Hands-on or no hands-on training in ultrasound imaging: A randomized trial to evaluate learning outcomes and speed of recall of topographic anatomy.

Medical students have difficulties in interpreting two-dimensional (2D) topographic anatomy on sectional images. Hands-on and no hands-on training in ultrasound imaging facilitate learning topographic anatomy. Hands-on training is linked with active search for patterns of anatomical structures and might train pattern recognition for image interpretation better although the added value on learning outcomes is unclear. This study explores first year medical students' knowledge in topographic anatomy of the upper abdomen after attending hands-on or no hands-on training in ultrasound in a randomized trial. While students in the hands-on ultrasound group (N = 21) generated and interpreted standardized planes of ultrasound imaging, students in the no hands-on seminar group (N = 22) interpreted provided ultrasound images by correlation to three-dimensional (3D) anatomical prosections. Afterwards knowledge in topographic anatomy was measured repetitively by text and ultrasound image-based multiple choice (MC) examinations. As surrogate for pattern recognition, students rated whether answers were known after reflection or instantly. While intrinsic motivation was higher in the ultrasound group, no differences in the MC-examination score were found between ultrasound and seminar group instantly (66.5 ±10.9% vs. 64.5% ±11.0%, P = 0.551) or six weeks (62.9% ±12.3% vs. 61.5% ±11.0%, P = 0.718) after training. In both groups scores in text-based questions declined (P < 0.001) while scores in image-based questions remained stable (P = 0.895) with time. After six weeks more image-based questions were instantly known in the hands-on ultrasound compared to seminar-group (28% ±17.3% vs. 16% ±13.5%, P = 0.047). Hands-on ultrasound-training is linked with faster interpreting of ultrasound images without loss in accuracy. The added value of hands-on training might be facilitation of pattern recognition.

A geriatric assessment in general practice: prevalence, location, impact and doctor-patient perceptions of pain.

BACKGROUND: To investigate what a geriatric assessment in general practice adds towards previous findings of prevalence, location, impact and the dyadic doctor-patient perception of pain in this age group. METHODS: Cross-sectional study. Consecutive patients aged 70 and over underwent a comprehensive geriatric assessment in general practice that included a basic pain assessment (severity, sites and impact). Patients with pain and their doctors then independently rated its importance. Pain was correlated with further findings from the assessment, such as overall health, physical impairments, everyday function, falls, mood, health related lifestyle, social circumstances, using bivariate and multivariate statistics. Patient-doctor agreement on the importance of pain was calculated using kappa statistics. RESULTS: 219 out of 297 patients (73.7 %) reported pain at any location. Pain was generally located at multiple sites. It was most often present at the knee (33.9%), the lumbar spine (33.5%) as well as the hip (13.8%) and correlated with specific impairments such as restrictions of daily living (knee) or sleep problems (spine). Patients with pain and their physicians poorly agreed on the importance of the pain problem. CONCLUSIONS: A basic pain assessment can identify older patients with pain in general practice. It has resulted in a high prevalence exceeding that determined by encounters in consultations. It has been shown that a geriatric assessment provides an opportunity to address pain in a way that is adapted to older patients' needs - addressing all sites, its specific impact on life, and the patients' perceived importance of pain. Since there is little doctor-patient agreement, this seems a valuable strategy to optimize concrete treatment decisions and patient centered care. TRIAL REGISTRATION: This study is registered in the German Clinical Trial Register ( DRKS00000792 ).

Drug-disease interaction in elderly patients in family practice.

OBJECTIVE: To determine the frequency of potential drug-disease interaction in elderly patients in family practice. To assess which drugs and diagnoses are associated with a high risk related to drug-disease interaction and whether there are gender- or age-related differences. METHODS: In routinely recorded electronic patient records, patients at least 65 years old with at least one diagnosis named in Beers list and one prescription were identified. Potential drug-disease interaction (PDDI) was presumed if within the same 3 months a "Beers" diagnosis and a potentially inappropriate prescription with respect to this diagnosis were documented for a patient. Multiple logistic regression analysis identified factors associated with a high risk of PDDI. RESULTS: Of 24,619 patients (63.4% women) corresponding to our inclusion criteria, 10.4% were exposed to at least one PDDI. Almost no (0.0%) PDDI was associated with the most common Beers disorder hypertension (prevalence 49.2%). However, 23.4% of men suffering from bladder outflow obstruction (prevalence 17.6% in males) were exposed to at least one PDDI. PDDI was quite common in some rarer conditions, for example, indications for anticoagulation (prevalence 2.6%, 31.5% PDDI). PDDI was not influenced by gender, but associated with taking more than 4 drugs (OR 1.91 (1.83 - 2.00)), suffering from more than one Beers disorder (OR 1.24 (1.16 - 1.31)), and advanced age (OR 1.10 (1.05 - 1.15)). CONCLUSIONS: High risk patient groups could be identified. Some disorders as well as some drugs are particularly prone to risky constellations; these should be reflected in systems assisting prescribing with regard to patient safety.

