[Quality assurance in specialized palliative home care (QUAPS): a questionnaire's feasibility]. / Qualitätssicherung in der spezialisierten ambulanten Palliativversorgung (QUAPS) ­ Praktikabilität eines Fragebogens.

BACKGROUND: Structure and process parameters are not sufficient for adequate quality assurance in specialized palliative home care (SAPV). Asking the patients and their relatives for their assessment is crucial. A focus group in Jena, Germany, developed the quality assurance in specialized palliative home care (QUAPS) questionnaire for this assessment of outcome parameters, which was tested in two studies. OBJECTIVES: The aim of the study was to evaluate the feasibility of a questionnaire for patients, relatives and SAPV teams. MATERIAL AND METHODS: The questionnaire collects outcome parameters on a Likert scale as well as the distress of respondents using the numeric rating scale (NRS). In the pilot study, QUAPS I was tested in three SAPV teams. The survey was simplified in the follow-up study, QUAPS II, where 17 teams were included. Both studies were conducted with an ex-post-facto design. RESULTS: In QUAPS I, complete datasets could be obtained for 43 out of 308 surveyed cases. In QUAPS II, 169 complete datasets resulted from 371 surveyed cases. The SAPV staff assessed the QUAPS II survey as being organizationally feasible. The questionnaire shows good internal consistency and high approval for the surveyed aspects of SAPV care. Ceiling effects occurred. More than 70% of respondents reported a distress score >5. CONCLUSIONS: The simplified survey in QUAPS II resulted in a higher rate of complete datasets. The detected ceiling effects restrict the conclusions of the survey. Biases like social desirability cannot be ruled out. In the future, a combination of different questionnaires (e. g. integrated palliative outcome score [IPOS] and QUAPS) should be explored.

Distinction between forensic evidence and dermatological findings.

The external examination after death requires knowledge in forensics/pathology, dermatology, as well as associated diseases and age-related alterations of the skin. This article highlights some findings with forensic evidence versus dermatological findings. The lectures in forensic medicine should be structured interdisciplinarily, especially to dermatology, internal medicine, surgery, pathology, and toxicology in order to train the overlapping skills required for external and internal postmortem examinations.

[Autopsies for anatomical teaching and training in clinical forensic medicine]. / Autopsien mit Situs-Lehre in der klinischen Rechtsmedizin.

BACKGROUND: Clinical forensic medicine does not only entail examination of patients after physical violence but also the option of clinical autopsies, e.g. after non-notifiable complications of medical interventions, after fatalities closely following medical interventions or fatalities as a result of injuries when the public prosecutor decides not to order a medicolegal autopsy. Based on this routine the Institute of Forensic Medicine at the University of Rostock offers a training course in topographical anatomy to physicians for further training in interventional and surgical disciplines. METHODS: At the beginning of autopsies the participants can explore the approaches of interventional puncture techniques as well as surgical techniques and the basic topographical anatomy in small groups of 2-4 persons under the supervision of forensic examiners. The format is essentially oriented to the early further training period but fulfils the requirements for the exploration of complex operative techniques. The course was adapted for physicians and offered separately to students. The explorations are performed manually or by support with autopsy instruments. RESULTS: The courses offer an ideal room for individual, discipline-specific topics and result in a great benefit for all participants. A statistical assessment can only be achieved with a larger number of participants. CONCLUSION: Making autopsy rooms available for teaching and further training represents an additional feature to the profile of clinical forensic medicine. Lessons in topographical anatomy provide a great benefit for patient safety. It seems to be important to offer the opportunity to address individual interests in a closed meeting to consolidate skills and abilities in a non-judgemental environment. The post-mortem examiners have to ensure that the autopsy is carried out lege artis. Basic ethical principles and all regulations from an accredited scope have to be adhered to.

The relevance of circulating epithelial tumor cells (CETC) for therapy monitoring during neoadjuvant (primary systemic) chemotherapy in breast cancer.

