[Telemedical prenotification in acute stroke treatment : Experiences from the Stroke Angel initiative from 2004 until the present]. / Telemedizinische Voranmeldung in der akuten Schlaganfallversorgung : Erfahrungen der Stroke-Angel-Initiative von 2004 bis heute.

OBJECTIVE: The Stroke Angel initiative investigates the implementation of telemedicine for improvement of preclinical communication between emergency medical services (EMS) and stroke units in cases of acute stroke. MATERIAL AND METHODS: Stroke Angel is a technical system for the telemedical prenotification of patients in cases of suspected stroke at a stroke unit by the EMS. Within the framework of an observational study, the team has been investigating the effects of the system on door-to-computed tomography (CT) and door-to-needle times as well as the lysis rate in the neighboring regions of Rhön-Grabfeld and Bad Kissingen since 2005. RESULTS: The system supports the acute treatment of neurological emergencies and functions as a catalyst for the interlinking of medical institutions in the region as well as for communication between emergency physicians/EMS and hospital physicians. The use of a computer-based data collection enables a continuous improvement process leading to an acceleration of internal clinical procedures and an increase of the lysis rate with the mortality rate staying constant. CONCLUSION: Telemedicine is applicable in the preclinical care of acute stroke and, thanks to the computer-based data collection, leads to an increase in process transparency, which helps to improve the internal clinical processes in and around a stroke unit.

[Mobile computing systems in preclinical care of stroke. Results of the Stroke Angel initiative within the BMBF project PerCoMed]. / Einsatz mobiler Computing-Systeme in der präklinischen Schlaganfallversorgung. Ergebnisse aus der Stroke-Angel-Initiative im Rahmen des BMBF-Projekts PerCoMed.

BACKGROUND: Telemedical networks that apply innovative mobile information technologies (IT) are an innovative approach to improve stroke care in community settings. Within the German Stroke Angel initiative and the research project PerCoMed (Pervasive Computing in Medical Care, funded by the Federal Ministry of Education and Research, http://www.percomed.de) the effects of such a solution were assessed by an interdisciplinary research approach. The main goal of the team of researchers and practitioners was to provide clear evidence of improvements in intersectional processes of the stroke chain survival, namely in the acute stroke processes between prehospital rescue services and hospital stroke units. MATERIAL AND METHODS: Between October 2005 and October 2007 the paramedical staff of five rescue service transporters in a rural area of northern Bavaria was included in a network with the stroke unit of the Neurological Clinic Bad Neustadt. Telemedical support by the Stroke Angel computing system - a software running on a personal digital assistant (PDA) to transmit patient data from the rescue team to the hospital during patient transporting time - was established. As procedural guidance, the Stroke Angel system suggests a predefined path through the necessary emergency procedures according to the structure of the mandatory protocol and the implemented Los Angeles Prehospital Stroke Screen (LAPSS). RESULTS: In the empirical study the authors obtained a complete data set of 226 consecutively admitted patients for analysis in Bad Neustadt and LAPSS data of 217 patients from a second scenario in Düsseldorf. Medical, economic and technical analyses were applied. The technological robustness of the Stroke Angel system could be proven and information entered was transmitted fully and correctly. Concerning medical research questions, for both scenario locations LAPSS with a sensitivity of 68.3% and a specificity of 85.1% has to be deemed insufficient. Hence, alternative algorithms will have to be used in the next steps of evaluation. The system significantly influenced the clinical process of acute stroke management more than the preclinical ones (door-to-CT: 32 min. before and 16 min. at the end of the project). Lysis treatment rose from 6.12% (2005) to 11.17% (2007) of patients with acute stroke. CONCLUSIONS: From the set of perspectives taken, the study illustrates that mobile computing technologies offer new and innovative approaches to improve intersectional acute stroke care. It also teaches the participants that interdisciplinary research can significantly deepen the understanding of such technologies and projects, which can lead to better decision making concerning solution implementation, management and improvements. The approach will be brought into daily practice in Bad Neustadt/Saale within the next months.

Simple explanation for the X(3872) mass shift observed in the decay X(3872)-->D*0 D0.

