[Development of quality standards for patients with axial spondyloarthritis for use in Germany]. / Entwicklung von Qualitätsstandards für Patient*innen mit axialer Spondyloarthritis zum Einsatz in Deutschland.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.

Should capacity assessments be performed routinely prior to discussing advance care planning with older people?

ABSTRACTBackground:People with dementia receive worse end of life care compared to those with cancer. Barriers to undertaking advanced care planning (ACP) in people with dementia include the uncertainty about their capacity to engage in such discussions. The primary aim of this study was to compare the Advance Care Planning-Capacity Assessment Vignette tool (ACP-CAV) with a semi-structured interview adapted from the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The secondary aim was to identify demographic and cognitive functioning variables that may predict whether a person has capacity to discuss ACP. METHODS: 32 older people (mean age = 84.1) with a Mini-Mental State Examination of 24 or above were recruited from two retirement villages in Auckland. Participants also completed Trail Making Test Part A & Part B and Geriatric Depression Scale (GDS-15) before undertaking the two capacity assessments that were video recorded to enable further analysis by four independent old age psychiatrists. RESULTS: Using the MacCAT-T as the gold standard, over half (53.1%) of the participants were considered as lacking in capacity to engage in ACP. Participants struggled with the "Understanding ACP" domain the most. Capacity was not predictable by any of the demographic or cognitive functioning variables. When compared to the gold standard, ACP-CAV was accurate in assessing capacity in 68.8% of the cases. CONCLUSION: Clinicians should routinely explain ACP to older people and ensure they fully understand it prior to an ACP discussion. If there is any concern about their understanding, further exploration and documentation of their capacity using the capacity assessment framework would be necessary. However, capacity assessment is a complex iterative process that does not easily lend itself to screening methodology and requires a high level of clinical judgment.

Upper-Urinary-Tract Effects After Irreversible Electroporation (IRE) of Human Localised Renal-Cell Carcinoma (RCC) in the IRENE Pilot Phase 2a Ablate-and-Resect Study.

PURPOSE: Irreversible electroporation (IRE) is a new potential ablation modality for small renal masses. Animal experiments have shown preservation of the urine-collecting system (UCS). The purpose of this clinical study was to perform the first evaluation and comparison of IRE's effects on the renal UCS by using urinary cytology, magnetic-resonance imaging, and resection histology in men after IRE of pT1a renal-cell carcinoma (RCC). METHODS: Seven patients with biopsy-proven RCC pT1a cN0cM0 underwent IRE in a phase 2a pilot ablate-and-resect study (IRENE trial). A contrast-enhanced, diffusion-weighted MRI and urinary cytology was performed 1 day before and 2, 7, and 27 days after IRE. Twenty-eight days after IRE the tumour region was completely resected surgically. RESULTS: Technical feasibility was demonstrated in all patients. In all cases, MRI revealed complete coverage of the tumour area by the ablation zone with degenerative change. The urographic late venous MRI phase (urogram scans) demonstrated normal morphological appearances. Urine cytology showed a temporary vacuolisation of the cyto- and caryoplasmas after IRE. Whereas the urothelium showed signs of regeneration 28 days after IRE-ablation, the tumour and parenchyma below it showed necrosis and permanent tissue destruction. CONCLUSIONS: Renal percutaneous IRE appears to be a safe treatment for pT1a RCC. The preservation of the UCS with unaltered normal morphology as well as urothelial regeneration and a phenomenon (new in urinary cytology) of temporary degeneration with vacuolisation of detached transitional epithelium cells were demonstrated in this clinical pilot study.

[The 7th international congress on spondyloarthropathy: Gent, October 2010]. / 7. Internationaler Spondyloarthropathie-Kongress: Gent, Oktober 2010.

At the Spondyloarthropathy (SpA) Congress 2010 new results were presented on the pathophysiology, imaging and therapy of this disease. With a better understanding in particular of the bone biology, the causes of the disease-specific alterations in bone could be explained in the future so that new therapy options can be developed. Magnetic resonance imaging is a milestone for a better understanding of the pathophysiology of SpA. Against the background of the pressure of increasing costs in the healthcare system and cost-intensive biologics it was discussed how well the therapeutic response to TNFα antagonists can be predicted. In connection with this it was critically commented that in the clinical routine time limited attempts at therapy in order to decide how the therapy should be continued depending on the response would be more useful than to make a strict selection of patients based on predictors.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months.