Attitudes towards general practice: a comparative cross-sectional survey of 1st and 5th year medical students.

OBJECTIVE: Positive attitudes towards General Practice can be understood as a prerequisite for becoming a General Practitioner (GP) and for collaboration with GPs later on. This study aimed to assess attitudes of medical students at the beginning and the end of medical school. METHODS: A total of 160 1(st) year students at Hannover Medical School were surveyed. Their attitudes were compared to those of 287 5th year students. Descriptive, bi- and multivariate analyses were performed to investigate influences of year of study and gender. RESULTS: Year of study and gender both were associated with the attitudes towards General Practice. The interest in General Practice and patient-orientation (communication, care of older patients with chronic diseases) was higher in 1st year students compared to more advanced students. Female students valued such requirements more than male students, the differences in attitudes between the years of study being more pronounced in male students. CONCLUSION: Despite some limitations caused by the cross-sectional design, the attitudes towards General Practice competencies changed to their disadvantage during medical school. This suggests a formative influence of the strategies used in medical education. Educational strategies, however, could be used to bring about a change of attitudes in the other direction.

A survey to assess family physicians' motivation to teach undergraduates in their practices.

BACKGROUND: In Germany, family physicians (FPs) are increasingly needed to participate in undergraduate medical education. Knowledge of FPs' motivation to teach medical students in their practices is lacking. PURPOSE: To describe a novel questionnaire that assesses the motivation of FPs to teach undergraduates in their practices and to show the results of a subsequent survey using this instrument. METHODS: The questionnaire was developed based on a review of the literature. Previously used empirical instruments assessing occupational values and motivation were included. A preliminary version was pretested in a pilot study. The resulting 68-item questionnaire was sent to 691 FPs involved in undergraduate medical education. Reliability was assessed and subgroups were analyzed with regard to differences in motivation. RESULTS: A total of 523 physicians in n = 458 teaching practices participated (response rate 75.7%). 'Helping others' and 'interest' were revealed as the predominant motives. Responses showed a predominantly intrinsic motivation of the participating FPs. Their main incentives were an ambition to work as a medical preceptor, to generally improve undergraduate education and to share knowledge. Material compensation was of minor importance. Time restraints were indicated as a barrier by some FPs, but were not a general concern. CONCLUSION: German FPs involved in medical education have altruistic attitudes towards teaching medical students in their practices. Motivational features give an important insight for the recruitment of FP preceptors as well as for their training in instructional methods.

["Working like a doctor": medical students' expectations of their final year elective in Family Medicine]. / "In der Funktion als Arzt": Erwartungen an das PJ Allgemeinmedizin aus Sicht von Studierenden.

BACKGROUND: Successful curricular development requires that consideration be given to the opinions of faculty members, teachers and students. The aim of the present study was to explore students' expectations of the final year Family Medicine elective. METHODS: Three focus group discussions took place with a total of 15 participants who were either in their fifth year (n=11) or had already passed Family Medicine in their final year (third focus group). The discussions were transcribed verbatim and analysed independently by two of the authors using qualitative content analysis. Final codes were developed and clustered under category names. RESULTS: As students found that Medical School was too theoretical, they aimed at learning through practice in order to be able to make decisions and act independently. Their ideal teacher would respect them as colleagues. Typical Family Medicine skills were mentioned less often by the "pre-" in contrast to the "post-" practical year students than the learning of technical aspects (ECG, ultrasound). The students discussed three different models of instruction and learning (student and patient alone, student or doctor observes consultation). CONCLUSIONS: Considering that the final year elective in Family Medicine will take place away from Medical School different teaching models should be evaluated for their effectiveness as well as their learner-centeredness.

