[Long-term complications, monitoring and interventional treatment of large vessel vasculitis]. / Langzeitkomplikationen, Monitoring und interventionelle Therapien bei Großgefäßvaskulitiden.

Giant cell arteritis (GCA) and Takayasu's arteritis (TAK) both belong to the group of large vessel vasculitides and require long-term drug treatment. Glucocorticoids (GC) are the first choice for the treatment of both diseases. For GCA immunosuppressants, such as tocilizumab or methotrexate should be considered in cases of treatment refractory and relapses or if there is a high risk for GC-related adverse events. In TAK patients the use of immunosuppressive agents should be considered for all patients. In the course of the disease, severe disease-associated and treatment-associated complications can occur. The most frequent disease-associated complications include visual impairment up to blindness in GCA, as well as vascular stenoses with ischemia and aortic aneurysms with possible dissection in GCA and TAK. Percutaneous transluminal angioplasty (PTA) and stenting are minimally invasive, low-risk interventional procedures for GCA and TAK patients with clinically significant vascular stenoses, despite a tendency to restenosis. Interventional procedures should be weighed up against vascular surgical approaches depending on the localization and the total clinical situation. All interventions should be conducted in a phase of stable remission when possible. For monitoring of disease activity in patients with GCA and TAK, assessment of clinical manifestations as well as C­reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are useful; however, both are unreliable under interleukin­6 block with tocilizumab. The value of new biomarkers independent from interleukin­6 and the importance of imaging (sonography, magnetic resonance angiography, computed tomography and positron emission tomography-CT) for monitoring GCA and TAK still have to be investigated in future studies.

Diagnostic values of history and clinical examination to predict ultrasound signs of chronic and acute enthesitis.

OBJECTIVE: To examine the diagnostic values of history of chronic enthesitic pain and clinical signs of acutely inflamed entheses to predict ultrasound (US) signs of enthesitis. METHODS: Cohort study of 21 consecutive rheumatic out-patients (female/male 18/3) with suspected multiple enthesitis and 12 controls (female/male 10/2). 429 enthesal sites according to the Maastricht Ankylosing Spondylitis Entheses Score (MASES) were evaluated by history, clinical examination, B-mode and power Doppler US. Sensitivity and specificity of history suggesting chronic enthesitic pain and clinical examination suggesting acute enthesitis were calculated using corresponding US findings as reference standard. RESULTS: Diagnostic accuracy widely varied between different MASES sites. Sensitivity and specificity of selected MASES points were 66.7 - 86.4% and 85.0 - 91.7% for history and 71.4 - 87.0% and 47.4 - 75.0% for clinical examination, respectively (p<0.05 for each). CONCLUSION: At specific enthesal sites, history of chronic enthesitic pain and clinical signs of acute inflammation are sensitive and specific for the diagnosis of chronic and/or acute inflammation.

The persistence of a broad range of antibiotics during calve, pig and broiler manure storage.

After administration to livestock, a large fraction of antibiotics are excreted unchanged via excreta and can be transferred to agricultural land. For effective risk assessment a critical factor is to determine which antibiotics can be expected in the different environmental compartments. After excretion, the first relevant compartment is manure storage. In the current study, the fate of a broad scope of antibiotics (n = 46) during manure storage of different livestock animals (calves, pigs, broilers) was investigated. Manure samples were fortified with antibiotics and incubated during 24 days. Analysis was carried out by LC-MS. The dissipation of the antibiotics was modelled based on the recommendations of FOCUS working group. Sulphonamides relatively quickly dissipate in all manure types, with a DT90 of in general between 0.2 and 30 days. Tetracyclines (DT90 up to 422 days), quinolones (DT90 100-5800 days), macrolides (DT90 18-1000 days), lincosamides (DT90 135-1400 days) and pleuromutilins (DT90 of 49-1100 days) are in general much more persistent, but rates depend on the manure type. Specifically lincomycin, pirlimycin, tiamulin and most quinolones are very persistent in manure with more than 10% of the native compound remaining after a year in most manure types. For all compounds tested in the sub-set, except the macrolides, the dissipation was an abiotic process. Based on the persistence and current frequency of use, oxytetracycline, doxycycline, flumequine and tilmicosin can be expected to end up in environmental compartments. Ecotoxicological data should be used to further prioritize these compounds.

The Evolving Role of Dental Responders on Interprofessional Emergency Response Teams.

Disaster and pandemic response events require an interprofessional team of health care responders to organize and work together in high-pressure, time-critical situations. Civilian oral health care professionals have traditionally been limited to forensic identification of human remains. However, after the bombing of the Twin Towers in New York, federal agencies realized that dentists can play significant roles in disaster and immunization response, especially on interprofessional responder teams. Several states have begun to incorporate dentists into the first responder community. This article discusses the roles of dental responders and highlights legislative advancements and advocacy efforts supporting the dental responder.

A set of constitutive relationships accounting for residual NAPL in the unsaturated zone.

