[Standards of care for people with rheumatoid arthritis in Europe : Translation and comments of the eumusc.net recommendations supported by EULAR performed by a national task force of the professional organisations DGRh and VRA supported by "Deutsche Rheumaliga"]. / Europäische Versorgungsstandards für Menschen mit rheumatoider Arthritis : Übersetzung und Kommentierung der von der EULAR unterstützten Vorschläge des eumusc.net durch eine Task Force von DGRh und VRA mit Unterstützung der Deutschen Rheuma-Liga.

In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European "standards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

[Treat to participation : Position paper of the German Society for Rheumatology on sustained improvement of functional health of patients with rheumatic and musculoskeletal diseases]. / Treat to Participation : DGRh-Positionspapier zur nachhaltigen Verbesserung des funktionalen Gesundheitszustandes von Rheumakranken.

From the perspective of patients with rheumatic diseases, the reduction of inflammatory disease activity alone is not a sufficient treatment goal. In addition the functional health and participation also have to be improved. Starting with the first symptoms the empowerment for the self-management of the disease is important for the patients; therefore, the established treat to target-strategy has to be expanded by the functional dimension to treat to participation. The position paper of the German Society for Rheumatology (GSR) summarizes the relevant fields of the multiprofessional action that is frequently necessary. This includes the acquirement of function-related competencies during training, further education and advanced training as well as implementation in the everyday practice of patient care. Furthermore, the GSR acknowledges the need for research related to functional and sociomedical consequences of rheumatic diseases and to individual and combined function-related programs in outpatient and inpatient care in rheumatology.

[Trends in rehabilitation of patients with rheumatic diseases in Germany]. / Leistungstrends der rehabilitativen rheumatologischen Versorgung in Deutschland.

Recent Deutsche Gesellschaft für Rheumatologie (DGRh, German Society of Rheumatology) guidelines emphasized the significance of coordinated multidisciplinary care and rehabilitation of patients with inflammatory rheumatic diseases. Nationwide data from the German pension insurance funds showed that inpatient rehabilitation due to rheumatoid arthritis (RA) varied by a factor of 2.6 between the different German states. From 2000 to 2012 rehabilitation measures were reduced by one third, most significantly in men with ankylosing spondylitis (AS). Rehabilitation measures because of RA or AS were provided up to 14 times more frequently by the German statutory pension insurance scheme compared with a large compulsory health insurance which is responsible for rehabilitation measures after retirement. In rehabilitation centers with high numbers of patients with inflammatory rheumatic diseases, higher structural and process quality were demonstrated. In 2011 a total of 40 % of RA patients in the national database of the collaborative arthritis centers showed medium or severe functional limitations. Among these disabled RA patients inpatient rehabilitation was reduced by about 50 % between 1995 and 2011. Out of all RA patients from outpatient rheumatology care with severe functional limitations 38 % had no functional restoration therapy within the previous 12 months with a high variation between rheumatologists. Experiences from other European countries may inspire German rheumatologists and other involved health professionals to initiate a wider range of rehabilitative interventions in the future.

Long-term cardiac and vascular disease outcomes following adjuvant tamoxifen therapy: current understanding of impact on physiology and overall survival.

The relative impact of tamoxifen therapy in women with breast cancer on overall survival, especially as it pertains to cardiac and cardiovascular outcomes, remains under debate in the literature. This review focuses specifically on outcomes of studies that examined large clinical trials with longest duration in patient follow-up relative to these parameters in which compliance with therapy could be documented. Over time, evidence supports potential cardioprotective effects and capacity of adjuvant therapy to improve lipid profiles in women treated with tamoxifen. While some benefit to cardiac health is supported, outcomes related to cardiovascular events remain variable across studies and challenging to interpret. In summary, overall survival in women treated with tamoxifen over time has increasingly shown a trend towards positive outcomes in the context of evaluation of post-treatment cardiac and vascular health. Potential mechanisms underlying the cardioprotective effects of tamoxifen are briefly discussed.

[Physiotherapy and ergotherapy are indispensable. Concrete prescription of remedies - without recourse]. / Physio- und Ergotherapie sind unverzichtbar. Konkretes Rezeptieren von Heilmitteln - ohne Regress.