We propose a simple explanation for the increase of approximately 3 MeV/c;{2} in the mass value of the X(3872) obtained from D(*0)D(0) decay relative to that obtained from decay to J/psipi(+)pi(-). If the total width of the X(3872) is 2-3 MeV, the peak position in the D(*0)D(0) invariant mass distribution is sensitive to the final state orbital angular momentum because of the proximity of the X(3872) to D(*0)D(0) threshold. We show that for total width 3 MeV and one unit of orbital angular momentum, a mass shift approximately 3 MeV/c(2) is obtained; experimental mass resolution should slightly increase this value. A consequence is that spin-parity 2(-) is favored for the X(3872).

[Acute treatment of patients after a stroke. From the incident site to the stroke unit]. / Akutversorgung des Patienten mit Schlaganfall. Vom Einsatzort bis zur "stroke unit".

Strokes are the third most common cause of mortality in western countries and the main cause of long-term invalidation. Systemic intravenous thrombolysis is the current therapeutical choice in acute stroke within 3 h after clinical onset but new pharmacological developments will have the potential to expand the time window for 6 h or more. To safeguard this option and for optimal treatment of stroke patients, better preclinical structures are necessary. A stroke is an extremely urgent case and emergency rescue services must treat this situation in a similar manner to polytrauma or cardiac arrest. Rescue services will need more training and knowledge in basic neurological examination and standard acute therapy, including maintaining sufficient oxidation of the brain, therapy of possible cardiac arrhythmias, blood pressure management, blood sugar disturbances and hyperthermia. Prior announcement of patients in the admitting hospital is desirable.

[Diagnostic angiography using multi-slice spiral CT in acute obstruction of the basilar artery]. / Angiographische Diagnostik mittels Mehrzeilen-spiral-CT beim Akutverschluss der Arteria basilaris.

OBJECTIVE: To evaluate the diagnostic efficiency of CT angiography in case of clinical signs of acute brainstem infarction for the therapeutic management of catheter-based local thrombolysis. MATERIAL AND METHODS: 3 patients (2 males, 1 female) suffering from an acute onset of brainstem symptoms and being suspicious of an occluded basilar artery were included into this report. 1 patient underwent selective vertebral arteriography. 2 patients were initially examined with CT angiography using a 4-row scanner and 100 ml intravenous contrast agent. RESULTS: In one patient, an occlusion of the basilar artery was excluded with catheter-based angiography. Subsequently, the patient was treated with systemic thrombolysis using r-tPA because of a thalamus infarction seen in MRI. 2 patients who have been initially examined with CT angiography presented with complete occlusions of the basilar arteries. These patients underwent r-tPA thrombolysis by means of superselective micro-catheter approaches of the vertebrobasilar vessels. CT angiography was very useful for determinating the occlusion length of the basilar artery pre-therapeutically, and in 1 case for ruling out an occluded vertrebral artery for catheterization. All patients recovered well under thrombolytic therapy applied systemically or selectively. CONCLUSION: Cerebral multi-slice CT angiography is a fast and save technique for detecting or ruling out an acute basilar artery occlusion. Thus, in cases of equivocal clinical signs CT angiography is recommended before the decision of thrombolytic therapy is made.

Hymenoptera venom allergy: time course of specific IgE concentrations during the first weeks after a sting.

Detection of IgE antibodies specific to honeybee or Vespula venoms is an important criterium firstly for the diagnosis of sensitization and secondly for the indication for a specific immunotherapy. Some authors recommend to postpone blood analysis after an insect sting for a certain time because circulating IgE antibodies might be consumed by the allergic reaction, which would result in a false-negative test outcome. We investigated IgE concentrations during the first weeks after an insect sting in 31 patients with an unequivocal history of an anaphylactic reaction after a honeybee (n = 13) or Vespula (n = 18) sting. Blood samples for analysis of specific IgE concentrations (CAP system, Pharmacia Diagnostics, Sweden) were collected within 2 weeks and 5+/-2 weeks after the insect sting. 12/13 patients with honeybee venom and 14/18 patients with Vespula venom sensitization had CAP classes 1 or higher within the first 2 weeks. Those 5 patients with CAP class 0 within the first 2 weeks had detectable IgE concentrations a few weeks later. We conclude that testing for specific IgE to hymenoptera venoms is in most cases useful even during the first 2 weeks after the hymenoptera sting. This allows early decisions on further diagnostic procedures and the therapeutic way to choose. Patients with no detectable IgE should, however, be retested after a few weeks.

