[Outpatient palliative medicine : Attitudes in the care of palliative emergencies. Prospective questionnaire-based investigation]. / Ambulante Palliativmedizin : Einstellungen in der Versorgung palliativer Notfälle. Prospektive Fragebogenuntersuchung.

BACKGROUND: The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations. METHODS: A standardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions. RESULTS: The survey response rate was 79% from a total of 81 SPCS in 2011. The following standards in palliative emergency care were recommended: (1) early integration of outpatient palliative care services and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4) emergency medical training (physicians and paramedics). CONCLUSION: Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.

Cholecalciferol 20 000 IU Once Weekly in HIV-Positive Patients with Low Vitamin D Levels: Result from a Cohort Study.

PURPOSE: To evaluate efficacy and safety of 20 000 IU cholecalciferol weekly in HIV-infected patients. METHODS: Longitudinal data for 243 HIV-infected patients with paired 25-OH-vitamin D3 values for the same month in 2 consecutive years were stratified by the initiation of supplementation in this retrospective study. RESULTS: After 1 year of administration of cholecalciferol 20 000 IU weekly, about 78% of patients with initial vitamin D level <20 µg/L achieved vitamin D levels >20 µg/L and 42% achieved levels >30 µg/L. Supplemented patients with baseline vitamin D levels <20 µg/L showed a significant risk reduction for hypocalcemia ( P = .006; risk difference: 20.8%) and a significantly lower increase in alkaline phosphatase (AP) compared to those in the nonsubstituted group. CONCLUSION: The dose of 20 000 IU of cholecalciferol once weekly was found to be safe and effective. Normalization of vitamin D levels within 1 year was observed in 42% to 75% of the patients.

[Is supplemental ear acupuncture for surgical tooth removal with local anesthesia effective? : A pilot study]. / Ist die Supplementierung der Ohrakupunktur bei operativer Zahnentfernung in Lokalanästhesie effektiv? : Eine Pilotstudie.

BACKGROUND: The application of ear acupuncture can contribute to a reduction of acute pain. Data on the application of ear acupuncture following oral surgery in odontology is insufficient. OBJECTIVE: This study investigated the effectiveness of ear acupuncture as an auxiliary analgesic treatment in addition to local anesthesia for operative tooth removal. METHODS: In this prospective open non-randomized pilot study (in accordance with the CONSORT publication) 2 cohorts of 50 patients each with the indications for an operative tooth removal either with or without the application of ear acupuncture in addition to local anesthesia with articain were observed. Patients were allocated to the groups according to their preference. Pain intensity while resting and while chewing was recorded as the primary parameter for a period of 10 days. The secondary parameters were the subjective experience of anxiety and symptoms, such as headaches, dizziness and nausea. RESULTS: The two groups did not differ significantly with respect to demographic variables or the use of local anesthetics. At the various measurement intervals, pain intensity while resting or chewing differed significantly between the two groups (ANOVA, p = 0.004, p = 0.007, respectively). Furthermore, the experience of anxiety (ANOVA, p = 0.0001), the number of patients taking analgesics (χ2-test, p = 0.017) and the total postoperative consumption of analgesics (t-test, 0.001) revealed significant differences. In both groups the numerical rating scales (NRS) for postoperative headaches, dizziness and nausea were low. DISCUSSION AND CONCLUSION: Despite a potential bias and methodological limitations of the study design, the results of this investigation suggest that ear acupuncture influences the experience of pain and anxiety in the postoperative period after tooth removal. As a treatment method with low adverse effects ear acupuncture can contribute to postoperative pain control, especially in patients with preoperative anxiety.

[Interprofessional education in pain management: development strategies for an interprofessional core curriculum for health professionals in German-speaking countries]. / Interprofessionelle Lehre in der Schmerzmedizin : Möglichkeiten und Strategien für die Entwicklung eines professionsübergreifenden Curriculums im deutschsprachigen Raum.

The care of patients, suffering from acute, chronic, or malignant pain, requires systematic and interprofessional collaboration between all team members to ensure a holistic approach to pain management. In doing so, the different professions are often in a competitive, tense, or dependent relationship resulting from a lack of precise definitions and concepts regarding their responsibilities in the wide field of pain management. Considering pain management as a whole, we can define numerous interfaces concerning competencies and tasks which may open up some new perspectives on concepts of interprofessional education (IPE). Internationally, there have been many attempts to establish concepts of interprofessional education, and it is considered a great challenge to improve continuing medical education. However, interdisciplinary subjects like pain management may benefit from it. Apart from enhancing specialized knowledge, interprofessional education aims to consider the different roles, skills, and responsibilities as well as interprofessional strategies of decision-making. In Germany, only a few efforts have been made with regard to interprofessional pain education. In the following paper, different challenges, tasks, and roles within the field of pain management are discussed in the sense of potential areas of collaboration in the context of interprofessional education. Against this background, the Regensburg model for interprofessional pain management education is described as one national program to enhance the effectiveness of pain management.

[Preventive crisis management in general outpatient palliative care - prospectively cross-sectional study of General Practitioners in Eastern Bavaria]. / Vorbeugendes Krisenmanagement in der allgemeinen ambulanten Palliativversorgung. Prospektive Querschnittstudie bei Hausärzten in Ostbayern.

