15 years of the model study course in medicine at the Ruhr University Bochum.

The Faculty of Medicine of the Ruhr University Bochum (RUB) introduced a model study course in medicine (MSM) in the winter semester 2003. For 9 consecutive years, 42 out of 280 first year students at the Ruhr University Bochum had the opportunity to begin their studies in the model study course in medicine. The places were allocated amongst the applicants internally through a raffle. The MSM was consistently problem-, practice- and patient-oriented and largely did away with lectures, broke with the distinction between a pre-clinical and clinical phase and tested basic knowledge in equivalent integrated exams focusing on clinical application. Following a comparative evaluation of the standard degree course (RSM) and the MSM, the faculty merged the two degree courses into the Integrated Reformed Medical Curriculum (IRMC), which has been on offer since 2013 and is characterized by a topic-oriented hybrid curriculum. This article examines experiences relating to the origins, conception and introduction of the MSM.

[Avoidance-endurance fast screening (AE-FS) : Content and predictive validity of a 9­item screening instrument for patients with unspecific subacute low back pain]. / Avoidance-Endurance Fast-Screen (AE-FS) : Inhalts- und Vorhersagevalidität eines 9­Item-Screeninginstruments für Patienten mit unspezifischen subakuten Rückenschmerzen.

BACKGROUND: Among screening measures to assess psychosocial risk factors (yellow flags) for chronic low back pain (LBP) economic tools which address dysfunctional endurance pain responses besides emotional distress and fear-avoidance pain processing are rare. Targeting contrasting types of pain processing might improve stratified patient counselling. OBJECTIVE: The aim of the study was to develop a short screening method, based on the avoidance-endurance model of pain and to investigate the prognostic validity for pain intensity, disability and physical function. MATERIAL AND METHODS: A prospective observational study was carried out on 144 patients with subacute LBP (<3 months) from 7 general practitioners and 5 orthopedic practices. The 9­item avoidance-endurance fast screening (AE-FS) was derived from a previous 37-item screening using correlational and receiver operating curve (ROC) analyses and the agreement of subgrouping was calculated using Cohen's kappa. Primary outcomes were assessed after 6 months by mail in 124 patients (86%). Endpoints were pain intensity and disability. RESULTS: The classification of subgroups as high and low risk by both measures had considerable agreement with a value of 0.71 (Cohen's Kappa). The sensitivity to predict pain intensity >2 was high (82%) as was the positive predictive value (80%) but the negative predictive value was moderate (61%). The ROC (AUC) characteristics (95% confidence interval CI) were 0.70 (0.60-0.80) for pain intensity and for limitations in the pain disability index (PDI) 0.70 (0.55-0.87). DISCUSSION: The 9­item AE-FS displayed sufficient prognostic validity for all three outcomes in a sample of primary care patients with subacute LBP. The differentiation of the high-risk patients into fear-avoidance and endurance-related pain processing enables the physician to provide an individualized counselling with the aim of a healthy balance between stress and relaxation.

[General practitioners in palliative care in Germany: a systematic review]. / Stand der hausärztlichen Palliativversorgung in Deutschland. Ein systematischer Literaturreview.

To investigate the role of general practitioners among the increasing specialization in outpatient palliative care, meaningful research topics, developments of new collaborations and structures in the outpatient sector of palliative care, 52 articles were reviewed. Results have shown that general practitioners are still involved in outpatient palliative care research and show a distinct participation in quality development. Typical research topics in outpatient palliative care research are quality of care and structures. However, cooperative structures between general practitioners and palliative specialists are rare in the field of outpatient palliative care research.

[Bouveret syndrome--a rare form of pyloric obstruction]. / Das Bouveret-Syndrom--eine seltene Form der Magenausgangsstenose.

Gallstone ileus represents a severe complication of cholelithiasis. The incidence of serious disease concomitant with gallstone ileus is high; it is most often seen in elderly patients and contributes to its high morbidity and mortality rates. Bouveret's syndrome is a rare form of gallstone ileus, characterized by its duodenal site after migration through a cholecysto-duodenal fistula in almost all cases. We report on a patient with Bouveret's syndrome. The etiology, pathogenesis, diagnosis and therapeutic approach with literature review are presented and discussed.

