[Empowerment and health literacy in medical rehabilitation - recommendations for strengthening patient education]. / Teilhabebefähigung und Gesundheitskompetenz in der medizinischen Rehabilitation - Empfehlungen zur Stärkung von Patientenschulungen.

UNLABELLED: The recommendations aim to increase patient participation and health literacy by strengthening the role of patient education in medical rehabilitation. Research shows patient education to be effective and efficient; making the implementation of high quality patient education a top priority. To strengthen the role of patient education it is important to address known obstacles, identify potential for improvement, and define future demands for rehabilitative care. Led by the German Society for Medical Rehabilitation (DEGEMED), the Centre for Patient Education at the Würzburg University, and the Institute for Quality Management and Clinical Audit in Medical Rehabilitation (IQEM) an inter- and multidisciplinary panel of 28 experts from research and practice developed recommendations to further patient education in medical rehabilitation. The recommendations address topics such as the implementation of legal requirements under book IX of the German Social Code, SGB 9, structural and organisational prerequisites to promote the importance of patient education in rehabilitation units, the incorporation of quality criteria for patient education in quality assurance, quality management, and certification, as well as networking between medical rehabilitation and other health care sectors. CONCLUSION: Providers of medical rehabilitation hold the power to strengthen patient education: by implementing patient education programmes that are well-evaluated, manual-based, and standardised, by providing sufficient resources within their institutions, and by placing patient education in the centre of their quality policy, i.e. by nomination of a patient education representative. Stakeholders need to acknowledge these activities by incorporating quality criteria for patient education in clinical audit, and last but not least by adequate funding of medical rehabilitation.

Early warning-system for operation-failures in biological stages of WWTPs by on-line image analysis.

By the observation and evaluation of the microscopic picture of activated sludge samples it is possible to introduce another biological parameter additional to conventional physico-chemical parameters for the control of biological stages of waste water treatment plants. Considering the fact that parameters like floc size and floc size distribution, structure of the flocs (compact/open), shape of the flocs (round/irregular) allow perceptions of the adjusted operation conditions of the biological stages, evidence for changing operation conditions or threatening operation disturbances can be recognised. This recognition takes place at a very early phase, because the morphology of activated sludge flocs reacts very fast to changing conditions. An automatic image analysis of activated sludge floc pictures would enable the introduction of a new sum parameter to enhance operation control of aeration tanks. By a statistical evaluation of the processed sludge images several parameters can be used to describe the alteration of activated sludge flocs characteristics. With these biological parameters it is possible to detect altered operation conditions or threatening or existing operation problems at an early phase. Thus it is possible to plan suitable countermeasures. Furthermore, the microscopic picture is the only parameter, that gives important information about the structure of the activated sludge flocs and the biozenosis. In comparison with the mainly used physico-chemical parameters, that just give information about the inlet and outlet of the wastewater treatment plants, the microscopic picture is the only parameter that gives information about the biology of the wastewater treatment process. By means of this biological parameter an improved control and regulation of the biological stages of wastewater treatment plants can be obtained.

[SGB IX - Magna Charta of a Functional Participation Philosophy]. / SGB IX - Magna Charta einer funktionalen Teilhabephilosophie.

Further development of needs-based, efficient health care structures in particular for people with chronic illness, and in conjunction with them, is the paramount objective of SGB IX, book 9 of the German social code. To achieve this it is necessary to define treatment sequences across sectoral boundaries in health care, and to establish cooperation between community-practice physicians, hospitals, rehab and long-term care facilities, cost carriers, and people with disabilities. In this context, the article discusses the current rank of rehabilitation and participation, points out the underlying conflicting issues and interests, and posits the preventive-integrative rehabilitation paradigm at the very centre of health protection networking.

Rescue of a telomere length defect of Nijmegen breakage syndrome cells requires NBS and telomerase catalytic subunit.

