[Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. / Polymyalgia rheumatica ­ eine Herausforderung in der Altersmedizin : Diagnostik und Therapie interdisziplinär dargestellt.

Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.

[Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. / Polymyalgia rheumatica ­ eine Herausforderung in der Altersmedizin : Diagnostik und Therapie interdisziplinär dargestellt.

Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.

TDP-43 pathology in Drosophila induces glial-cell type specific toxicity that can be ameliorated by knock-down of SF2/SRSF1.

Accumulation of cytoplasmic inclusions of TAR-DNA binding protein 43 (TDP-43) is seen in both neurons and glia in a range of neurodegenerative disorders, including amyotrophic lateral sclerosis (ALS), frontotemporal dementia (FTD) and Alzheimer's disease (AD). Disease progression involves non-cell autonomous interactions among multiple cell types, including neurons, microglia and astrocytes. We investigated the effects in Drosophila of inducible, glial cell type-specific TDP-43 overexpression, a model that causes TDP-43 protein pathology including loss of nuclear TDP-43 and accumulation of cytoplasmic inclusions. We report that TDP-43 pathology in Drosophila is sufficient to cause progressive loss of each of the 5 glial sub-types. But the effects on organismal survival were most pronounced when TDP-43 pathology was induced in the perineural glia (PNG) or astrocytes. In the case of PNG, this effect is not attributable to loss of the glial population, because ablation of these glia by expression of pro-apoptotic reaper expression has relatively little impact on survival. To uncover underlying mechanisms, we used cell-type-specific nuclear RNA sequencing to characterize the transcriptional changes induced by pathological TDP-43 expression. We identified numerous glial cell-type specific transcriptional changes. Notably, SF2/SRSF1 levels were found to be decreased in both PNG and in astrocytes. We found that further knockdown of SF2/SRSF1 in either PNG or astrocytes lessens the detrimental effects of TDP-43 pathology on lifespan, but extends survival of the glial cells. Thus TDP-43 pathology in astrocytes or PNG causes systemic effects that shorten lifespan and SF2/SRSF1 knockdown rescues the loss of these glia, and also reduces their systemic toxicity to the organism.

[Assessment of mobility/motor skills in old age : Based on the S1 guideline "Geriatric assessment level 2, living guideline"]. / Assessment der Mobilität/Motorik im Alter : Basierend auf der S1-Leitlinie "Geriatrisches Assessment der Stufe 2, Living Guideline".

In addition to locomotion, mobility also includes any motor performance that serves other purposes and movements that are unplanned. This article presents the instruments mentioned in the S1 guideline "Geriatric assessment level 2, living guideline", as well as additional ones that are less known. The classification is into three categories: instruments that focus on the upper extremities, instruments without performance, which mainly focus on the functions and capabilities of the lower extremities, and those that do this using performance tests.

[Validation of the German version of the 6­item screener : Brief cognitive test with broad application possibilities]. / Validierung der deutschen Fassung des Six-Item Screeners : Kognitiver Kurztest mit breiten Anwendungsmöglichkeiten.

BACKGROUND: Especially during admission the detection of cognitive deficits relevant to everyday life should burden patient and examiner as little as possible. The 6­item screener (SIS) takes approximately 1 min, is easy to learn, does not require any material and is independent of the patient's visual and fine motor skills. The test was first published in 2002 by Callahan who approved the present German translation. OBJECTIVE: We checked the convergent and discriminant validity, reliability and sensitivity to change of the German translation among geriatric patients. MATERIAL AND METHODS: A total of 165 patients in an acute geriatric department performed the SIS (4 times), the mini mental state examination (MMSE, 2 times), clock-drawing test according to Shulman (2 times), the Regensburg verbal fluency test (2 times) and the Montgomery-Åsberg depression rating scale within a period of 16 days. The overall judgment of a physician blinded to the test results served as the reference standard. RESULTS: The SIS closely correlated with the medical judgment (-0.729). The retest reliability was 0.705 and the internal consistency 0.821 (Cronbach's alpha). The sensitivity to detect cognitive deficits relevant to activities of daily living was 100% if a threshold of 5 points was chosen. The achievement of maximum points largely rules out even mild cognitive impairment. CONCLUSION: The SIS is a valid, reliable short cognitive test. Using a threshold of 5 points the SIS detects cognitive deficits relevant to daily living with a higher sensitivity than the MMSE with a threshold of 25. When the maximum score is achieved there are no medical indications for further cognitive assessment of clinically unremarkable geriatric patients. The brevity and simple application of the SIS also enable its application outside geriatric wards.