[Extensive cutaneous-subcutaneous infiltration as a side-effect of interferon-beta injection]. / Grossflächige kutan-subkutane Infiltrate als Nebenwirkung von Interferon-beta-Injektion.

Interferon alpha and gamma have been used to treat several hepatic, hematological and oncological diseases for years. Recently, interferon beta has been introduced as a therapeutic agent in relapsing-remitting multiple sclerosis. A 41-year-old female patient with multiple sclerosis developed non-tender, palm-sized, cutaneous-subcutaneous, reddish infiltrates at the injection sites on her thighs after 8 weeks of treatment with subcutaneous interferon beta injections. Histopathology revealed a perivascular lymphoid infiltrate of the dermis and a subtle lobular lymphoid infiltrate of the subcutis. Interferon beta therapy was discontinued for 4 weeks. With topical corticosteroids, the skin lesions resolved. When subcutaneous injections were resumed at a reduced dose, only erythema around injection sites developed without induration or pain. Slight erythema and swelling at interferon beta injection site are frequent and rare cases of cutaneous necrosis have been described. However, no reports of large, painful, cutaneous-subcutaneous infiltrates after interferon beta therapy have been published.

[Conception, implementation and evaluation of the new general medicine continuing education curriculum in Südbaden]. / Konzeption, Durchführung und Evaluation der neuen Kursweiterbildung Allgemeinmedizin in Südbaden.

Since 1994, seminars for the new curriculum in general practice are conducted by the Academy of Continuing Medical Education (consists of the regional medical board and the association of public health insurance in Südbaden). Specialists of different medical disciplines supported by general practitioners in the role of moderators are preparing and teaching a wide range of topics. The general practitioners are supervising the different courses, thus, facilitating the learning process of the participants. Furthermore, the facilitators have to work out the specific needs and requirements of general practice and family medicine. The topics are presented in a form of lessons and clinical cases discussed in small groups (problem-oriented approach). The evaluation of two seminars was carried out in 1994 and 1995 including two thirds of the complete curriculum in general practice. From the positive results of the evaluation, modification and improvement of the didactic concept for future seminars in 1996 are derived.

[Patch testing with the "Austrian standard series"--epidemiologic test values and results]. / Epikutantestung mit der "Standardreihe Osterreich"--Testepidemiologische Kenngrössen und Ergebnisse.

Patch testing for contact allergies is routinely performed by applying a "standard series" of the most frequently occurring contact allergens. Internationally "established" standard series have to be adapted to country- and population-specific factors (i.e., distribution of gender and age, occupational behavior, environmental factors etc.). In 1992 and 1993 altogether 11,690 patients were patch tested in 14 Austrian test centers with the "Austrian standard patch test series" as recommended by the working group "Contact Allergy" of the Austrian Society of Dermatology. Altogether data on 11,544 patients were complete and are analyzed in this study. 71.5% of the test population were female with an average age of 39 years, whereas the male patients had an average age of 40 years. 38.1% of the patients were younger than 30 years, 47.8% were in the group ranging from 31 to 60 years and 14% of the tested patients were older than 60 years. Cutaneous sensitization was found in 51% of the people tested with the "Austrian standard series". This proportion varied between 40.8 and 61.4% from center to center (with more than 100 tested persons). 15 (60%) of the 25 test substances in 1992 and 17 (68%) in 1993 surpassed the limit of a sensitization frequency of 1%. The "hit list" of substances did not differ qualitatively from those of other international studies, with only one remarkable, well described "Austrian-specific" exception, namely the mercury-containing thiomersal (second place).(ABSTRACT TRUNCATED AT 250 WORDS)

Experimentally induced malignant lymphoma due to chronic antigen stimulation.