Physical therapy and occupational therapy are essential for the treatment of inflammatory rheumatic diseases equal in rank to any drug therapy. They have enough evidence and are part of all current guidelines even if mostly not specified. In the German social security system the doctor prescribing physical therapy or occupational therapy has to act according to the different rules and forms as described in the current "Heilmittel Richtlinie" (Remedy directive) effective since July 2011. The multiple formal conditions and requirements of prescriptions are described in detail. Of special interest is that the global diagnosis of rheumatoid arthritis can no longer be used as the reason or justification for the individual prescription but detailed sub-diagnoses, regarding the essential ICF domains of structural damage, functional impairment, activity limitation and participation restriction as well as individual context factors are necessary. Of special interest is the fact that the prescribing doctor is no longer responsible for the formal correctness of prescriptions but the performing therapist, who will not be reimbursed if the prescription shows even minor formal errors. Another important improvement is the newly introduced long-term prescription of physical and occupational therapy. This facilitates the application of these therapies in the multimodal treatment regimen of rheumatic diseases.

Perioperative application of L-alanyl-L-glutamine in cardiac surgery: effect on the polarized T cell cytokine expression.

At risk patients undergoing cardiac surgery with cardiopulmonary bypass have increased rates of postoperative infectious morbidity. Postoperatively, after cardiac surgery, an immunosuppression in the form of a polarization of T helper (Th) cells with a decreased Th1 response (IL-2 and IFN-gamma) and an increased Th2 response (IL-4 and IL-10) is recognized. Therapeutic strategies to modulate the immunological response include special key nutrients such as the amino acid glutamine favoring the Th2 response. There is no information available concerning its effect in patients undergoing cardiac surgery. The aim of this clinical study was to evaluate the effects of a perioperative infusion of glutamine on the polarized lymphocyte T cell cytokine expression and on infectious morbidity in cardiac surgery patients at risk of infection. Seventy-eight patients were included in the study undergoing elective cardiac surgery with a lymphopenia less than 1.2 giga/l. One or more of the following criteria had to be met: age older than 70 years, ejection fraction less than 40%, or mitral valve replacement. We randomly assigned patients to receive infusions of either high-dose L-alanyl-L-glutamine dipeptide [0.5 g/(kg day) glutamine] dissolved in an amino acid solution or an isonitrogeneous, isocaloric, isovolemic nutritional solution. An additional group with normal saline served as control to eliminate any nonspecific nutritional effect. We started the infusion after induction of anesthesia with 1,000 ml/24 h and continued it for 3 days. The primary endpoint was intracellular T cell cytokine expression (including the description in tertiles) on the first postoperative day (pod 1). Secondary endpoints were postoperative infection rate, mortality rate, cardiovascular circulation ventilation time, and renal function. A high-dose perioperative glutamine application leading to mean plasma levels of 1,177 microM had only a minor influence on the polarized intracellular T cell cytokine expression. On pod 1 there was a polarization of T cells, i.e., an augmented Th2 response with an increased number of IL-6 and IL-10 producing cells. On the other side the Th1 response with IL-2 and TNF-alpha declined on pods 1 and 2. Only the intracellular IL-2 response in the lower tertile of IL-2 production was improved with glutamine indicating a small influence. We did not observe any effects on the numbers of postoperative infections; on mortality rate; on cardiovascular circulation; on ventilation time or on renal function. The elevation of glutamine plasma levels by a perioperative intravenous infusion of L-alanyl-L-glutamine influenced the intracellular expression of IL-2 in the lower tertile only slightly. However, mean glutamine values in the other groups remained above or close 500 microM, thus suggesting that glutamine supply to the immune cells was still adequate in most patients, and that glutamine deficiency, if it occurred, was marginal. In the event of a severe glutamine deficiency the observed effect on cytokine production could be more pronounced. Furthermore, we could not observe any obvious clinical advantage in this at risk cardiac surgical patient population. A glutamine supplementation for patients undergoing cardiac surgery without a clear glutamine deficiency is not recommended.

Glutamine administration in patients undergoing cardiac surgery and the influence on blood glutathione levels.

BACKGROUND: Cardiac surgery with an extracorporeal circulation cardiopulmonary bypass (CPB) is characterized by an oxidative stress response. Glutathione (GSH) belongs to the major antioxidative defense. In metabolic stress, glutamine (GLN) may be the rate-limiting factor of GSH synthesis. Decreased GLN plasma levels were observed after various critical states. We evaluated, in patients undergoing open heart surgery with CPB, the effects of a peri-operative GLN supplementation on GSH in whole blood and assessed their influence on the Sequential Organ Failure Assessment score and the intensive care unit length of stay. METHODS: In this prospective, randomized, double-blinded study, we included 60 patients (age older than 70 years, ejection fraction <40% or mitral valve replacement) undergoing an elective cardiac surgery with CPB. We randomly assigned each subject to receive an infusion with either GLN (0.5 g/kg/day, group 1) or an isonitrogeneous, isocaloric, isovolemic amino acids solution (group 2) or saline (group 3). RESULTS: From the first post-operative day GLN plasma levels in group 1 were significantly increased compared with the other groups. With saline GSH the levels decreased significantly post-operatively compared with GLN. We observed a significant correlation between GLN delivery and GSH levels. CONCLUSIONS: A peri-operative high-dose GLN infusion increased plasma GLN concentrations and maintained the GSH levels after cardiac surgery with CPB.