Nijmegen breakage syndrome (NBS) is a rare human disease displaying chromosome instability, radiosensitivity, cancer predisposition, immunodeficiency, and other defects [1, 2]. NBS is complexed with MRE11 and RAD50 in a DNA repair complex [3-5] and is localized to telomere ends in association with TRF proteins [6, 7]. We show that blood cells from NBS patients have shortened telomere DNA ends. Likewise, cultured NBS fibroblasts that exhibit a premature growth cessation were observed with correspondingly shortened telomeres. Introduction of the catalytic subunit of telomerase, TERT, was alone sufficient to increase the proliferative capacity of NBS fibroblasts. However, NBS, but not TERT, restores the capacity of NBS cells to survive gamma irradiation damage. Strikingly, NBS promotes telomere elongation in conjunction with TERT in NBS fibroblasts. These results suggest that NBS is a required accessory protein for telomere extension. Since NBS patients have shortened telomeres, these defects may contribute to the chromosome instability and disease associated with NBS patients.

Metabolic effects of HAY's diet.

The aim of the study was, to evaluate the metabolic effect of HAY's diet on protein turnover, fat oxidation, respiratory quotient, body fat and weight loss. Twelve healthy adults received an individually regular diet and thereafter a corresponding isocaloric and isonitrogenous 10-day HAY-diet. Protein turnover and 13C-fat oxidation were investigated after administration of [15N]glycine and an [U-13C]algae lipid mixture. The 15N and 13C enrichment in urine and breath were measured by isotope ratio mass spectrometry. The respiratory quotient was measured by indirect calorimetry. Body fat, total body water and lean body mass were estimated by bio-electric impedance analysis. HAY's diet led to a significantly higher 13C-fat oxidation (15.4 vs. 22.0% P < 0.01), corresponding to a lower respiratory quotient (0.88 vs. 0.81; P < 0.01), whereas the protein turnover remained constant in both diets (3.06 vs. 3.05 g/kg/day). HAY's diet did not reduce total body water, lean body mass, body fat and body weight (72.2 vs. 71.4 kg).

[Small unilocular hepatocellular carcinoma (0 < 5 cm) in patients with liver cirrhosis. Early diagnosis, surgical indications, resection and prognosis]. / Singuläres, hepatozelluläres Karzinom (0 < 5 cm) beim Leberzirrhotiker. Frühdiagnose, chirurgische Indikation, Resektion und Prognose.

In 151 (17.5%) of 861 patients with liver cirrhosis regularly screened by sonography and determination of alpha-fetoprotein a hepatocellular carcinoma (HCC) was detected. Diagnosis was verified by sonographically guided fine needle puncture and exceptionally by laparoscopy and direct puncture. In 34 patients (22.5%) selection criteria for operation were a tumour diameter under 5 cm, no central localisation in the liver and at least 5 mm distant from the main structures; furthermore multilocular HCC and intra- and extrahepatic metastases were contraindications. Additionally Child-Pugh-classification should be A + B and urea synthesis rate 6 g per day. 27 patients (80%) had esophagogastric varices seen at endoscopy and 20 (59%) had bleeding episodes from varices managed endoscopically or surgically. Types of surgical resections were segmentectomy [17], bisegmentectomy [10] and oncologically defined wedge resections [7] using controlled hypotension and interrupted occlusion of the hepatoduodenal ligament. 4 patients (11.8%) died within 30 days of liver failure [3] and sepsis [1]. All patients could be followed up for eleven years: 18 patients died after 1.5-10 years of liver failure, tumour recurrence or second tumour and a cause not associated with HCC, 12 patients are living. Kaplan-Meier survival curves show that survival at 5 years is 50% and at 10 years 34%. The main indicators for a good prognosis were clinically the HBsAG-activity, the Child-Pugh-classification and the application of autologous blood, pathologic-anatomically the classification and grading and histologically the absence of vascular invasion, absence of satellites and a number of mitoses under 7 in the visual field. For tumour recurrence dysplasia is of positive influence.--Liver resection remains the most widely used therapeutic option for treatment of HCC in cirrhosis. The early and long-term results can be improved by early diagnosis, strict selection of patients for operation and the use of well defined clinical, pathological and histological criteria.