BACKGROUND: Having demonstrated in a previous report that the response of circulating epithelial tumor cells (CETC) during the first cycles of primary (neoadjuvant) chemotherapy perfectly reflects the response of the tumor, in the present study the changes in cell numbers during subsequent cycles and their possible impact on the therapy's outcome were examined. PATIENTS AND METHODS: In 58 breast cancer patients CETC were quantified during therapy with either EC (epirubicin/ cyclophosphamid) or dose intensified E (epirubicin) followed by taxane, with or without trastuzumab, and subsequent CMF (cyclophosphamid/methorexate/ fluorouracil). RESULTS: CETC numbers declined more than 10-fold (good response) in 65% (her2/neu-negative) and 55% (her2/neu-positive) of patients during EC, and in 60% during dose intensified E, respectively, followed by an increase of CETC in all patients. CETC remained increased, decreasing only when adding CMF. A good initial response correlated with estrogen-receptor negativity, a poor response with early distant relapse (P < 0,0001, hazard ratio = 11.91). CONCLUSION: Response of CETC already during the first cycles of neoadjuvant treatment predicts the final response of the tumor. Hitherto unknown effects of the release of tumor cells during therapy further our understanding of tumor-blood interaction and may improve access of agents like antibodies to cells. The impact on the further course of disease remains to be evaluated.

Cystic fibrosis in 65- and 67-year-old siblings. Clinical feature and nasal potential difference measurement in patients with genotypes F508del and 2789+5G-->A.

Cystic fibrosis (CF) is a recessive genetic disease caused by defects of the cystic fibrosis trans-membrane regulator (CFTR) gene with a median survival of less than 35 years. This work reports on the oldest living German siblings with CF. Besides clinical history, CF genotype and nasal potential difference (NPD) measurement results, the remarkably high exercise activity of the siblings is discussed as a disease-modifying factor. Both male patients have an overall mild pulmonary manifestation. They have suffered from abdominal symptoms since their early childhood, including recurrent pancreatitis and diffuse symptoms leading to partial gastric resection. They were diagnosed as having CF with positive sweat tests at the advanced ages of 45 and 43 years, respectively. Later on genotyping revealed compound heterozygosity for F508del and 2789+5G-->A. Using NPD we demonstrated a CF-typical inhibition of the NPD by the Na channel blocker amiloride, although in both siblings the remaining CFTR function and alternate chloride channel function were detected during superfusion of the nasal epithelium with isoproterenol and ATP. Long-term survival with CF is basically influenced by the CFTR genotype. The patients' genotype was discussed as a mild one with remaining CFTR function. We demonstrated this residual CFTR function in both siblings using NPD. Additionally the siblings' continuous healthy lifestyle and their engagement in a remarkably high level of exercise activities from early childhood to the present possibly have an important effect on the long-term outcome of CF as disease-modifying factors. In this regard this report can encourage CF patients to maintain a high level of physical activity in their daily lives.

[Foreign body granuloma after lower eyelid avulsion and surgical revision with silicone tube splint]. / Fremdkörpergranulom nach Unterlidabriss und operativer Revision mit Silikonröhrchenschienung.

BACKGROUND: Foreign-body-reactions with granulomas after use of silicone-containing biomaterials are of clinical importance [4]. HISTORY AND SIGNS: A 4-year old patient entered our hospital with a reddish vascularised tumor. The tumor's origin was in the conjunctiva of the nasal lid-angle of the right eye. THERAPY AND OUTCOME: After a traumatic disconnection of the canaliculus lacrimalis inferior, a bicanalicular silicon-tube intubation had been performed with the patient in the age of one year. Only 3 years after this intervention a secondary clinical examination could be performed. At this time, an extended solid conjunctival-tumor appeared at the operated eye. After removal and histological examination it could be classified as a foreign body granuloma. CONCLUSIONS: The blood- and tissue compatibility of silicone is only insufficiently guaranteed on the basis of the hydrophobic material-surface. After reconstructive lacrimal surgery postoperative care and the removal of the stabilizing silicone material is necessary.

[Effect of diabetes mellitus on anterior central lens epithelium in cataract patients]. / Einfluss des Diabetes mellitus auf das vordere zentrale Linsenepithel bei Kataraktpatienten.