Animal experiments were started in 1988 with the aim of inducing malignant lymphomas. 52 guinea pigs were exposed to potassium dichromate using the TINA test (plus 39 control animals). Following the sensitization procedure, the test animals and 15 control guinea pigs were exposed daily (5 x a week) epicutaneously to the antigen up to the present time. Currently, 30 exposed and 17 control animals are still in the experiment. In 3 out of 17 post-mortem examinations, histologically evident lymphomas were found. In the control animals, no tumor has been seen. The experiments support lymphoma causation by chronic antigen stimulation. The experiments are continuing.

Induction of type IV hypersensitivity to contact allergens in guinea pigs by in vitro haptenized allogenic peritoneal exudate cells.

The induction of type IV hypersensitivity to contact allergens in guinea pigs has been studied by using allogenic peritoneal exudate cells (> 90% macrophages), which had been incubated primarily in vitro with dinitrochlorobenzene, formaldehyde, potassium dichromate, nickel II sulphate or para-aminobenzoic acid. In these guinea pig sensitization experiments Freund's complete adjuvant was used. In all haptens investigated the sensitization rates of the presented method were parallel to the known contact allergenicity in humans and, apart from the potassium dichromate results, comparable with those of the guinea pig maximization test. Because of its alternative immunization procedure, in which only few or no allergen molecules escape the effective presentation pathway, the authors conclude that this method could be developed into a predictive test assay for the evaluation of the contact allergenicity of water-soluble substances.

[Chemically-induced scleroderma]. / Chemisch induzierte Sklerodermie.

Scleroderma-like diseases can be induced by a number of chemical compounds, such as plastics, solvents and drugs. Contaminated rapeseed oil was the cause of the toxic oil syndrome and L-tryptophan induces the so-called eosinophilia-myalgia-syndrome. On the other hand, paraffin and silicon can trigger so-called adjuvant disease, while long-term exposure to silica can lead to idiopathic scleroderma (associated with silicosis in some cases). In addition to the clinical features, some pathogenetic data in the literature, such as genetic factors (HLA, chromosomal anomalies, enzyme deficiencies) and the metabolism of chlorinated ethylenes via reactive epoxide intermediate products, and our own findings are reported. Silica-induced scleroderma cannot be distinguished from the idiopathic form by epidemiological, clinical or immunological studies or by parameters referring to the blood vessels or collagen metabolism. In cell culture studies it has been shown that macrophages/monocytes release IL1, IL6 and TNF after ingestion of silica, which affects fibroblasts, T-helper cells and endothelial cells. Comparative results from the silicosis literature are reported. Finally, the possibly stimulating role of ionizing irradiation (uranium mining) in favouring the development of scleroderma is discussed.

[Contact eczema and "standard test"--do "International Standard Test Series" coincide with Austrian local characteristics?]. / Kontaktekzem und "Standardtest"--Entsprechen "Internationale Standardtestreihen" den österreichischen Gegebenheiten?

Testing with a "standard" group of substances has proved of great value when allergic contact dermatitis is suspected and the offending agent cannot be pinpointed by careful history-taking. But internationally standardized series do not take into account locally important and individual factors, changing consumer habits or economic aspects. We have, thus, compared the suitability of two standard series, the ICDRG-European and the DKG-German standard, for Austrian purposes. 1,478 patients with a clinical diagnosis of contact dermatitis were patch tested between 11/88 and 4/90 with the ICDRG allergens; the second collective of 505 patients was tested between 5/90 and 1/91 with the DKG series. Only 12 out of the 27 substances of the ICDRG series exceeded the critical incidence of 1%; 6 were below this limit but positive in more than 0.5% and 9 hardly ever aroused positive reactions. In the DKG series, 17 out of 23 substances surpassed the limit, 2 were positive in more than 0.5%, and 4 caused virtually no reactions. However, 4 allergens with frequent sensitization rates were included neither in the ICDRG nor in the DKG series and 2 others were missing in the over-dimensioned ICDRG standard. Our results demonstrate that internationally established standard series have to adapted for the local situation in Austria, and that a constant review is essential with replacement of allergens as necessary according to changing production techniques and consumer habits. Suggestions for an "Austrian standard patch test series" are proposed on the basis of our results but in spite of being helpful in general terms interpretation of such a test in the individual patient with eczema remains problematic.