OBJECTIVE: To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage. DESIGN: A prospective study with follow up at 6 and 13 months after miscarriage. SETTING: Three Scottish Early Pregnancy Assessment Units. SAMPLE: Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months. METHODS: On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments. MAIN OUTCOME MEASURES: The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples. RESULTS: Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors. CONCLUSIONS: These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

[Perineal sonography: using time modulated 2D-ultrasound in a freehand 3D technique]. / Zeitmodulierte 2D-Sonographie in Freehand-3D-Technik als Perinealsonographie.

AIM: The employment of a new transperineal ultrasound technique, which demonstrates the dynamics of the temporal change in the positions of the urethra and bladder under standardized Valsalva pressure, was evaluated with regards to the possibility of diagnosing and classifying the various types of descension. METHOD: Transperineal ultrasound using a 3 - 5 MHz Curved array transducer was performed on 21 female patients with urinary incontinence. The results were compared with the clinical examinations and the urodynamic measurements. RESULTS: 17 of 21 profiles could be clearly classified as either rotatory or vertical descension types. 2 of the profiles could not be classified due to lack of patient cooperation, and 2 could not be classified due to technical problems. CONCLUSION: This new method allows a safe diagnosis of the descension types in most cases. All dynamics of the examination can be documented.

[Do questionnaires for patients improve the diagnosis of craniomandibular dysfunction with chronic facial pain? A patients' questionnaire study from outpatient practice]. / Verbessern Patientenfragebögen die Diagnostik der kraniomandibulären Dysfunktion (CMD) mit chronischen Gesichtsschmerzen? Fragebogenstudie aus der Praxis.

PURPOSE: The differential diagnosis of craniomandibular dysfunction (CMD) is of central importance for the therapy and diagnosis of chronic facial pain. Nevertheless, opinions on causes and treatment differ extremely and are sometimes even contradictory. The necessity of obtaining a precise and thorough patient history is indisputable. This raises the question of whether a questionnaire can offer additional information in order to improve the quality of the history, diagnosis and therapy. MATERIAL AND METHODS: From May 1998 until February 1999, 230 patients who received a monoblock were requested to fill out a questionnaire referring to the previous 4-6 weeks, as an addition to the initial diagnostic tests. In 175 cases we were able to repeatedly examine the patient and compare the effects of therapy with the questionnaires. The questionnaire contains 14 visual, 11-step analogue scales, which are to be marked spontaneously and subjectively. The test-retest reliance at 1 week before treatment was r=0.82 ( n=86). The questionnaire requests information on diverse kinds of pain, sensations and findings in the dental, oral, maxillary and facial areas. For evaluation, a summation-score is built. RESULTS: To our surprise, from a total of 175 patients 41.7% ( n=73) indicated their pain exclusively on the questionnaire. The number and frequency of answers indicated CMD. The average score of the patients whose pain was only mentioned on the questionnaire (31.16+/-19.16) was just slightly below the score of patients with additional, verbal pain descriptions (36.49+/-20.79). CONCLUSION: The picture provided by the answers is impressive for the patient, improves compliance and makes diagnosis easier. In the same way, one can document the success of therapy and explore individual outcomes which show a resistance to therapy.

Three-dimensional multiplanar time-motion ultrasound or anatomical M-mode of the fetal heart: a new technique in fetal echocardiography.

OBJECTIVE: To assess the application of a three-dimensional multiplanar rendering technique for examination of the fetal heart. MATERIAL AND METHODS: Free-hand acquisition of a three-dimensional volume was performed without moving or tilting the transducer. While the anatomical plane shows the four cardiac chambers, the two other orthogonal planes show vertical and horizontal time-axis planes as M-mode traces. Because off-line plane positioning is possible on three-dimensional multiplanar reconstruction, M-mode traces can be obtained from different stored cardiac structures independently of the fetal position. Fifty-two women with normal singleton pregnancies at 22-40 weeks underwent transabdominal ultrasound examination and five women with singleton fetuses between 13 and 15 weeks were assessed transvaginally. Clinical application of the echocardiographic technique was tested in a further two fetuses with arrhythmia. RESULTS: Off-line M-mode traces from atrioventricular valve excursions and myocardial contractions were possible in 45/52 (86.5%) cases examined at 22-40 weeks. Among the 32 fetuses in which visualization of the outflow tracts was attempted, M-mode traces of the aortic and pulmonary valves were possible in 22 (68.7%) and 20 (62.5%) cases, respectively. In three of five cases examined transvaginally, M-mode traces could be registered. Both cases with supraventricular extrasystoles (26 and 31 weeks) were easily diagnosed using this technique. CONCLUSION: The new technique presented here enables the easy acquisition of optimal M-mode traces from different fetal heart structures. Based on our promising findings we would recommend that, in the future, three-dimensional multiplanar imaging should not be limited to automatic volume acquisition but should include the free-hand technique.