In vivo monitoring of natural killer cell-dependent clearance of lung metastasis using dynamic positron emission tomography.

Immunohistological methods indicated a rapid onset of cellular defence shortly after seeding of mammary adenocarcinoma cells into the lungs of F344 rats. The purpose of the present study was to monitor natural killer (NK) cell-mediated effects on tumour cell clearance in vivo, in this model of lung metastasis using dynamic positron-emission tomography (dPET). MADB106 breast cancer cells were labelled with 2'-[(18)F]-2'-deoxy-D-glucose (FDG) then injected intravenously, after the F344 rats had been anaesthetized and placed in a PET scanner. NK cell-depleted and sham-treated control rats were investigated in parallel. The radioactivity per region of interest (ROI) over the lungs peaked at 60 s past injection and was followed by a slow decline over the observation time of 40 min in both groups. Statistical analysis using a linear mixed model revealed that release of radioactivity from tumour cells or tumour cell disintegration was significantly slower in animals after depletion of NK cells compared with controls. There was no significant tumour cell homing in organs other than the lungs. Early kinetics of tumour cells after injection were defined. PET with FDG was shown to be an adequate method to further investigate novel options for using cellular host defence mechanisms in cancer patients.

Attitudes of medical students towards general practice: Effects of gender, a general practice clerkship and a modern curriculum.

AIMS: Planning a career in general practice depends on positive attitudes towards primary care. The aim of this study was to compare attitudes of medical students of a Modern Curriculum at Hannover Medical School with those of the Traditional Curriculum before (pre) and after (post) a three-week clerkship in general practice. In parallel, we aimed to analyse several other variables such as age and gender, which could influence the attitudes. METHODS: Prospective survey of n=287 5th-year students. Attitudes (dependent variable, Likert-scale items) as well as socio-demographic characteristics (age, gender, rural/urban background), school leaving examination grades, former qualifications, experiences in general practice and career plans were requested. Attitudes were analysed separately according to these characteristics (e.g. career plans: general practitioner (GP)/specialist), curriculum type and pre/post the clerkship in general practice. Bi- and multivariate statistical analysis was used including a factor analysis for grouping of the attitude items. RESULTS: Most and remarkable differences of attitudes were seen after analysis according to gender. Women appreciated general practice more than men including a greater interest in chronic diseases, communication and psychosocial aspects. The clerkship (a total of n=165 students of the "post" survey could be matched) contributed to positive attitudes of students of both gender, whereas the different curricula did not show such effects. CONCLUSIONS: Affective learning goals such as a positive attitude towards general practice have depended more on characteristics of students (gender) and effects of a clerkship in general practice than on the curriculum type (modern, traditional) so far. For the development of outcomes in medical education research as well as for the evolution of the Modern Curriculum such attitudes and other affective learning goals should be considered more frequently.

Newly diagnosed incident dizziness of older patients: a follow-up study in primary care.

BACKGROUND: Dizziness is a common complaint of older patients in primary care, yet not much is known about the course of incident dizziness. The aim of the study was to follow-up symptoms, subjective impairments and needs of older patients (≥65) with incident dizziness and to determine predictors of chronic dizziness. Furthermore, we analysed general practitioners' (GPs') initial diagnoses, referrals and revised diagnoses after six months. METHODS: An observational study was performed in 21 primary care practices in Germany, including a four-week and six-month follow-up. A questionnaire comprising characteristic matters of dizziness and a series of validated instruments was completed by 66 participants during enrollment and follow-up (after 1 month and 6 months). After six months, chart reviews and face-to-face interviews were also performed with the GPs. RESULTS: Mean scores of dizziness handicap, depression and quality of life were not or only slightly affected, and did not deteriorate during follow-up; however, 24 patients (34.8%) showed a moderate or severe dizziness handicap, and 43 (62.3%) showed a certain disability in terms of quality of life at the time of enrollment. In multivariate analysis, n = 44 patients suffering from chronic dizziness (dependent variable, i.e. relapsing or persistent at six months) initially had a greater dizziness handicap (OR 1.42, 95%CI 1.05-1.47) than patients with transient dizziness. GPs referred 47.8% of the patients to specialists who detected two additional cases of benign paroxysmal positional vertigo (BPPV). CONCLUSIONS: New-onset dizziness relapsed or persisted in a considerable number of patients within six months. This was difficult to predict due to the patients' heterogeneous complaints and characteristics. Symptom persistence does not seem to be associated with deterioration of the psychological status in older primary care patients. Management strategies should routinely consider BPPV as differential diagnosis.