[The mentally ill artist in the work of E. T. A. Hoffmann in relation to psychological theories at that time]. / Der geistig gestörte Künstler im Werk E.T.A. Hoffmanns vor dem Hintergrund zeitgenössischer psychologischer Theorien.

The work of one of the greatest writers of German Romanticism, E.T.A. Hoffmann, incorporates a great deal of current medical knowledge, which Hoffmann used in a skillful and detailed manner in the portrayal of his characters and their motives. Immersed as he was in contemporary medical practice, an interest fuelled by his own deep-seated hypochondria, he was particularly taken with the works of Philippe Pinel, Johann Christoph Reil, Carl A.F. Kluge, and Gotthelf Heinrich Schubert, who were all interested in the working of the mind. This article demonstrates how attention to Hoffmans's medical reading list offers insights useful for critical understanding of his work, using as an example the analysis of the mad goldsmith Cardillac in one of Hoffmann's most famous stories, 'Das Fräulein von Scuderi'.

Silica-associated systemic sclerosis is clinically, serologically and immunologically indistinguishable from idiopathic systemic sclerosis.

To determine whether the clinical, immunological and serological features of patients with silica-associated systemic sclerosis are different from patients with the 'idiopathic' form of systemic sclerosis (SS) we studied 22 underground coal miners who were exposed to silica dust (SD), 30 mine workers who later developed silicosis (S) and 17 mine workers exposed to silica dust who subsequently developed a systemic sclerosis-like disease (SA-SS). The patients with SA-SS had features clinically indistinguishable from individual patients with SS. They all had Raynaud's phenomenon, 14 had cutaneous sclerosis identical to that seen in acrosclerosis and three had a generalized cutaneous sclerosis. Sixteen patients had bibasilar pulmonary fibrosis, 10 had necrosis of the fingertip pulps, nine had oesophageal involvement and only one patient had renal involvement. Antinuclear antibodies and circulating immune complexes were detected in three and eight patients with SD, 14 and five patients with S and in 16 and nine patients with SA-SS, respectively. Anti-Scl-70 antibody was detected in eight of the 17 patients with SA-SS. Evidence for in vivo endothelial cell damage, as determined by elevated levels of von Willebrand factor, was found in nine patients with SD, 14 patients with S and in 10 patients with SA-SS. Following incubation of the patient's serum with confluent cultures of human umbilical vein endothelial cells there was only a significant reduction in calcium ionophore-induced release of prostacyclin with the serum from SA-SS patients compared to that with control serum (NC). The mean +/- SEM release of 6-keto-PGF1 alpha (the stable metabolite of prostacyclin expressed as ng/10(4) cells) decreased from 2.90 +/- 0.27 to 2.01 +/- 0.33 (SD), 3.34 +/- 0.42 to 1.76 +/- 0.31 (S), 1.98 +/- 0.12 to 0.64 +/- 0.07 (SA-SS) and 2.28 +/- 0.33 to 1.36 +/- 0.21 (NC) with 1 and 20% serum, respectively. This study demonstrates that immune complex and antinuclear antibody formation and in vivo endothelial cell damage occurs following occupational exposure to silica. The patients who subsequently develop a systemic sclerosis-like disease have clinical, immunological and serological features which are indistinguishable from the idiopathic form of the disease although as a group the SA-SS patients have a higher prevalence of pulmonary involvement and the anti-Scl-70 antibody.

[Occupational progressive systemic sclerodermia caused by a quartz-containing scouring agent]. / Berufsbedingte progressive systemische Sklerodermie durch ein quarzhaltiges Scheuermittel.