UNLABELLED: The relationship between diabetic metabolic disorder and the impairment of lens epithelium in the development of age-related cataract cannot be completely defined yet. In this prospective study, morphological criteria and the phosphorus content of the anterior central lens epithelium in type-II diabetics and nondiabetics are compared. PATIENTS AND METHODS: Fifty-six of the overall 159 patients with age-related cataracts were suffering from type-II diabetes (group I) and 103 are nondiabetics (group II). In each case, a fragment of the anterior central lens epithelium was evaluated morphologically using a scanning electron microscope (S-2400) and examined by EDXA (X-ray spectrometer TN-5500), with regard to phosphorus content. The criteria considered were the degree of damage to the epithelium (score 1-3), the morphologically evaluated cell density and the "peak/background" relationship for phosphorus. RESULTS: The mean degree of damage to the epithelium was 1.48 +/- 0.53 in the type-II diabetic group (I) and 1.55 +/- 0.65 in the nondiabetic group (II), respectively. The median cell density of type-II diabetics (group I) was 4838 +/- 1033 cells/mm2 compared with 5454 +/- 1368 cells/mm2 of the nondiabetics (group II). The mean "peak/background" relationship for phosphorus was 0.46 +/- 0.20 in group I and 0.51 +/- 0.26 in group II, respectively. CONCLUSION: In the younger patients, the significant decrease in cell density and the increased degree of damage to the anterior central lens epithelium in the type-II diabetic group could be attributed to the cataractogenic influence of diabetic metabolic disorder on the lens epithelium. Another possible indication for that was the smaller phosphorus content in this group as evidence of the decrease in the biological activity of the cells (ATP-function). The primary cataractogenic importance of the lens epithelium in type-II diabetics could not be concluded.

Myocardial injury due to lightning.

The report deals with a 27-year-old male who was standing in a tent and was injured by lightning as it struck a tree about 1.5 m away. He immediately lost consciousness and exhibited ventricular fibrillation when the emergency physician arrived. A clinical picture of hypoxaemic brain damage emerged after initially successful resuscitation. Brain death was diagnosed on the fifth day after injury. The discrete external findings (remaining arborescent skin marks) contrasted markedly with the severe thermal damage to the pectoral muscle and cardiac musculature found during the autopsy. The histological cardiac findings indicated severe acute myocardial infarction affecting virtually all parts of the myocardium.

Fibromuscular dysplasia of coronary arteries as a rare cause of death.

A case of fibromuscular dysplasia of the coronary arteries in a 15-year-old boy is reported. After a quarrel involving no violence the boy suddenly suffered from ventricular fibrillation, collapsed and was initially successfully defibrillated. After 37 days of deep unconsciousness the boy died of bronchopneumonia. The cause of the ventricular fibrillation was clarified only after histological investigations. Fibromuscular dysplasia of the coronary arteries with narrowing was found, which has very occasionally been described in the literature. However, its localization in the A-V node artery, as described here, only seems to have been observed once.

Biosynthesis and desaturation of prokaryotic galactolipids in leaves and isolated chloroplasts from spinach.

Mono- and digalactosyldiacylglycerol (MGDG and DGDG) were isolated from the leaves of sixteen 16:3 plants. In all of these plant species, the sn-2 position of MGDG was more enriched in C(16) fatty acids than sn-2 of DGDG. The molar ratios of prokaryotic MGDG to prokaryotic DGDG ranged from 4 to 10. This suggests that 16:3 plants synthesize more prokaryotic MGDG than prokaryotic DGDG. In the 16:3 plant Spinacia oleracea L. (spinach), the formation of prokaryotic galactolipids was studied both in vivo and in vitro. In intact spinach leaves as well as in chloroplasts isolated from these leaves, radioactivity from [1-(14)C]acetate accumulated 10 times faster in MGDG than in DGDG. After 2 hours of incorporation, most labeled galactolipids from leaves and all labeled galactolipids from isolated chloroplasts were in the prokaryotic configuration. Both in vivo and in vitro, the desaturation of labeled palmitate and oleate to trienoic fatty acids was higher in MGDG than in DGDG. In leaves, palmitate at the sn-2 position was desaturated in MGDG but not in DGDG. In isolated chloroplasts, palmitate at sn-2 similarly was desaturated only in MGDG, but palmitate and oleate at the sn-1 position were desaturated in MGDG as well as in DGDG. Apparently, palmitate desaturase reacts with sn-1 palmitate in either galactolipid, but does not react with the sn-2 fatty acid of DGDG. These results demonstrate that isolated spinach chloroplasts can synthesize and desaturate prokaryotic MGDG and DGDG. The finally accumulating molecular species, MGDG(18:3/16:3) and DGDG(18:3/16:0), are made by the chloroplasts in proportions similar to those found in leaves.