Home visits - central to primary care, tradition or an obligation? A qualitative study.

BACKGROUND: Home visits are claimed to be a central element of primary care. However, the frequency with which home visits are made is declining both internationally and in Germany despite the increase in the number of chronically ill elderly patients. Given this, the question arises as to how to ensure sufficient primary health care for this vulnerable patient group. The aim of this study was to explore German general practitioners' (GPs) attitudes with regard to the feasibility, burden and outlook of continued home visits in German primary care. METHODS: Qualitative semi-structured interviews were carried out with 24 GPs from the city of Hannover, Germany, and its rural surroundings. Data was analysed using qualitative content analysis. RESULTS: The GPs indicated that they frequently conduct home visits, but not all of them were convinced of their benefit. Most were not really motivated to undertake home visits but some felt obliged to. The basic conditions covering home visits were described as unsatisfactory, in particular with respect to reimbursement and time constraints. House calls for vulnerable, elderly people remained undisputed, whereas visits of a social nature were mostly deleted. Urgent house calls were increasingly delegated to the emergency services. Visits to nursing homes were portrayed as being emotionally distressing. GPs considered good cooperation with nursing staff the key factor to ensure a successful nursing home visit. The GPs wanted to ease their work load while still ensuring quality home care but were unable to suggest how this might be achieved. Better financial compensation was proposed most often. The involvement of specially trained nurses was considered possible, but viewed with resentment. CONCLUSIONS: Home visits are still an integral aspect of primary care in Germany and impose a considerable workload on many practices. Though the existing situation was generally perceived as unsatisfactory, German GPs could not envisage alternatives if asked to consider whether the current arrangements were sustainable in the future. To guarantee an unaltered quality of primary home care, German GPs and health care policy makers should actively initiate a debate on the need for and nature of home visits in the future.

Circulating soluble urokinase plasminogen activator receptor is stably elevated during the first week of treatment in the intensive care unit and predicts mortality in critically ill patients.

INTRODUCTION: suPAR is the soluble form of the urokinase plasminogen activator receptor (uPAR), which is expressed in various immunologically active cells. High suPAR serum concentrations are suggested to reflect the activation of the immune system in circumstances of inflammation and infection, and have been associated with increased mortality in different populations of non-intensive care patients. In this study we sequentially analyzed suPAR serum concentrations within the first week of intensive care in a large cohort of well characterized intensive care unit (ICU) patients, in order to investigate potential regulatory mechanisms and evaluate the prognostic significance in critically ill patients. METHODS: A total of 273 patients (197 with sepsis, 76 without sepsis) were studied prospectively upon admission to the medical intensive care unit (ICU), on Day 3 and Day 7, and compared to 43 healthy controls. Clinical data, various laboratory parameters as well as investigational inflammatory cytokine profiles were assessed. Patients were followed for approximately one year. RESULTS: Upon admission to the ICU suPAR serum concentrations were elevated in critically ill patients as compared with healthy controls. In sepsis patients suPAR levels were higher than in non-sepsis patients (with or without systemic inflammatory response syndrome (SIRS)). During the first week after admission to the ICU serum suPAR concentrations remained stably elevated. suPAR serum concentrations measured upon admission were closely and independently correlated to various laboratory parameters, specifically biomarkers of inflammation (tumor necrosis factor (TNF), C-reactive protein (CRP)), hepatic and renal dysfunction. High suPAR levels at admission and at Day 3 were a strong independent predictor for both ICU and long-term mortality in critically ill patients. CONCLUSIONS: In sepsis and non-sepsis patients suPAR serum concentrations are increased upon admission to the ICU, likely reflecting the activation state of the immune system, and remain stably elevated in the initial course of treatment. Low suPAR levels are a positive predictor of ICU- and overall survival in critically ill patients, including sepsis and non-sepsis patients. Aside from its value as a promising new prognostic biomarker, both experimental and clinical studies are required in order to understand the specific effects and regulatory mechanisms of suPAR in SIRS and sepsis, and may reveal new therapeutic options.