[Excessive peripheral conversion of thyroxine (T4) to triiodothyronine (T3) in the pathogenesis of T3-hyperthyroidism (author's transl)]. / Exzessive periphere Konversion von Thyroxin (T4) zu Trijodthyronin (T3) in der Pathogenese der T3-Hyperthyreose

In a 41-year-old woman and a 3-year-old girl, both of them with T3-thyrotoxicosis, serum levels of total and free T4 and T3 were measured serially during anti-thyroid drug treatment. Attempts to substitute thyroxine during the antithyroid treatment had to be interrupted because the patients became hyperthyroid again with excessive increases in total and free serum T3, even when concentrations of total and free T4 were brought to subnormal levels. The increased conversion of administered thyroxine ceased later on and higher amounts of oral T4 were tolerated after one year of treatment. In both patients there was an extremely low serum T4/T3 ratio, differing in this respect significantly from six other patients with T3-thyrotoxicosis and 41 patients with "conventional" T3/T4-hyperthyroidism. It is concluded that, in patients with T3-thyrotoxicosis due to excessive peripheral T4 to T3 conversion, substitution during antithyroid drug treatment should be either with very low doses of thyroxine or with triiodothyronine in divided daily doses. In such cases the level of serum T3 represents the most reliable biochemical measurement for the control of treatment, serum T4 levels being irrelevant.

Serum triiodothyronine 7-15 years after fractionated low dose radioiodine therapy of thyrotoxicosis.

In 189 of 334 patients, who had been treated with fractionated doses of radioiodine for Graves' disease 7-15 years ago, the serum concentrations of triiodothyronine have been estimated in additition to the following parameters: Protein bound 127-iodine (PB-127-I), free thyroxine index, cholesterol- and TSH-level in serum, tendon reflex time and clinical index according to Billewitz et al. (1969). In forty-one of the 189 sera the free T4 (AFT4) and free T3 (AFT3) concentrations were measured as well. The following hormonal and clinical patterns were observed: (1) Euthyroidism, with all parameters within the normal range in 148 patients (equals 78-4%). (2) Hypothyroidism with low serum T3, PBI, AFT4, AFT3 and elevated TSH six subjects (equals 3-2%). (3) Persistent hyperthyroidism with increased thyroid hormone concentrations and low TSH in seven cases (equals 3-7%). (4) In twenty-eight clinically euthyroid patients (equals 14-8%) TSH was elevated with normal PBI and AFT4. Twenty of these subjects had a low normal T3 and in nine the T3 was clearly in the hypothyroid range (40 plus or minus 12 mug/dl). (5) The constellation of normal T3, low T4 and elevated TSH, which has been frequently found after radioiodine therapy, has been seen in only moderate form in ten cases.

Thyroid function and triiodothyronine and thyroxine kinetics in rabbits immunized with thyroid hormones.

Neck-uptake studies, thyroid scintiscans and triiodothyronine (T4)-kinetic studies were performed in normal rabbits and in animals producing antibodies against thyroid hormones. In immunized animals the radioiodide uptake and turnover were increased 3-fold and 6-17-fold, respectively. The thyroid glands were found to be enlarged scintigraphically and showed a denser tracer distribution pattern. T3 and T4 kinetic data were obtained from 5 rabbits immunized with T3 (ABT3), 4 immunized with T4 (ABT4) and from 5 controls. In T3 immunized animals total T3 in the serum rose from 86 to 59 000 ng/100 ml, in T4 immunized rabbits total T4 increased from 2.5 to 53.8 mug/100 ml. The fundamental principles of regulation were similar in both T3 and T4 immunized rabbits: There were enormous decreases in the total distribution spaces (TDS) as well as in the fractional turnover rates (k), resulting in markedly decreased metabolic clearance rates (MCR). The fall in T3-MCR was directly proportional to the T3 binding activity of the sera. However, striking differences between the respective alterations of T3 and T4 kinetic data were obtained in the immunized animals: T3-MCR fell about 70-fold in ABT3, whereas T4-MCR was diminished 15-fold in T4 immunized rabbits. In both groups of immunized animals T3-TDS decreased more than the T3 fractional turnover, whereas T4-TDS was less affected than k T4. The T3 production rates (PR) were increased 10-fold in ABT3 and 5-fold in ABT4, whereas the increases in T4-PR were of only moderate degree both in ABT3 and ABT4. Using presently available radiochemical methods in metabolic status of immunized rabbits could not be definitely assessed: "clinically" the animals were euthyroid. However, the dialyzable fraction in the serum of both T3 and T4 did not decrease proportionately to the enormous increase in total hormone concentration, so the free hormone concentrations were elevated over the normal. The results of the calculations of the cellular hormonal T3- and T4-clearance were more consistent with a euthyroid state: In ABT4 the cellular metabolism of both hormones was not different from the normal; in ABT3 a 1.7-fold increase in the cellular clearance of T3 was accompanied by a significant decrease of that in T4.