Although laboratory experiments show that non-aqueous phase liquid (NAPL) is retained in the unsaturated zone, no existing multiphase flow model has been developed to account for residual NAPL after NAPL drainage in the unsaturated zone. We developed a static constitutive set of saturation-capillary pressure relationships for water, NAPL and air that accounts for both this residual NAPL and entrapped NAPL. The set of constitutive relationships is formulated similarly to the set of scaled relationships that is frequently applied in continuum models. The new set consists of three fluid-phase systems: a three-phase system and a two-phase system, that both comply with the original constitutive model, and a newly introduced residual NAPL system. The new system can be added relatively easily to the original two- and three-phase systems. Entrapment is included in the model. The constitutive relationships of the non-drainable residual NAPL system are based on qualitative fluid behavior derived from a pore scale model. The pore scale model reveals that the amount of residual NAPL depends on the spreading coefficient and the water saturation. Furthermore, residual NAPL is history-dependent. At the continuum scale, a critical NAPL pressure head defines the transition from free, mobile NAPL to residual NAPL. Although the Pc-S relationships for water and total liquid are not independent in case of residual NAPL, two two-phase Pc-S relations can represent a three-phase residual system of Pc-S relations. A newly introduced parameter, referred to as the residual oil pressure head, reflects the mutual dependency of water and oil. Example calculations show consistent behavior of the constitutive model. Entrapment and retention in the unsaturated zone cooperate to retain NAPL. Moreover, the results of our constitutive model are in agreement with experimental observations.

Infiltration and redistribution of LNAPL into unsaturated layered porous media.

Enhanced understanding of light non-aqueous phase liquid (LNAPL) infiltration into heterogeneous porous media is important for the effective design of remediation strategies. We used a 2-D experimental facility that allows for visual observation of LNAPL contours in order to study LNAPL redistribution in a layered porous medium. The layers are situated in the unsaturated zone near the watertable and they are inclined to be able to observe the effect of discontinuities in capillary forces and relative permeabilities. Two experiments were performed. The first experiment consisted of LNAPL infiltration into a fine sand matrix with a coarse sand layer, and the second experiment consisted of a coarse sand matrix and a fine sand layer. The numerical multi-phase flow model STOMP was validated with regard to the experimental results. This model is able to adequately reproduce the experimental LNAPL contours. Numerical sensitivity analysis was also performed. The capillarity contrast between sands was found to be the main controlling factor determining the final LNAPL distribution.

Decrease of proteinuria in a patient with adult-onset Still's disease and glomerulonephritis after anti-TNFalpha therapy.

We report the case of a 41-year-old man diagnosed with Still's disease. Multiple disease-modifying anti-rheumatic drug (DMARD) therapies failed to induce disease remission or to prevent progressive joint destruction. The man presented with active arthritis and classical Still's rash accompanied by fever. Anti-tumour necrosis factor-alpha (TNFalpha) therapy was planned but during the medical check-up prior to the biological therapy, renal insufficiency with marked proteinuria (PU) was discovered. With PU of 912 mg/24 h a renal biopsy was performed and a histopathological evaluation revealed the diagnosis of a residual mesangio-proliferative immunocomplex-based glomerulonephritis (GN). After excluding contraindications, infliximab therapy was initiated and a good response of the arthritis was documented after 6 weeks. A significant decrease in PU (279 mg/24 h) was noted after the third infliximab infusion. Because of an allergic reaction during the fifth dose, the infliximab was discontinued. During the time frame without anti-TNFalpha therapy, active joint disease reoccurred and the proteinuria increased significantly. Because of the active disease entanercept therapy was initiated. The arthritis diminished and the PU was reduced markedly within 4 weeks. In the follow-up period of 12 months a good response to therapy was sustained. As described by other investigators, the joint disease showed a rapid and sustained response to anti-TNFalpha therapy. The decrease in proteinuria during biological therapy was notable. It was concluded that the significant decrease in PU in this patient was achieved by eliminating the inflammatory activity of the underlying kidney disease.

Evaluation of warmed intravenous fluids in the prehospital setting.

INTRODUCTION: This study was designed to determine if warmed intravenous fluid (IVF) in the prehospital setting improves core body temperature and patient comfort. METHODS: Data were collected in a controlled, nonblinded, prospective study during the winter months of 2 consecutive years. Prehospital adult patients qualified if they received a bolus of 250 mL of fluid (20 mL/kg for pediatrics). Patient and IVF temperatures were measured on arrival at the ED. If the patient's condition allowed, a visual analog survey was completed. RESULTS: Twenty adult patients were enrolled. The warmed IVUF demonstrated an average temperature of 32.5 degrees C (90.1 degrees F) versus 23.5 degrees C (74.3 degrees F) for nonwarmed fluids. The patients with warmed IVF demonstrated a higher core body temperature than the nonwarmed-36.8 degrees C (98.2 degrees F) versus 35.5 degrees C (95.9 degrees F). Overall, patient surveys showed increased comfort with warmed IVF. CONCLUSION: Prehospital IVF can be warmed in the field and should help prevent the adverse effects of hypothermia. Although this study shows a trend in favor of warmed IVF, the population is too small to justify any broad statements. This matter warrants further investigation with a larger group of patients.