A three-group comparison of acute-onset dizzy, long-term dizzy and non-dizzy older patients in primary care.

BACKGROUND AND AIMS: The hypothesis of increased cardiovascular risk contributing to chronic dizziness has been discussed controversially so far. We investigated older patients suffering from acute (<6 months), chronic (≥ 6 months) or no dizziness, in terms of their cardiovascular risk and other impairments. METHODS: A cross-sectional three-group comparison of 257 patients (65+) presenting at family medicine surgeries in Germany was performed. Measures of cardiovascular risk, including overall scores, scores of quality of life (SF-12), activities of daily living (ADL), depression (GDS), dizziness handicap (DHI) and patients' needs (DiNA), as well as comorbidity and medication, were compared in univariate and multivariate logistic regression analysis. RESULTS: In univariate analysis, systolic and diastolic blood pressure were significantly lower in the dizziness groups. The overall cardiovascular risk was not increased in dizzy patients. Anxiety was strongly associated with dizziness, whereas other associations were of marginal importance. In multivariate analysis, age (OR 1.10, 95% CI 1.03-1.17), female gender (OR 2.07, 95% CI 1.01-4.26) and anxiety (OR 2.50, 95% CI 1.03-6.05) were associated with acute dizziness, whereas only female gender was significant in chronic dizziness (OR 1.96, 95% CI 1.02- 3.75). Comparing all dizzy patients with the non-dizzy group, lower systolic blood pressure was also significantly associated with dizziness. CONCLUSIONS: Results from our sample suggest that low systolic blood pressure is more important for dizziness in older patients than increased cardiovascular risk. Acute-onset and long-term dizzy patients were comparable in many aspects, which makes this classification less clinically important.

Fracture risk of patients suffering from dizziness: a retrospective cohort study.

BACKGROUND: Dizziness is known to be associated with the risk of falls. However, there is not much evidence for the increase of fractures caused by dizziness. OBJECTIVES: The aim of the study was to investigate whether the symptom of dizziness is associated with an increased fracture rate. METHODS: We performed a retrospective cohort study using a population-based administrative database in the Province of Quebec, Canada. A cohort of n = 2442 patients with at least one diagnosis of dizziness was compared to n = 16,125 unexposed patients. The main outcome measure was any kind of first fracture after the index date of dizziness. RESULTS: Analysis revealed a moderate effect of dizziness as an independent contributing factor to fractures (adjusted hazard ratio (HR) 1.26, 95% confidence interval 1.03 to 1.55). A fracture in the year before the index date was highly associated with the incidence of a subsequent fracture (HR 2.69, 2.09 to 3.47), and fractures were less frequent in women (HR 0.70, 0.60-0.82). Analysis further revealed that dizziness (HR 1.31, 1.05-1.64) and prior fractures (HR 2.41, 1.81-3.22) were associated with non-osteoporotic fractures, which were also less frequent in women (HR 0.59, 0.50-0.71). The incidence of fractures in sites typical for osteoporosis correlated with a precedent fracture (HR 3.91, 2.31-6.63), but not with dizziness (HR 1.10, 0.69-1.75). CONCLUSION: Besides the 'typical' elderly female patient being at risk of osteoporotic fractures, male patients suffering from dizziness should be carefully evaluated, and prevention strategies should be considered to minimise their risk of suffering non-osteoporotic fractures.

Postnatal experiences influence the behavior in adult male and female Fischer and Lewis rats.

