[Improvement of rehabilitation aftercare through long term follow along of the patients--results of a pilot study]. / Optimierung der Rehabilitationsnachsorge durch eine längerfristige Begleitung der Rehabilitanden--Ergebnisse einer Pilotstudie.

BACKGROUND: The population grows older, patients suffer from chronic diseases more frequently, and working life will be longer. Against this background, medical rehabilitation becomes more important. However, various studies indicate that rehabilitation lacks in sustainability beyond positive short-term outcomes: After three to six months there are hardly any detectable effects. For some time now the answer to this lack of sustainability is seen in an increase of aftercare. But here too, the situation seems rather deficient as in-patient treatment that usually lasts for three weeks is still predominant in the minds of many rehab patients and physicians. METHOD: In a multicentre research project a new strategy and organisation of aftercare was developed and tested by orthopaedic clinics and patients with chronic low back pain. The main emphasis was put on changes in physical activity and mobility. The central item was higher personal activity of rehab patients and an aftercare plan for doctors and therapists that can easily be realised. Therefore numerous means of implementation (checklists, information material, patient documentation) were developed. Six rehab clinics and 77 rehab patients tested the new credo. RESULTS: On the whole we received positive reactions from clinical staff and rehab patients. The mobility diary during rehabilitation was greatly accepted and accurately filled-in by patients. After rehabilitation two-thirds of them returned the mobility diary they had completed at home. In general it had also been filled-in reliably. Starting points for supports to be offered by clinics are readily identifiable. CONCLUSION AND PERSPECTIVE: Results of the pilot study showed that the concept is practicable and promising. Yet, long-term follow-along of rehab patients can only be realised by supplementary personal contact. Should the now starting controlled longitudinal study reveal that the concept contributes to securing the longer-term rehab effects, the time and expense for appointing an aftercare contact would be more than justified.

[Cervical myelopathy as a complication of rheumatoid arthritis]. / Die Zervikale Myelopathie als Komplikation der Rheumatoiden Arthritis.

Arthritis of the cervical spine with instability of the atlantodental joint is a typical and frequent complicaiton in rheumatoid arthritis. Subsequent cervical myelopathy is rare but usually a severe complication. There is no stringent correlation between arthritis of cervical spine an occurrence of cervical myelopathy. Cervical myelopathy is often difficult to discern from parallel multilating peripheral joint damage, which makes the diagnosis difficult. The decision between conservative and operative therapeutic intervention has to be based on subtle clinical, neurophysiological and radiological assessment and-in particular-requires exact analysis of the course of the underlying rheumatoid arthritis and myelopathy. In this diagnostic process close collaboration of rheumatologist, surgeon and neurologist is essential.

Rituximab induces remission in refractory HCV associated cryoglobulinaemic vasculitis.

OBJECTIVES: To report the successful induction of remission with the monoclonal anti-CD20 antibody rituximab in a patient with hepatitis C virus (HCV) associated cryoglobulinaemic vasculitis and a non-Hodgkin's lymphoma (NHL) resistant to previously advocated conventional treatments. CASE REPORT: The patient was a 45 year old woman with HCV associated cryoglobulinaemic vasculitis, with purpura, arthralgia, constitutional symptoms, and a polyneuropathy. A malignant NHL was found as underlying lymphoproliferative disease. At this stage the disease was refractory to interferon alpha2b and ribavirin and to subsequent immunosuppressive treatment with cyclophosphamide. Six rituximab infusions targeting the CD20 antigen on cells of the B cell lineage induced remission of the vasculitis. Bone marrow biopsy disclosed absence of the NHL. Remission has subsequently been maintained and HCV eliminated with the new pegylated interferon alpha2b and ribavirin for nearly one year. CONCLUSIONS: Transition of the underlying "benign" lymphoproliferative disease to a malignant lymphoma may result in difficult to treat HCV associated cryoglobulinaemic vasculitis. Rituximab offers a new possibility for inducing remission in refractory HCV associated cryoglobulinaemic vasculitis and the lymphoproliferative disorder. After remission, HCV may subsequently be eliminated with pegylated interferon alpha2b and ribavirin.

Severe CNS manifestations as the clinical hallmark in generalized Wegener's granulomatosis consistently negative for antineutrophil cytoplasmic antibodies (ANCA). A report of 3 cases and a review of the literature.