Screening cervical spine CT in the emergency department, Phase 2: A prospective assessment of use.

BACKGROUND AND PURPOSE: The National Emergency X-Radiography Utilization Study Low-Risk Criteria were established to identify patients with a low probability of cervical spine injury in whom imaging of the cervical spine was unnecessary. The purpose of this study was to ascertain the number of unnecessary cervical spine CT studies on the basis of proper application of established clinical guidelines and, secondarily, to determine indications for ordering studies in the absence of guideline criteria. MATERIALS AND METHODS: All patients presenting to a level I trauma center for whom a screening cervical spine CT was ordered in the setting of blunt trauma were eligible for enrollment. For each study, the requesting clinician completed a survey regarding study indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data to determine the presence or absence of cervical spine injury. RESULTS: Of 507 CT examinations, 5 (1%) were positive and 497 (98.0%) were negative for acute cervical spine injury. Five studies (1%) were indeterminate for acute injury but demonstrated no abnormality on subsequent imaging and clinical follow-up. Of the 502 studies without cervical spine injury, 81 (16.1%) were imaged despite meeting all 5 NEXUS criteria for nonimaging. Of these, the most common study indication was dangerous mechanism of injury (48.1%) followed by subjective neck pain (40.7%). CONCLUSIONS: Strict application of NEXUS criteria could potentially reduce the number of screening cervical spine CT scans in the setting of blunt trauma; this change would avoid a considerable amount of unnecessary radiation and cost.

Effects of acetylsalicylic acid on ascorbic acid concentrations in plasma, gastric mucosa, gastric juice and urine--a double-blind study in healthy subjects.

OBJECTIVE: This study investigated concentrations of ascorbic acid (ASC) in gastric mucosa, gastric juice, urine and plasma in healthy subjects under steady state and fasted conditions with and without concomitant administration of acetylsalicylic acid (ASA). MATERIAL AND METHODS: This was a prospective, randomized, double-blind, parallel-group study in healthy subjects. It has assessed the effects of a 6-day administration of 0.8 g ASA or 0.48 g ASC, 3 times daily and the combination of both on concentrations of ASC in gastric mucosa, gastric juice, urine and plasma. Treatments were switched after 6 days without any washout for assessment of compartment sensitivity to changes in study medication resulting in an overall 14-day study period. Each of the 3 treatment groups consisted of 15 subjects. RESULTS: ASC concentrations were highest in the gastric mucosa (251+/-11 microg/g), followed by gastric juice (29+/-6 microg/ml), plasma (10+/-0.2 microg/ml), and urine (5+/-1 microg/ml). On day 7, ASC concentrations in gastric mucosa, plasma and urine had increased in those groups receiving ASC and decreased in the group receiving ASA only. All differences were statistically significant and indicate an interaction with ASA. In gastric juice, differences in ASC concentrations between the treatment groups were not statistically significant between baseline and day 7. ASC concentrations in plasma were strongly correlated with corresponding ASC concentrations in gastric mucosa (r = 0.34) and urine (r = 0.83), as were ASC concentrations in gastric mucosa with ASC in urine (r = 0.28). CONCLUSIONS: The gastric mucosa is the largest depot of ASC in the human body with ASC concentrations 25 times higher than in plasma. In healthy subjects, clinically relevant doses of ASA reduced ASC concentrations in gastric mucosa by about 10% within 6 days resulting from antioxidative defense mechanisms. In patients with long-term ASA treatment or conditions with additional risks such as elderly subjects with unfavorable dietary conditions and impaired antioxidative protection, a protective adjunct administration of ASC appears to be beneficial.

Effects of buffered and plain acetylsalicylic acid formulations with and without ascorbic acid on gastric mucosa in healthy subjects.