The postnatal environment with the rat pups' dam as the most important regulator, plays a central role in determining developmental processes of the offspring. Early disturbances of the dam-pup-dyade, like separation from the dam for hours (maternal deprivation, MD), or a short period of separation, and exposure to novelty, like the handling stimulation (HA), might induce long-lasting changes within the individual. To further investigate the susceptibility to these postnatal manipulations with regard to both, sex and genetic background, we used male and female Fischer (F344) and Lewis (LEW) rats. F344 and LEW rats were daily subjected to either HA, MD, or were left undisturbed until weaning. The immediate effects of these manipulations were studied using the mother-pup-interaction-test on postnatal days 3-7. At the age of 4 months, animals were subjected to a behavioral test battery, determining activity, exploration, and anxiety-like behavioral parameters. Postnatal manipulations induced significant alterations of the mother-pup-interaction patterns that were more pronounced in F344 dams. MD and HA F344 dams were longer off pups than LEW dams. MD F344 pups were longer groomed than MD LEW pups and HA F344 pups were longer passive nursed than HA LEW pups. In adulthood, F344 rats showed increased anxiety-like behavior compared to LEW rats. Furthermore, females of both strains exhibited more anxiety-like behavior than males. Test independently, MD led to more anxiety-like behavior and less exploratory responses, while handled rats exhibited an anxiolytic-like behavior and increased exploratory responses. In conclusion, postnatal experiences specifically altered the behavioral phenotype in adulthood. While these changes were co-directional in the two strains and in both sexes, the degree of susceptibility varied.

Themes and methods of research presented at European General Practice Research Network conferences.

BACKGROUND: The World Organization of Family Doctors (Wonca) defined core characteristics of general practice and general practitioners' competencies. It is unclear to which extent research has addressed these issues so far. OBJECTIVE: To determine themes and research methods of general practice research as reflected by presentations at the European General Practice Research Network (EGPRN) meetings. METHODS: Descriptive and retrospective study. All abstracts presented at each of the 14 EGPRN conferences between June 2001 and October 2007 were analysed for content and study design/methodology. Categories for content were developed inductively; a predefined hierarchical scheme was used for study designs. RESULTS: A total of N=614 abstracts were classified. The main research topics were related to GP/health service issues (n=232), clinical (n=148) and patient-related themes (n=118). Original data (n=558) were mainly derived from cross-sectional designs (38.7%). Intervention studies (11.0%), longitudinal designs including case-control and cohort studies (13.3%) as well as instrumental research (2.2%) were less common. More than one-fourth of all original studies were qualitative studies (27.6%). Stratified analysis revealed that cross-sectional designs were less frequent in the second half of conferences. Analysis by country showed that, in contrast to different quantitative designs, the proportion of qualitative studies was comparable. CONCLUSIONS: To test effectiveness of diagnostic and therapeutic interventions under primary care conditions, a higher proportion of experimental studies would be preferable. This could increase the acceptance of general practitioners' specific approaches and provide clear guidance on approaches and procedures, especially in health care systems not predominantly based on primary care.

The priorities of elderly patients suffering from dizziness: a qualitative study.

BACKGROUND: Integrating patients' priorities can improve the quality of care in general practice. Therefore, we aimed to learn more about patients' priorities in terms of their dizziness complaints. METHODS: Patients were recruited by nine general practitioners. Inclusion criteria were an age of at least 65 years and dizziness due to any cause for any duration, assuring heterogeneity of included patients. Semi-structured interviews of 20 patients (12 women, mean age 79 years) were analysed by qualitative content analysis. RESULTS: Patients were very much focused on finding causes for their dizziness, and some found their doctor had not taken the dizziness problem seriously yet. Each patient expressed own theories of aetiology that sometimes revealed apparent misconceptions of possible causes. Treatment aims were prioritised by patients in different ways (wish for recovery, relief or stabilisation). Some patients had not very well understood common therapy options, and interviewees frequently mentioned what they did on their own to face the dizziness (self-help measures). Remarkably, many patients were very much concerned about different aspects of mobility (fear of falling, loss of independence). CONCLUSION: These patients' lack of understanding, their resources and concerns indicate the importance of a patient-centred communication about their dizziness complaints.

[Frequency of dizziness-related diagnoses and prescriptions in a general practice database]. / Diagnosehäufigkeiten und Verordnungen bei Schwindel im Patientenkollektiv einer hausärztlichen Routinedatenbank.