OBJECTIVE: Antineutrophil cytoplasmic antibodies (ANCA) directed against proteinase 3 are highly specific for Wegener's granulomatosis (WG); their sensitivity for active generalized WG is nearly 100%. There are patients, however, who fulfill both the ACR 1990 criteria and the CHC 1992 definition for WG but who remain ANCA negative. The authors report 3 young patients with biopsy-proven active generalized WG who were consistently negative for ANCA over observation times ranging from 58 to 114 months. METHODS: ANCA titers were determined serially every 3 months. ANCA-negativity was defined by the absence of any fluorescence pattern on IFT plus the absence of any specific ELISA reactions. This included negative results for the antibody classes IgG, IgM and IgA. The sera of all patients were also tested in a capture PR3-ANCA ELISA. At 1- to 6-month intervals each patient underwent a standardized set of interdisciplinary examinations. RESULTS: Although CNS involvement in large WG cohorts is about 10%, severe CNS manifestations were the clinical hallmark in all 3 patients. One patient suffered from both intraspinal and intracerebral disease with fatal outcome; the other 2 had meningeal manifestations that responded favorably to immunosuppressive therapy. CONCLUSION: Severe CNS manifestations could represent a clinical hallmark of patients with generalized Wegener's granulomatosis who are consistently negative for antineutrophil cytoplasmic antibodies (ANCA).

Standardized neurologic evaluations of 128 patients with Wegener granulomatosis.

OBJECTIVE: To assess the frequency and type of neurologic involvement in a cohort of patients with generalized Wegener granulomatosis (WG). PATIENTS AND METHODS: In a prospective analysis the clinical, electrophysiologic, radiological, and serologic data of 128 patients have been studied over a median observation period of 19 months (range, 1-60 months). RESULTS: Sixty-four patients (50%) revealed central or peripheral nervous system involvement. Peripheral neuropathy (PN) affected 56 patients, in 9 cases the central nervous system was involved, and in 6 cases the cranial nerves were involved. Thirty-one patients showed a distal symmetrical polyneuropathy, 25 a mononeuritis multiplex. Within the first 2 years of the disease course 47 of the 56 patients had developed their PN, sometimes as the initial symptom of WG. Patients with PN were significantly more often male (34 of 65 patients) than female (22 of 63 patients, P =.04), were significantly older at the onset of WG (median age, 53 vs 44 years; P =.001), had a significantly larger disease extent (P =.001), and had higher classic antineutrophil cytoplasmic antibody titers (P =.002) than neurologically unaffected patients. Response to immunosuppression was moderate concerning peripheral nervous system manifestations. CONCLUSIONS: Peripheral neuropathy is frequent in generalized WG, occurring early in the disease course. As PN can be the first and sole symptom of a beginning systemic vasculitis, it is important that in cases of PN of an unclear origin, interdisciplinary investigations are initiated to detect, treat, and closely follow-up a possible underlying WG, especially as these patients seem to have a more severe disease course.

Common variable immunodeficiency (CVID) and inclusion body myositis (IBM).

A case of a 38-year old man with a common variable immunodeficiency syndrome (CVID) is demonstrated who suffered at the same time from a histologically proven inclusion body myositis (IBM). The myositis did not resolve after institution of regular intravenous IgG infusions. This case demonstrates a very long lasting benign course of IBM. The occurrence with CVID may be a clinical hint for a viral pathogenesis of IBM. So far only two similar cases are reported in the literature.

Sensitivity functions of a human head movement model.

With time as the criterion to be optimized, the divergences from optimal head movements show systematic differences of their control signal variables with respect to single behaviours. To clarify these relationships, this study uses manipulation and mathematical analysis of the 6th order nonlinear head movement model, i.e. the threefold approach of sensitivity analysis. In addition to sensitivity coefficients, graphs and trajectories sensitivity functions have been analysed. This is the sensitivity of a nominal head movement to changes of the model parameters during the time course of the movement. This demonstrated both the specific change of the visco-inertial properties of the head movement model during the movement and also the potential pathological deficits that may occur.

Sensitivity coefficients, trajectories and graphs of a human head-movement model.

With time as the criterion to be optimized, the divergences from optimal head movements show systematic differences in their control signal variables with respect to single behaviours. To clarify these relationships, this study applies manipulation and mathematical analysis of the 6th-order nonlinear head movement model, using the three-fold approach of sensitivity analysis. The sensitivity analysis of the improved and refined head movement model explains the different tasks of the control parameters and their relation to the plant. It shows that width more than height of the agonistic and antagonistic pulses dominate the important behaviours of the movement: acceleration, magnitude and duration.