[3D-sonography as "2D-M-mode sonography in fetal echocardiography]. / 3D-Sonographie als "2D-M-Mode-Sonographie" in der fetalen Echokardiographie.

AIM: Establishing a technique employing 3D-ultrasound for the echocardiographic examination of foetuses. METHOD: M-mode sonography has reached considerable importance in the detection of arrhythmia as well as pathological changes of the heart valves and contraction disorders of the foetal heart. The variability of the position of the foetus leads to problems typically arising with this method. The ventro-anterior position along the long axis of the foetal heart, being the optimal position for prenatal echocardiography, allows no examination in M-mode because the plane of the valve lies vertically in relation to the direction of the ultrasound. A special appliance of 3D-sonography solves the problem by providing a 2-dimensional examination technique of the heart in M-mode independent of the position of the foetal heart. The method allows simultaneous measurement of the movement of different parts of the myocardium in several different planes. By fixing the position of the applicator (in B-mode) and choosing the 3D-sequence in the "free-hand-mode" one gets a 2-dimensional time-tissue-block which contains all movements in the chosen axis. These "time planes" can be deliberately selected for the examination of different planes in the fixed B-mode image which shows their variations along the time axis. RESULTS: Our study describes the application and evaluation of this examination during pregnancy between the 28th and 40th week. Reliable images of the AV-valves or the aortic valve could be produced in 73% of examinations.

[Recommendations for the standardized evaluation and classification of patients with painful temporomandibular disorders]. / Schmerzen im Bereich der Kaumuskulatur und Kiefergelenke Empfehlungen zur standardisierten Diagnostik und Klassifikation von Patienten.

INTRODUCTION: Due to the considerable degree of variation that exists among care providers with respect to the assessment of patients suffering from painful temporomandibular disorders (TMDs), an interdisciplinary working group for the study of orofacial pain aimed at developing recommendations for the evaluation and diagnostic classification of such patients. METHODS: Following an extensive literature search (computer-based search and handsearch), several working sessions were needed to develop a standardized diagnostic protocol. It was a prerequisite that recommended measures and instruments should have acceptable reliability and validity. Three independent reviewers - well-known experts in the pain field - critically reviewed the contents of our recommendations. RESULTS: A two-axis approach is recommended to assess the somatic and psychosocial parameters of the pain experience. Our concept closely follows the Research Diagnostic Criteria for Temporomandibular Disorders. In addition, we distinguish a minimal, a standard, and an extended evaluation. CONCLUSIONS: The recommendations appear to be useful to enhance the diagnostic quality in the evaluation of patients with painful TMDs.

[Theoretical and experimental models of sonographic diagnosis of umbilical cord knot and their application in practice]. / Theoretisch-experimentelle Uberlegungen über die sonographische Diagnose des Nabelschnurknotens und deren praktische Anwendung.

Modern sonographic technique allows the detection of cord complication as neck cord entanglement. Far more difficult is the detection of a real cord knot. This article describes a theoretical model for detection of a cord knot and proves it in an in-vitro model.

[Dental trigeminal neuralgia]. / Dentogene Trigeminusneuralgie.

INTRODUCTION: Although the majority of patients with recurrent hyperalgesia of the nervus trigeminus may benefit from drug treatment or invasive (thermocoagulation) and other surgical interventions, a minority of patients does not respond to these strategies. Hence, unusual etiologies must be taken into consideration. CASE REPORT: Mrs F., a 74-year-old women suffered from acute left-side trigeminalgia ten days after receiving a new dental prosthesis (upper jaw). Intensive pain attacks occurred spontaneously when she was speaking and could also be evoked by gentle exogenous pressure at the upper lip. INTERVENTION: The painful area has been identified by careful clinical evaluation. Local administration of antibiotics combined with laser coagulation successfully cured the trigeminalgia after 4 weeks which did not recur in the follow-up period over 2 months. CONCLUSION: Since patients longer history revealed pain attacks of minor severity we suggest that local inflammation at the gingiva might have stimulated quiescent nociceptors over time. The local pressure to this area evoked by the new prosthesis seems to be definitive trigger factor to intensify the nociceptor response resulting in higher number of trigeminalgia attacks of marked severity. We therefore conclude that differential diagnosis of symptomatic trigeminalgia should include dental gingival mechanisms at least in a case exhibiting resistances to other treatment.