BACKGROUND: The most frequently reported adverse events associated with acetylsalicylic acid intake are minor gastrointestinal complaints. Galenic modifications, such as buffered formulations with or without ascorbic acid, may improve the benefit-risk ratio by decreasing the local mucosal side-effects of acetylsalicylic acid. AIM: To assess endoscopically-proven gastrointestinal lesions and the amount of gastric microbleeding of four different buffered and plain acetylsalicylic acid formulations, one containing paracetamol. METHODS: A randomized, four-fold cross-over study was performed in 17 healthy subjects who underwent serial oesophago-gastro-duodenoscopy before and after each course of 4-day dosing. Gastric aspirates were collected for the determination of haemoglobin concentrations to detect microbleeding. RESULTS: Buffered acetylsalicylic acid plus ascorbic acid yielded the lowest Lanza score, the lowest increase in the number of mucosal petechiae and the lowest increase in the amount of gastric microbleeding. Subjects receiving acetylsalicylic acid plus paracetamol plus caffeine showed the highest Lanza score of all treatments, and a considerably greater sum of petechiae in the oesophagus, stomach and duodenum compared with those receiving buffered acetylsalicylic acid plus ascorbic acid. CONCLUSIONS: The trial confirms that buffering of acetylsalicylic acid improves local gastric tolerability. Acetylsalicylic acid in combination with ascorbic acid shows significantly fewer gastric lesions and the lowest increase in gastric microbleeding compared with the other tested formulations.

Pharmacokinetic properties of tramadol sustained release capsules. 3rd communication: investigation of relative bioavailability under steady state conditions.

In an open, randomized two-period crossover study in 24 healthy male volunteers multiple doses of tramadol (CAS 27203-92-5) test and reference medication were administered as follows: Test: sustained release capsules containing 100 mg tramadol hydrochloride, a total of 6 capsules at intervals of 12 h; Reference: instant release capsules containing 50 mg tramadol hydrochloride, a total of 12 capsules at intervals of 6 h. As a result of the statistical analysis of AUCss(48-72 h) after logarithmic transformation a bioavailability of 100% for the sustained release capsules compared with the instant release capsules was obtained. As expected statistical analysis of the peak trough fluctuation at steady state PTFss(48-72 h) yielded a distinct diminution of the fluctuation.

Influence of large intakes of trace elements on recovery after major burns.

Because Cu, Se, and Zn are involved in immune and antioxidative defense mechanisms and tissue repair, deficiencies might aggravate complications classically observed with burns. After measuring massive cutaneous trace element losses in 10 burn patients, our aim in this study was to determine whether large intravenous intakes of Cu, Zn, and Se can modify serum trace element levels and recovery after major burns. Ten patients, aged 34 +/- 6 yr (mean +/- SD), admitted to the burns center of a Swiss university hospital with thermal burns on 41 +/- 9% of their body surface were studied prospectively, with trace element balance studies from day 1 (D1) to D7 postinjury. Urine and blood samples were also collected on D10, D15, D20, and D25. The patients were divided into two groups of five and received either standard (group 1, control) or greatly increased (group 2, treatment: 4.5 mg Cu, 190 micrograms Se, and 40 mg Zn/day) trace element intakes. Energy and protein intake and wound treatment were similar in both groups. The treatment group was characterized by improved Cu, Se, and Zn status (increase in serum levels and various protein indicators), a much larger leukocyte increase between D4 and D14 (mainly neutrophils), and shorter hospital stay (45 days) compared with the untreated group (57 days). Grafting requirements were more extensive in group 1. Although severity of injury and wound treatment were similar in the groups, the duration of hospitalization was lower in the treated group. Further studies are required to determine whether this is related to trace element supplementation.

Mid-term results with cultured epidermal autografts, allogenic skin transplants and cyclosporin A medication.

Transplantation of allogenic split thickness skin grafts (STSG) and immunosuppression with cyclosporin A enable early and definitive skin replacement of extensive, deep partial and full thickness burns. Covering burn defects with definitely engrafted, allogenic dermis and cultivated epithelial autografts (CEA) permits the subsequent withdrawal of cyclosporin A medication. Light-microscopy examination of biopsies, taken 12 and 24 months postgrafting, and electron microscopy of biopsies taken 12 months postgrafting, demonstrates a re-established, but somewhat reduced anchoring of the CEA as compared with a normal epidermal-dermal junction. Clinical inspection, 20 months postgrafting, confirms the histological observations that epifascial transplantation is qualitatively inferior to placing the allogenic STSG on the subcutaneous tissue. In the first situation, the dermis is inelastic and collagen deposition is excessive, whereas in the second case collagen deposition is comparatively reduced and the dermis shows clinically some elasticity.

Cutaneous copper and zinc losses in burns.