Polymorphism of K(2)Co(2)Mo(3)O(12): variations in the packing schemes and changes in molybdenum coordination under high pressure.

Within systematic studies on the K-Co-Mo-O system so-called high-temperature and high-pressure modifications of K2Co2Mo3O12 were found. The Birch-Murnaghan fits for the ambient-conditions modification alpha (Z = 4) and the high pressure phase II (Z = 8) lead to V0 = 1193.09 (4) A3, K =30.8 (8) GPa, K'0= 5.4 (4) and V0 = 2170 (10) A3, K =51 (2) GPa with K'0 fixed at 4.0, respectively. The high-pressure phase transition is denoted as pseudoreconstructive [Wiesmann et al. (1997). J. Solid State Chem. 132, 88-97], because some [MoO4] tetrahedra turn into edge-sharing pairs of [MoO5] pyramids or face-sharing pairs of [MoO6] octahedra. The new phases are presented and compared with the alpha phase.

Anomalous thermal expansion in rare-earth gallium perovskites: a comprehensive powder diffraction study.

Crystal structures of rare-earth gallium perovskites LaGaO(3), PrGaO(3), NdGaO(3) and Pr(1-x)Nd(x)GaO(3) (x = 0.25, 0.50, 0.75) solid solutions were investigated in the temperature range 12-300 K by high-resolution powder diffraction using synchrotron or neutron radiation. The previously reported negative thermal expansion in the b direction of the PrGaO(3) lattice has been found to be persistent in Pr(1-x)Nd(x)GaO(3) solid solutions and its magnitude has been revealed as proportional to the amount of praseodymium. Evaluation of the obtained temperature evolution of cell dimensions indicated a weak anomalous behaviour of the b lattice parameter in NdGaO(3), and its origin is supposed to be the same as in PrGaO(3), i.e. a coupling of the crystal electric field levels with phonon excitations of about 23-25 meV energy. The performed bond length analysis revealed an anomalous behaviour of both LnO(12) (Ln-rare-earth) and GaO(6) coordination polyhedra, which can be a structural manifestation of anomalous thermal expansion in the considered compounds.

The effects of floor space and nest box access on the physiology and behavior of caged laying hens.

Confinement housing appears to be at the forefront of concern about laying hen welfare. This experiment examined the effects of floor space during rearing (315 or 945 cm2/bird) and adulthood (542 or 1648 cm2/bird) and access to a nest box on the welfare of caged laying hens. Measurements of the normality of biological functioning, such as plasma, egg albumen and yolk and fecal corticosterone concentrations, and heterophil to lymphocyte ratios, behavioral time budgets, mortality and efficiency of productivity, and measurement of hen preferences, such as choice behavior in Y maze tests, were used to assess hen welfare. There were no effects of treatment on physiological measurements. Hens given less space during adulthood spent less time mobile, inedible pecking, drinking, and preening and spent more time resting and feed pecking and sitting (P < 0.05). Hens with access to a nest box spent more time resting (P = 0.046) and less time sham dust bathing (P = 0.044) than hens without access to a nest box. There were no effects of space allowance on choice behavior for space or a nest box over food; however, hens with access to a nest box chose the nest box over food more than hens without access to a nest box (P = 0.0053). The present experiment provides no convincing evidence that either reducing space allowance in adulthood from 1648 to 542 cm2/bird or eliminating access to a nest box results in disruption of biological function. Less space and no access to a nest box did not increase the choice for more space or a nest box, respectively, over food in the preference tests. However, reduced floor space reduced behavioral freedom and denying access to a nest box eliminated the opportunity for the motivated behavior of laying their eggs in a discrete enclosed nest box, both of which presumably provide hens with the opportunity for positive affective experiences.

Validity of three rating scales for measuring pain intensity in youths with physical disabilities.

