinically important change (minimal clinical changes, [MCC]) while performing SSE. No strong interrelations between the ability to correctly perform SSE and the MCC of LBP could be identified. Participants reported exercising SSE for 12 min on average 4-5 days a week. At 3 months after the intervention, 76% of participants reported using SSE ''always'' in their work with patients. CONCLUSION: First findings are that SSE can be learned by the majority of the participants of a group program for the prevention of LBP. Additionally, SSE reduces present LBP and so can help people with LBP learn to help themselves. We are unable to explain how participants benefited from SSE even when they were unable to perform SSE correctly, as measured by the prone test.

[The international classification of functioning, disability and health. Potential applications in Germany]. / Die Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF). Einsatzmöglichkeiten in Deutschland.

The ICF is a new classification for the description of disease consequences and with health conditions associated phenomena. It is complementary to the presently established classification of diseases (ICD). Prior to endorsement by the World Health Assembly in Mai 2001, the ICF was taken up in legislation and regulations of the German health system. The importance and the potential of the ICF are not only reflected within laws, but also in the practical work with patients and within the documentation. Although the official German translation was only available starting in October 2005, much training material already exists. Most of the material and publications were made from a rehabilitation perspective. However, this does not imply that the ICF should be exclusively applied to rehabilitation alone. ICF is a multipurpose classification designed to serve various disciplines and different sectors. There are many possible applications, and many projects have been initiated for use in policy, patient care, documentation, communication and research.

How to assess the impact of arthritis on the individual patient: the WHO ICF.

The ICF is not only a comprehensive and adequate framework for assessing the impact of arthritis on individual patients but also its impact on populations. The ICF framework and applications such as the ICF Core Sets for rheumatoid arthritis, osteoarthritis, osteoporosis, and low back pain are therefore likely to be used extensively not only in clinical practice but also in outcomes and rehabilitation research, education, health statistics, and regulation.

[Patient-centered assessment of functional health in systemic sclerosis -- where are we now?]. / Patientenzentriertes Assessment der funktionalen Gesundheit bei systemischer Sklerodermie -- Wo stehen wir?

Self-administered patient-centered questionnaires have been shown to be practical, reliable and valid in terms of evaluating functional limitations in rheumatic diseases. In systemic sclerosis a modified version of the HAQ and condition-specific questionnaires have been used. The Health Assessment Questionnaire (HAQ) does not comprehensively cover functional limitations in patients with systemic sclerosis. Visual Analogue Scales added to the modified HAQ reflect general and organ-specific symptoms only to some extent. The Self-administered Systemic Sclerosis Questionnaire (SySQ) includes general, organ-specific and musculoskeletal symptoms with a focus on functional limitations of the upper and lower extremities. The SySQ has not been examined longitudinally nor has it been validated cross-culturally. WHO's International Classification of Functioning, Disability and Health (ICF) could serve as a future reference framework and common language in terms of the design of new disease-specific, patient-centered, comprehensive questionnaires for systemic sclerosis as well as in the further improvement of established questionnaires.

[Physical therapy to treat spinal stenosis]. / Physikalisch-medizinisches Behandlungskonzept beim Syndrom des engen Spinalkanals.

Spinal stenosis mainly is a disease of the elderly. In most cases the lumbar spine is affected. The assessment is based on the typical constellation of symptoms (neurogenic claudication, subjective weakness) and physical findings (abnormal reflex status, loss of strength, sensory deficits, impairment in balance and coordination). The diagnosis is further supported by the radiologic proof of a stenosis of the spinal canal, the lateral recess, and the intervertebral foramina. The main targets of physical and rehabilitative medicine are the relief of pain and an improvement in the activities of daily living, which are especially impaired by reduced walking distance and difficulties in climbing stairs. These can be achieved by multimodal, conservative management: physiotherapy, occupational therapy, treatment of myofascial disorders, and oral medication/local injections. Physiotherapy aims at a stabilization of the lumbar spine in a flexed posture rather than in lumbar lordosis and at an increase of overall physical fitness. Oral analgetic and/or anti-inflammatory medical management is based on the three-step scheme of the World Health Organization, which also can be applied for low back pain. Local injections can help to control symptoms. Myofascial disorders are treated by techniques and procedures such as traditional massage.