BACKGROUND: General out-patient palliative care (GOPC) must be integrated into the care of patients with life-limiting diseases. Aim of the study was to evaluate experiences of general practitioners concerning advance directives and palliative emergency sheets. METHODS: A self-provided survey was mailed to all general practitioners in Regensburg (cross-sectional study). Main outcome measures included responses regarding a palliative emergency sheet (PES) and a palliative emergency plan (PEP). The investigation period was four months. The analysis was performed using defined criteria (e. g. professional experience concerning palliative care patients, patients treated in nursing homes, patients with dementia). RESULTS: Sixty-nine questionnaires from 259 were analysed (response rate 27 %). 86 % of respondents named practical experience in the care of palliative patients, 46 % named theoretical knowledge in this field. 41 % and 40 % consider creating an advance directive for their practical work as important/very important (p = 0.004 concerning the treatment of more than five palliative care patients per three months). 52 % and 49 % regard a PES or a PEP to be relevant (PES median: 6.5, SD ± 2.7; PEP median: 6.5 SD ± 2.9; inter-group analysis p < 0.05). 94 % of respondents name the general practitioner to be suitable for creating an advance directive. CONCLUSION: In Germany, GOPC in end-of-life care is very important. This study shows that advance directives were declared as an important instrument for patients? autonomy. The sense of PES and PEP to ensure patients? autonomy, especially for acute emergency medical palliative care, must be better recognized. However, the increase in acceptance in the GOPC for such instruments must be disclosed. Further studies to investigate this problem are necessary.

pH regulation in apoplastic and cytoplasmic cell compartments of leaves.

The regulation of pH in the apoplast, cytosol and chloroplasts of intact leaves was studied by means of fluorescent pH indicators and as a response of photosynthesis to acid stress. The apoplastic pH increased under anaerobiosis. Aeration reversed this effect. Apoplastic responses to CO2, HCl or NH3 differed considerably. Whereas HCl and ammonia caused rapid acidification or alkalinization, the return to initial pH values was slow after cessation of fumigation. Addition of CO2 either did not produce the acidification expected on the basis of known apoplastic buffering or even caused some alkalinization. Removal of CO2 shifted the apoplastic pH into the alkaline range before the pH returned to initial steady-state levels. In the presence of vanadate, the alkaline shift was absent and the apoplastic pH returned slowly to the initial level when CO2 was removed from the atmosphere. In contrast to the response of the apoplast, anaerobiosis acidified the cytosol or, in some species, had little effect on its pH. Acidification was rapidly reversed upon re-admission of oxygen. The CO2-dependent pH changes were very fast in the cytosol. Considerable alkalinization was observed after removal of CO2 under aerobic, but not under anaerobic conditions. Rates of the re-entry of protons into the cytosol during recovery from CO2 stress increased in the presence of oxygen with the length of previous exposure to high CO2. Effective pH regulation in the chloroplasts was indicated by the recovery of photosynthesis after the transient inhibition of photosynthetic electron flow when CO2 was increased from 0.038% to 16% in air. As photosynthesis became inhibited under high CO2, reduction of the electron transport chain increased transiently. The time required for recovery of photosynthesis from inhibition during persistent CO2 stress was similar to the time required for establishing steady-state pH values in the cytosol under acid stress. The high capacity of leaf cells for the rapid re-attainment of pH homeostasis in the apoplast and the cytoplasm under acid or alkaline stress suggested the rapid activation or deactivation of membrane-localised proton-transporting enzymes and corresponding ion channel regulation for co-transport of anions or counter-transport of cations together with proton fluxes. Acidification of the cytoplasm appeared to activate energy-dependent proton export primarily into the vacuoles whereas apoplastic alkalinization resulted in the pumping of protons into the apoplast. Proton export rates from the cytosol into the apoplast after anaerobiosis were about 100 nmol (m2 leaf area)(-1) s(-1) or less. Proton export under acid stress into the vacuole was about 1200 nmol m(-2) s(-1). The kinetics of pH responses to the addition or withdrawal of CO2 indicated the presence of carbonic anhydrase in the cytosol, but not in the apoplast.

Myelin transcription factor 1 (Myt1) of the oligodendrocyte lineage, along with a closely related CCHC zinc finger, is expressed in developing neurons in the mammalian central nervous system.

The establishment and operation of the nervous system requires genetic regulation by a network of DNA-binding proteins, among which is the zinc finger superfamily of transcription factors. We have cloned and characterized a member of the unusual Cys-Cys-His-Cys (also referred to as Cys2HisCys, CCHC, or C2HC) class of zinc finger proteins in the developing nervous system. The novel gene, Myt1-like (Myt1l), is highly homologous to the original representative of this class, Myelin transcription factor 1 (Myt1) (Kim and Hudson, 1992). The MYT1 gene maps to human chromosome 20, while MYT1L maps to a region of human chromosome 2. Both zinc finger proteins are found in neurons at early stages of differentiation, with germinal zone cells displaying intense staining for MyT1. Unlike Myt1, Myt1l has not been detected in the glial lineage. Neurons that express Myt1l also express TuJ1, which marks neurons around the period of terminal mitosis. The Myt1l protein resides in distinct domains within the neuronal nucleus, analogous to the discrete pattern previously noted for Myt1 (Armstrong et al.: 14:303-321, 1995). The developmental expression and localization of these two multifingered CCHC proteins suggests that each may play a role in the development of neurons and oligodendroglia in the mammalian central nervous system.