BACKGROUND: There is growing evidence confirming that youths with physical disabilities are at risk for chronic pain. Although many scales for assessing pain intensity exist, it is unclear whether they are all equally suitable for youths. The aim of this study was to address this knowledge gap by comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among youths (aged 8-20) with physical disabilities. METHODS: One hundred and thirteen youths (mean age = 14.19 years; SD = 2.9) were interviewed and asked to rate their current pain intensity and recalled (in the past week) worst, least, and average pain with the NRS-11 and the FACES. Participants were also asked to rate their average pain intensity during the past 4 weeks using a VRS-6, and were administered measures assessing pain interference, disability and psychological functioning. RESULTS: Analyses showed that all of the pain intensity measures were associated positively with each other. Nevertheless, the NRS-11 appeared to out-perform both the VRS-6 and in particular the FACES scale with respect to: (1) the associations with the validity criterion (i.e. pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables. CONCLUSIONS: The findings support the validity of the NRS-11 for assessing pain intensity in youths with physical disabilities between the ages of 8 and 20 years.

Oculo-palatal-cerebral syndrome: a second case.

Oculo-palato-cerebral syndrome is an extremely rare disorder consisting of low birth weight, microcephaly, short stature, persistent hyperplastic primary vitreous, microphthalmia, large ears, small hands and feet, cleft palate, joint hypermobility, developmental delay, and cerebral atrophy. There has been one report of a consanguineous family with three affected children, suggesting autosomal recessive inheritance. We report on the second case of this disorder. Our patient, a 2-year-old boy, had growth delay, microcephaly, bilateral persistent hyperplastic primary vitreous with right microphthalmia, long ears with thickened helices, small hands and feet, highly arched palate, joint hypermobility, hypoplastic nails, frontal cerebral atrophy and thinning of the corpus callosum on brain magnetic resonance imaging, and mild developmental delay. He has much milder features than those seen in the previously reported cases.

Use of the carbon dioxide laser in the drainage of subretinal fluid.

Hemorrhage and retinal perforation are two sight-threatening complications associated with techniques employed to drain subretinal fluid in rhegmatogenous retinal detachment. We hypothesized that the carbon dioxide (CO2) laser would reduce these complications because of its cauterizing action and high absorption in water. The CO2 laser was compared with a conventional technique of using a penetrating diathermy electrode to drain subretinal fluid in rabbits with experimentally detached retinas. No hemorrhage occurred in 223 drainage trials using the CO2 laser, whereas hemorrhage occurred in 21 (4.8%) of 434 trials using the penetrating diathermy electrode. Furthermore, a depth of saline of only 45 microns protected the retina from perforation at CO2 laser dose adequate for drainage. These results indicate that further evaluation of the CO2 laser in treating human retinal detachment is warranted.

Enteral nutrition practice in a surgical intensive care unit: what proportion of energy expenditure is delivered enterally?

The object of this study was to document enteral feeding practice in critically ill patients in a surgical intensive care unit. We asked what proportion of measured energy expenditure is delivered enterally. Patient, material, and therapy-related factors should be assessed and related to enteral nutrition. Sixty patients receiving enteral nutrition for a period of at least 10 days were included in the study. Mean daily energy expenditure was 27.8+8.7 kcal/kg. Mean daily enteral delivered calories reached 19.7+/-10.3 kcal/kg (P<0.05). Twenty-one out of 60 (35%) patients were fed isocalorically; 46% of enteral nutrition days failed to reach 80% of energy expenditure. Ten out of 30 patients (33%) fed over a gastric tube were nourished isocalorically in comparison to 8 out of 20 patients (40%) fed over a duodenal tube. Factors associated with hypocaloric enteral feeding in multiple logistic regression were abdominal, pelvic and lumbal spine trauma, gastrointestinal intolerance, problems with the feeding tube, additional surgical interventions, airway management and use of fentanyl. In the course of the study, gastrointestinal complications were the cause for more than 50% of insufficient enteral delivery cases, while therapy and material related reasons contribute to only a minor part.Abdominal, pelvic and lumbal spine traumas are associated with a higher possibility towards developing problems with enteral delivery, as shown by odds-ratios greater than eight. These diagnoses amounted in our investigation to nearly 40% and make a great difference to medical patients. Therefore, recommendations for optimising enteral feeding must take the concerned patient collective into account.

Ultrasound in elective biliary tract surgery.