INTRODUCTION: Dizziness can be due to multiple causes. However, the aetiology often remains unclear. At the same time, there is a lack of evidence-based treatment options. The aim of this study was to investigate the frequency of dizziness-related diagnoses, referrals and prescriptions in a general practice database. METHODS: Data from computerized patient records of 138 general practices participating in the MedViP project were used for cross-sectional analysis of the time period April 2001 until December 2002. The identification of dizzy patients was performed via ICD-10 diagnoses, free text fields and medication issued for dizziness. Frequencies were counted and odds ratios calculated to describe associations between diagnoses and medication. RESULTS: For the period of investigation, 10,971 patients (from a total of 317,042 documented patients) were given at least one diagnosis of dizziness (prevalence 3.4%; mean age 59 years, 67.2% female). In 80.2% of the cases dizziness was coded as a symptom (R42) rather than a discrete disease. Prescriptions for dizziness were rather uncommon. An analysis of ATC codes showed that 6.6% of all affected patients were prescribed a specific drug for dizziness, most frequently betahistine. Antiemetics were prescribed in 7.1%, and the homeopathic preparation "Vertigoheel" in 2.8% of the dizzy patients. Betahistine was significantly more often prescribed for "unspecified" dizziness, vestibular neuritis, and benign paroxysmal positional vertigo; but not for Meniere's disease. It was given less often in "other peripheral" and in central vertigo as well as in cases where the symptom was coded (R42). 3.9% of the dizzy patients had been referred to the neurologist (55.4%), ENT-specialist (30.5%) or to both specialists (14.1%). CONCLUSIONS: The manner of coding and prescribing reflects both a symptom-orientated classification used by general practitioners and the limitation of treatment options.

Inhibition of CD26/dipeptidyl peptidase IV enhances CCL11/eotaxin-mediated recruitment of eosinophils in vivo.

Chemokines mediate the recruitment of leukocytes to the sites of inflammation. N-terminal truncation of chemokines by the protease dipeptidyl peptidase IV (DPPIV) potentially restricts their activity during inflammatory processes such as allergic reactions, but direct evidence in vivo is very rare. After demonstrating that N-terminal truncation of the chemokine CCL11/eotaxin by DPPIV results in a loss of CCR3-mediated intracellular calcium mobilization and CCR3 internalization in human eosinophils, we focused on the in vivo role of CCL11 and provide direct evidence for specific kinetic and rate-determining effects by DPPIV-like enzymatic activity on CCL11-mediated responses of eosinophils. Namely, it is demonstrated that i.v. administration of CCL11 in wild-type F344 rats leads to mobilization of eosinophils into the blood, peaking at 30 min. This mobilization is significantly increased in DPPIV-deficient F344 rats. Intradermal administration of CCL11 is followed by a dose-dependent recruitment of eosinophils into the skin and is significantly more effective in DPPIV-deficient F344 mutants as well as after pharmacological inhibition of DPPIV. Interestingly, CCL11 application leads to an up-regulation of DPPIV, which is not associated with negative feedback inhibition via DPPIV-cleaved CCL11((3-74)). These findings demonstrate regulatory effects of DPPIV for the recruitment of eosinophils. Furthermore, they illustrate that inhibitors of DPPIV have the potential to interfere with chemokine-mediated effects in vivo including but not limited to allergy.

Postnatal life events affect the severity of asthmatic airway inflammation in the adult rat.

Genetic and hygienic factors influence susceptibility to asthma. In autoimmune and inflammatory diseases, additional effects of the psychosocial environment have been demonstrated that might also play a role in asthma. In this study, the impact of different early postnatal stressors on an OVA-induced model of asthma was tested in adulthood. Fischer 344 rats were subjected to either repeated handling stimulation (HA), maternal separation (MS), or were left undisturbed in their first 4 wk of life. Behavioral differences were characterized at the age of 4 mo. At 5 mo of age, immunological cellular and serologic changes were investigated and experimental asthma was induced. Results show significantly increased exploratory behavior and reduced anxiety in HA rats compared with MS and controls. Without further behavioral or immunological challenges, HA animals exhibited an increased ex vivo NK cell cytotoxicity but no other obvious immunological differences. After induction of asthma, in contrast, MS animals exhibited proinflammatory effects in leukocyte subset composition including increased eosinophil numbers, whereas levels of IgE and the allergy-specific cytokine IL-13 were reduced compared with HA. There was a most remarkable increase of adrenocorticotropin in HA animals, comparing pre- to postchallenge plasma levels. These data demonstrate for the first time that early postnatal stimulative or adverse experiences exert long-lasting changes of the "neuroendocrinoimmune" interface in adulthood, resulting in either protective or aggravating mechanisms in allergic airway disease. Thus, in addition to genetic and hygienic factors, nongenetically acquired individual differences contribute to the pathobiology of asthma.