We present the case of a 65-year-old woman with progressive systemic sclerosis. For 14 years, she had been occupationally exposed to scouring powder containing crystalline silica. In the skin of the finger of the patient, silica crystals were detected by polarizing microscopy. By means of a special dust measurement at the former working places where scouring powder was used, a silica exposition could be found exceeding the maximum allowable concentrations. Legal recognition of an occupational disease could be achieved in a special procedure by the top expert commission for occupational diseases.

Type III collagen aminopropeptide and laminin P1 levels in serum of patients with silicosis-associated and idiopathic systemic scleroderma.

A group of 191 patients with systemic scleroderma and 12 patients with silicosis-associated scleroderma were investigated for connective tissue turnover. The serum levels of type III collagen aminopropeptide (P-III-P), the laminin PI (Lam PI) fragment and the acid lysosomal beta-galactosidase (beta-Gal) were determined by specific radioimmunoassays and spectrofluorometry, respectively. Increased levels of type III collagen aminopropeptide strongly correlated with enhanced activity of beta-galactosidase. Both parameters correlated with the clinical course in idiopathic systemic scleroderma and in silicosis-associated scleroderma. Serum levels of Lam PI were also found to be elevated in both groups, although there was no correlation with the severity of the disease. Autoantibodies directed against the DNA topoisomerase Scl-70 and against centromeric proteins were found in a similar range in patients with idiopathic systemic and silicosis-associated scleroderma. These results suggest that P-III-P, Lam PI and beta-Gal are useful serological markers of fibrotic activity and demonstrate similarities between idiopathic systemic scleroderma and scleroderma associated with silica-dust exposure.

Brofaromine (CGP 11 305 A) in treatment of depression: biological estimation of plasma concentrations.

In an open clinical trial, 13 depressives were treated with the reversible and selective type-A monoamine oxidase (MAO)-inhibitor brofaromine (CGP 11 305 A), the inhibitory potency of deproteinated plasma on a crude MAO preparation from human placenta was measured as a parameter for plasma brofaromine and possibly active metabolites of brofaromine. Patients significantly (p less than 0.01) improved under brofaromine. There were, however, no significant differences in plasma MAO-inhibitory potency between responders (improvement greater than 50%; n = 5) and nonresponders and no correlations with the change from baseline of the total Hamilton Depression Score (HAMD) or with changes of sleep (change from baseline of the HAMD sleep items). MAO-inhibitory potency significantly (p less than 0.05) increased parallel to the increase of the dosage from 50 mg b.i.d. to t.i.d., confirming the validity of this technique. The biological assay applied is a simple and reliable alternative when estimating the plasma concentrations of brofaromine and, possibly, other reversible MAO inhibitors.

Silica-induced scleroderma.

In a survey done in East Germany between 1981 and 1988, we found that 93 of 120 male scleroderma patients had long-term exposure to silica dust. We describe our findings in 12 patients with scleroderma and silicosis. The exposure time to silica dust was between 3 and 34 years; the interval between the beginning of exposure and the onset of scleroderma averaged 27.3 years (range 9 to 40 years). Antinuclear antibodies in titers between 80 and 10,240 with nucleolar and/or speckled patterns were found in 10 patients, antibodies against double-stranded DNA in three, Scl-70 (topoisomerase I) in three, and anticentromere antibodies in five. The following markers of collagen metabolism were increased in serum: beta-galactosidase in 12 patients, laminin peptide-P1 in 10 patients, N-terminal procollagen type III peptide in 10, and urinary sialic acid excretion in 7. We propose that crystalline particles of silica less than 5 microns may be phagocytosed by macrophages and release lymphokines and monokines, which activate fibroblasts and enhance their collagen and glycosaminoglycan synthesis. In addition, silica may act as an adjuvant to increase immune reactivity.

[Quartz crystals in the skin as a cause of progressive systemic scleroderma]. / Quarzkristalle in der Haut als Ursache der progressiven systemischen Sklerodermie.

There is a close correlation between the systemic sclerosis and the exposure to crystalline silica in the GDR. The silica content was investigated in the skin of the patients. Silica particles were found using phase-contrast and polarizing microscopy. The size of the crystals varied from 1 to 90 micrometer. Below a silica content of 10% in the dust it is unlikely that systemic sclerosis is developing.