To measure the exudative cutaneous copper (Cu) and zinc (Zn) losses in burns, 10 patients, aged 36 +/- 9 years (mean +/- s.d.) with burns covering 33 +/- 10 per cent of the total body surface area, were studied from the first postburn day (D1) until D7. All intakes and losses were analysed for Cu, Zn and nitrogen (N) content. Cutaneous losses were extracted from textiles surrounding the patients. Urinary excretions were 0.12 +/- 0.06mg/24h for Cu, 0.9 +/- 0.6mg/24h for Zn, and 14.1 +/- 4.4g/24h for N. Mean daily exudative losses through wound seepage from D1 to D7 were 4.7 +/- 2.1mg/24h for Cu, 27.1 +/- 14.4mg/24h for Zn, and 8.7 +/- 3.8g/24h for N. The cumulated mean losses over 7 days were 37mg for Cu, and 212mg for Zn, representing respectively 20-40 per cent and 5-10 per cent of normal body content. Serum Cu and Zn levels were strongly depressed. The urinary Cu/N ratios correlated with clinical improvement. We conclude that the exudative Cu and Zn losses during the first week postburn contribute significantly to the increased nutrient requirements in burns.

Current concepts in pediatric burn care: management of burn wounds with cultured epidermal autografts.

Our experience with CEA is based on 21 patients operated on from 1986 to 1991. The areas covered with CEA measured 500 cm2 to 3160 cm2. At one setting no more than 40 sheets of 40 cm2 CEA have been transplanted. The take of CEA is over 75% when applied to dermis. The same holds true when covering "deepithelialised" skin homografts on immunosuppressed patients. Scar formation has not been a problem, and the overall results have been good.

The neurosensory musculocutaneous tensor fasciae latae flap: long term results.

In 1971 we started covering pressure sores and unstable scars with transposition-rotation-muscle and musculocutaneous flaps. In 1980 we published the first results with 6 neurosensory musculocutaneous tensor fasciae latae flaps. Until April 1989, 31 tensor fasciae latae flaps (TFL) were used, and we review a consecutive series of 19 neurosensory TFL-flaps. Questions such as whether to delay the procedure; early and late complications; evolution of the sensation; and indications are outlined under the aspects of long term follow up studies. The conclusion is that if the neurological pattern permits a neurosensory flap, such flaps should be done because no local recurrence occurred. In extended neurosensory TFL-flaps sensation of the filling status of the rectum is improved, and sitting control and perception of the 'body scheme' are also improved.

Selenium losses in 10 burned patients.

To determine the selenium (Se) losses and balances, 10 patients with burns of 32 +/- 9% (mean +/- SD) of total body surface and aged 36 +/- 9 years were studied from D1 (first post-injury) unitl D7. Cutaneous losses were extracted from the textiles surrounding the patients. Serum and urine were collected until D20. Exudative losses of nitrogen decreased progressively (mean 8.7 +/- 3.8 g/24H). Se was detectable in wound seepage only during excision-grafting: mean operative loss was 342 +/- 191 mug. Mean urinary Se excretion was 41 +/- 13 mug/24H. Operative cutaneous losses led to some negative balances. Serum Se and glutathione peroxydase (GSHPx) were depressed until D20. Serum Se was related to N intake (p < 0.001). The decreased Se and GSHPx levels reflect a deficiency state, which measured losses did not explain, but limitations of the measurement methods prevented detection of Se cutaneous losses 100 mug/24H.

[Cutaneous reconstruction of external genital organs: an older method still in current use]. / Reconstruction cutanée des organes génitaux externes: une ancienne méthode toujours d'actualité.

The authors present four patients with cutaneous defects of the genital organs, one with a degloving injury to the penis, one with Fournier's gangrene, one with massive lymphoedema and one with a full thickness burn. In those four cases, a stable coverage was obtained through skin grafts, maintained by an external splint. The use of this older method gave an excellent esthetic and functional result.

[Thoracic fascio-cutaneous flap]. / Lambeaux fascio-cutanés thoraciques.

Fascio-cutaneous flaps (LFC) of the thoracic wall are of rather historical interest with the exception of axillary and lateral thoraco-dorsal LFC. The reason has been the development of muscular, musculo-cutaneous and microvascular flaps which provide larger surfaces for defect cover, greater arc of rotation or none at all as well as superior vascularisation. The axillary LFC is used to correct axillary contractures after burns or to cover skin defects following radical excision for hidradenitis suppurativa. The lateral thoraco-dorsal LFC permits immediate reconstruction of an amputated breast with a minimum of time and blood loss and an unsurpassed fiability. Furthermore it allows postoperative X-ray treatment if necessary as well as uninhibited control of loco-regional metastases.