Zinc gluconate lozenges for common cold. A double-blind clinical trial.

In a double-blind clinical trial, a total of 463 volunteers were enrolled in a study designed to compare the effects of zinc gluconate lozenges (4.5 mg zinc) and a placebo for common cold. The tablets were to be taken every 1-1 1/2 waking hours at the first symptoms and for the following days until the common cold was over, but for no longer than 10 days. During the winter months of 1987 and 1988, 145 experienced a common cold and 130 completed the study. For final analysis, 61 patients in the zinc lozenge group and 69 patients in the placebo lozenge group were evaluated. Based on the patients' records the duration and severity of the common cold were compared. No statistically significant differences were found between the patient groups. Two recent studies using a five-time higher zinc dose per lozenge for common cold showed a significant, positive effect, but associated with frequent side-effects, first of all taste distortion. In the present study there was a weak tendency (not statistically significant, p = 0.12) towards more patients in the zinc lozenge group than in the placebo lozenge group reporting side-effects.

[Synovial chondromatosis of the temporomandibular joint--a differential diagnosis to parotid gland tumor]. / Die synoviale Chondromatose des Kiefergelenkes--eine Differentialdiagnose zum Tumor der Glandula parotis. Ein Fallbericht.

Synovial chondromatosis of the temporomandibular joint is an uncommon disease of cartilaginous transformation of synovial membrane with formation of loose bodies within the joint space. The stimulus for synovial chondromatosis at this site is unknown. Symptoms frequently include pain and preauricular swelling with occasional snapping during jaw movements. Radiographs of the TMJ may be normal or show multiple, partially calcified loose bodies within the joint. Treatment consists of removal of the loose bodies together with all affected synovium. In this paper a case of synovial chondromatosis affecting the temporomandibular joint is reported and the literature of 38 cases is reviewed.

Comparison of Phosphoenolpyruvate-Carboxykinase from Autotrophically and Heterotrophically Grown Euglena and Its Role during Dark Anaerobiosis.

Euglena gracilis (1224-5/9) contains phosphoenolpyruvate carboxykinase when grown autotrophic with CO(2) in the light. Its yield is higher when an additional carbon source like glucose has been added. The enzyme is lacking in cells provided with CO(2) alone and kept in the dark, whereas highest yields result if both glucose and CO(2) are provided together in the dark. The enzyme was purified by ammonium sulfate precipitation, gel filtration on Sephacryl S-300 and affinity chromatography on GMP-Sepharose. The latter step was most effective to protect the enzyme from inactivation. Its homogeneity was tested electrophoretically and immunologically. Enzymes from autotrophic and heterotrophically grown cells have identical pH optima and similar isoelectric points. The molecular weight was different: 761,000 for the enzyme from autotrophic and 550,000 for that from heterotrophic cells as determined by gel filtration. The subunit molecular weight of both enzymes is nearly the same. The kinetic data of the enzymes are slightly different. Glycolytic and tricarboxylic acid cycle intermediates are of limited influence on enzyme activity and inhibitory in unphysiological high concentrations. From Ouchterlony double immunodiffusion and enzyme-linked immunosorbent assay, it is evident that the enzyme is localized in the cytosol. With the latter quantification test the phosphoenolpyruvate carboxykinase protein content was found 10 times higher in heterotrophically grown cells than when cultivated under autotrophic conditions.

Comparison of eye protection with methylcellulose an paraffin ointments during general anaesthesia.

A total of 120 patients who were all anaesthetized for more than 90 minutes were given eye protection with paraffin-based oculentum simplex, Ph. Nord. 63, in one eye, and water-based four per cent methylcellulose in the other. Anaesthesia was conducted with halothane, or thiopentone an meperidine, or by a neurolept technique. Peri-ocular oedema and reaction in the conjunctiva resembling conjunctivitis was less pronounced after methylcellulose. When both paraffin-based ointment and halothane anaesthesia were used, there were signs of drug interaction, as the patients' conjunctivae were now distinctly red. In all three types of anaesthesia, methylcellulose produces a firm gluing of the eyelids with the result that the eye is not dried out and the eye is protected mechanically so that foreign bodies and corneal abrasions are avoided. There were no untoward effects of methylcellulose. It is concluded that methylcellulose four per cent provides better eye protection than paraffin during general anaesthesia.