The background, technique and ultrasonic criteria used in the diagnosis of biliary tract disease are reviewed and illustrative case histories and sonograms presented. The results in 100 prospective patients undergoing both biliary tract ultrasound and orall cholecystography are presented with surgical follow-up in 53 patients. Ultrasound was technically adequate in 96% of the patients examined and was accurate in 51 of the 53 patients who came to surgery. The gray scale ultrasound examination was more accurate than oral cholecystography, especially in the subgroup of patients with nonvisualizing oral cholecystograms. The current role of elective biliary tract sonography is discussed and gray scale ultrasound is recommended as the initial screening test in all patients with suspected biliary tract disease.

Acute acalculous cholecystitis. Ultrasonic diagnosis.

Ultrasonography is an effective and accurate diagnostic test for acalculous cholecystitis. Until recently, however, little attention was focused on the gallbladder wall as an indicator of disease. By accurately visualizing and measuring the gallbladder wall, ultrasonography can be used to screen patients in whom acute acalculous cholecystitis is suspected. If the gallbladder wall measures 3.5 mm or greater, in the absence of ascites, a diagnosis of acalculous cholecystitis can be made safely with a specificity greater than 98 percent. Four of our five patients with acute acalculous cholecystitis had ultrasonically measured gallbladder walls 3.5 mm or greater in width. We have found ultrasonography useful in any clinical situation, even in the face of ileus, jaundice or pancreatitis. In addition, with the use of the portable real-time ultrasound machine, postoperative, traumatized and other critically ill patients can be examined at the bedside.

Ultrasound of the spine in focal stenosis and disc disease.

In the course of reviewing ultrasound scans of the lumbar spine in 67 symptomatic patients, focal stenosis, either as an isolated finding or in conjunction with diffuse stenosis, was noted in 44 patients. The results of ultrasonograms are compared with findings at myelography and surgery. In addition, using gray-scale technique, we found it possible to examine areas of focal stenosis and to visualize herniated discs with a high degree of accuracy. The finding of focal stenosis alone was associated with disc herniation in 53% of patients who came to surgery. Where ultrasound identified a "triple density" representing soft-tissue protrusion between two bony landmarks within the extradural space resulting in focal stenosis, the sensitivity for indicating disc disease was 89%.

The reliability of measurements of the lumbar spine using ultrasound B-scan.

Diagnostic ultrasound is used in research and clinical settings to determine the size of the lumbar spinal canal. When the technique was first introduced, measurements were obtained directly from an A-scan while concurrently viewing a B-scan. However, measurements obtained directly from a B-scan are now commonly used despite the undetermined reliability of the technique. To determine the reliability, 50 randomly selected ultrasound B-scan examinations were read on two separate occasions by three investigators. For each spinal level, the mean intraobserver error (same investigator), from the first to the second reading was determined, as was the interobserver error (between investigators) and the error due to variability in obtaining the ultrasound images. The resultant errors were approximately double those reported previously for the technique using A-scan. Interobserver variations were the major source of measurement error.

Anomalies of gut rotation mimicking appendicitis in the adult.

Malrotation in the adult can mimic acute appendicitis. A complete abdominal exploration is needed to find any obstructing bands or midgut volvulus. The difference between mixed rotation, which usually presents with midgut voluvlus and or duodenal obstruction, and nonrotation, which is usually asymptomatic or presents with intermittent attacks of abdominal pain, is stressed. Therapy is recommended according to the type of defect present.

Ultrasonic detection of acute cholecystitis with pericholecystic abscesses.

Perforation of the gallbladder is a life-threatening complication of acute cholecystitis that is often difficult to diagnose at an early stage. Standard radiographic and laboratory tests have not been reliable in identifying patients with this complication. In contrast, biliary sonography correctly diagnosed pericholecystic abscesses preoperatively in three patients with acute cholecystitis. The ultrasonic appearance of acute cholecystitis with a pericholecystic abscess was similar in all three patients. There was an extraluminal fluid collection located contiguous to a thick-walled gallbladder in the fundic region. The fluid collection was constant in location and could be seen in at least two different views. Two of these three patients had acalculous cholecystitis; the initial clinical diagnosis in one was pancreatitis, and in the other alcoholic hepatitis. Biliary sonography, by demonstrating a thickened gallbladder wall in the absence of ascites, strongly suggested that these two patients had acute acalculous cholecystitis, and not hepatitis or pancreatitis. The ultrasonic examination was a critical factor in the decision for prompt surgery instead of continued nonoperative management in these patients. These data suggest that not only can biliary sonography aid in the diagnosis of acute cholecystitis, calculous as well as acalculous, but can also visualize a pericholecystic abscess when it is present.