Development and evaluation of an inexpensive sensor system for use in measuring relative finger positions.

An inexpensive sensor was developed using a carbon-based electrically conductive ink. A correlation of the actual flex angle to the measured flex angle of the sensors was obtained by experimentally determining a third-order polynomial that represented the response of the sensor and its hardware system (r = 0.999). The response time, when going from an angle of 0-90 degrees, was extremely good. The sensors exhibited an acceptable dynamic response with an error of less than 5% when flexed repeatedly to an angle of 90 degrees. A second-order polynomial was found to express the resistance as a function of angle (r = 0.999) for all of the sensors tested. Although these sensors are not as precise as the more expensive sensors that are available, it was estimated that the production cost of these sensors was less then US $0.50 a piece. In addition, there are many ways that the sensor production method might be improved to produce more accurate sensors using carbon-based electrically conductive ink. While much additional work is still necessary, the system presented in this paper could be incorporated into a complete device to monitor the rehabilitation of an impaired hand. Unlike other systems that are currently available commercially, this system is inexpensive, easily manufactured, accurate, and could be readily used in a variety of clinical settings.

Syntheses and biological activities of new N1-aryl substituted quinolone antibacterials.

A series of quinolones with a systematically varied substitution at the phenyl ring at N1 has been synthesized. Three lipophilicity descriptors (log K, log P, Rm) and the pKa values have been determined as well as the microbiological activity: The MIC values for eight different strains of three Gram-positive and three Gram-negative species and the inhibitory concentrations of DNA supercoiling (IC90 and IC100) were determined. From a principal component and a QSAR analysis relationships between antibacterial activity concerning the whole-cell system and electronic properties as well as the length of the substituents at the phenyl rings could be derived. The activity in a cell-free system was governed by the lipophilicity and the width of the substituents. It is speculated that the quinolones take a defined place in the DNA gyrase-DNA complex which is characterized by polar amino acids. This is in agreement with findings from studies of mutant gyrases.

The effect of castration on steady state levels of luteinizing hormone-releasing hormone (LHRH) mRNA and proLHRH processing: time course study utilizing semi-quantitative reverse transcription/polymerase chain reaction.

Many studies have consistently shown that castration induces a prompt increase in serum levels and pituitary content of the gonadotropins, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), as well as a concomitant rise in steady state levels of the messenger RNAs directing their synthesis. The reports of effects of castration on the overall physiology of hypothalamic luteinizing hormone-releasing hormone (LHRH)--steady state levels of LHRH mRNA, post-translational processing and secretion--have, however, not been consistent. The goal of the studies reported here was to provide the first analysis of the effect of castration, at multiple postoperative time points, on steady state levels of LHRH mRNA and on the levels of hypothalamic proLHRH. All these data are correlated with hypothalamic levels of the mature LHRH decapeptide and with serum and pituitary levels of immunoreactive LH and FSH. Adult male rats were either castrated or sham-castrated (controls) and then sacrificed at 1, 3, 5, 7, 14, 21 or 28 days postoperatively. As expected, there was a prompt and sustained rise in serum immunoreactive LH and FSH in castrates compared with sham-operated animals. Intra-pituitary LH levels rose above levels in the sham-operated animals by 14 days post castration. Intra-pituitary FSH showed a biphasic response, first falling significantly below control levels, then rising above control levels at 21 days. Steady state levels of LHRH mRNA in castrates, measured by reverse transcription/polymerase chain reaction, were increased about 2-fold above control levels by 1 day postoperatively, but were virtually identical to control levels at each of the other time points despite marked changes in the gonadotropins. ProLHRH content in castrates was 1.8-times that seen in controls at 1 day post castration (P<0.05), concomitant with the rise in steady state levels of LHRH mRNA at that time point. However, proLHRH content in castrates was no different from that seen in controls at each of the later time points examined. LHRH content was unchanged through 7 days after castration, but then fell significantly to 57% of control levels in hypothalami from animals gonadectomized 14 to 21 days previously (P<0.001 vs control), and to 54% of sham-operated levels at 28 days postoperatively (P<0.001). We conclude that: (1) changes in steady state levels of LHRH mRNA after castration are small and transient and (2) increased proLHRH coupled with unchanged LHRH levels at 1 day post castration, and castrate animal proLHRH at control levels coupled with falling LHRH at later post-castration time points indicate that the effect of gonadectomy on post-translational processing of proLHRH to LHRH is, likewise, small and transient. In aggregate our data suggest that most of the increase in serum LH and FSH seen in male rats after castration is not mediated at the hypothalamic level.

Identification of a candidate CD5 homologue in the amphibian Xenopus laevis.

We identified a novel T cell Ag in the South African clawed toad (Xenopus laevis) by a mAb designated 2B1. This Ag is present in relatively high levels on most thymocytes, approximately 65% of splenocytes, 55% of PBL, and 65% of intestinal lymphocytes, but is rarely seen on IgM+ B cells in any of these tissues. Lymphocytes bearing the 2B1 Ag proliferate in response to stimulation with Con A or PHA, whereas the 2B1- lymphocytes are reactive to LPS. Biochemical analysis indicates that this Ag is a differentially phosphorylated glycoprotein of 71 to 82 kDa. The protein core of 64 kDa bears both N- and O-linked carbohydrate side chains. The amino-terminal protein sequence of the 2B1 Ag shares significant homology with both the macrophage scavenger receptor type 1 motif and the mammalian CD5/CD6 family. The biochemical characteristics and cellular distribution of the 2B1 Ag suggest that it represents the CD5 homologue in X. laevis. While T cells constitutively express this highly conserved molecule, Xenopus B cells acquire the CD5 homologue only when they are stimulated in the presence of T cells.

[Evaluation of third molar surgery by patients choosing between local anaesthesia alone and with additional conscious sedation.]. / Bewertung der operativen Weisheitszahnentfernung durch sedierte und nicht sedierte Patienten.

UNLABELLED: This study was conducted on patients undergoing third molar surgery to evaluate their opinions on surgery and the follow-up period. Two groups were formed, as patients were able to choose between local anaesthesia alone or with additional conscious sedation by means of intravenous Midazolam. METHODS: A total of 426 patients ranging in age from 11 to 61 years (mean 20.8 years) participated, 335 of whom preferred Midazolam sedation (0.1 mg/kg) while 91 voted for local anaesthesia only. During the operation an impacted lower third molar was removed by osteotomy, and in 80% of these cases the upper third molar on the same side was also removed. A questionnaire on the operation, the follow-up period, postoperative pain and use of analgesics was distributed before the event. RESULTS: Women and younger patients preferred conscious sedation. Surgery was described as significantly less distressing by the sedated group (diagram 1), whereas there was no difference in views of the follow-up period or postoperative pain. Patients in the Midazolam group took more analgesics on postoperative days 1-3. Nonsedated men tended to evaluate surgery as more distressing than women in the same group, while there were no sex differences in the Midazolam group. CONCLUSION: Following the evaluation of surgery as more "pleasant" by sedated patients, it might be expected that this would contribute to a similar experience of the follow-up period. In this study, however no such connection was found. It is possible that preoperative self-selection of the patients (more sensitive and cautious persons preferred conscious sedation) might be responsible for these results.

[Multiple work stations for an ultrasound device]. / Multiple Arbeitsplätze für ein Ultraschallgerät.

A possible technical innovation of ultrasound technique could take into consideration the multiple use of the ultrasound system and thereby facilitate the utilisation for the examining physician and the equipment. This innovation is described and discussed in detail in the following essay.

[Detection of EWS-/FLI-1 gene fusion transcripts by RT-PCR as a tool in the diagnosis of tumors of the Ewing sarcoma group]. / Nachweis von EWS/FLI-1-Genfusionstranskripten mit RT-PCR als diagnostische Hilfe bei Tumoren der Ewing-Sarkom-Gruppe.

Recent cloning of the chromosome breakpoint regions of the reciprocal chromosomal t(11;22) (q24;q12) has revealed that the breakpoints were localized within the EWS gene (Ewings sarcoma gene) on chromosome 22 and the FLI-1 gene on chromosome 11. Thus, molecular genetic techniques were applicable for the detection of this genetic aberration, which occurs as a consistent feature of the Ewings tumor family. By reverse transcription and polymerase chain reaction technique (RT-PCR) in 78% of Ewings sarcoma derived cell lines, and in 91% of primary Ewings tumor tissue t(11;22) specific EWS/FLI-1 fusion transcripts were detected. Furthermore, in bone marrow samples from an Ewings sarcoma patient contaminating tumor cells could be shown by RT-PCR. Our results indicate that molecular genetic detection of the t(11;22) translocation opens a new modality for the differential diagnosis and the staging of Ewings tumor patients.