ATM phosphorylation of Nijmegen breakage syndrome protein is required in a DNA damage response.

Nijmegen breakage syndrome (NBS) is characterized by extreme radiation sensitivity, chromosomal instability and cancer. The phenotypes are similar to those of ataxia telangiectasia mutated (ATM) disease, where there is a deficiency in a protein kinase that is activated by DNA damage, indicating that the Nbs and Atm proteins may participate in common pathways. Here we report that Nbs is specifically phosphorylated in response to gamma-radiation, ultraviolet light and exposure to hydroxyurea. Phosphorylation of Nbs mediated by gamma-radiation, but not that induced by hydroxyurea or ultraviolet light, was markedly reduced in ATM cells. In vivo, Nbs was phosphorylated on many serine residues, of which S343, S397 and S615 were phosphorylated by Atm in vitro. At least two of these sites were underphosphorylated in ATM cells. Inactivation of these serines by mutation partially abrogated Atm-dependent phosphorylation. Reconstituting NBS cells with a mutant form of Nbs that cannot be phosphorylated at selected, ATM-dependent serine residues led to a specific reduction in clonogenic survival after gamma-radiation. Thus, phosphorylation of Nbs by Atm is critical for certain responses of human cells to DNA damage.

[Effects of oral administration of bifidobacteria on intestinal microflora in premature and newborn infants]. / Wirkungen oral verabreichter Bifidobakterien auf die intestinale Mikroflora von Früh- und Neugeborenen.

In a prospective, randomised study the effects of orally administered bifidobacteria on the intestinal microflora were investigated in 100 preterm and term neonates under intensive care conditions during the first 21 days of life. The 50 infants (group with bifidobacteria) received lyophilized bifidobacteria (Töpfer Bifidus) via nasogastral tube with an initial dosage of 3 times daily 1.25 x 10(8) bifidobacteria on day 2 of life and a daily dosage of 6 times 1.25 x 10(8) bifidobacteria on day 3 until day 21 of life. The other 50 infants (control group) did not receive bifidobacteria. The preterm and term neonates were fed either with pasteurized mother's milk or milk from healthy female donors (n = 79) or with an infant formula (Alfaré, n = 13) or initially with Alfaré and thereafter with mother's milk (n = 8). The intestinal microflora of preterm and term neonates under intensive care conditions could be influenced by the oral administration of bifidobacteria. The administration of bifidobacteria resulted in the group of inoculated infants in a significantly earlier colonization of bifidobacteria (8.1 +/- 3.9 days of life) than in the control group (11.3 +/- 4.7 days of life). On day 7 a bifidobacterial dominance (> 90% of the intestinal microflora) could be found in 26% of infants with inoculation of bifidobacteria and only in 2% of the control group (p < 0.001). These significant differences could be shown until day 21 of life. A difference in septicemia frequency between the two groups could not be demonstrated. At the beginning of the infection a bifidobacterial dominance was found in only one of 23 cases of septicemia.

Clostridium innocuum: a glucoseureide-splitting inhabitant of the human intestinal tract.

Glycosylureides were recently described as non-invasive markers of intestinal transit time. The underlying principle is an enzymatic splitting of (13)C-labelled ureides by intestinal bacteria. The (13)CO(2) released from the urea moiety of the glycosylureides can be measured in breath samples when the ingested tracer substrate reaches the caecum that is colonised with microbes. To date, the microbes that degrade glycosylureides are unknown. In order to identify the glucoseureide (GU)-splitting bacteria, 174 different strains of intestinal microbes obtained from five healthy adults were checked for their ability to degrade GU. The results of the microbial cultures and thin layer chromatography revealed that GU was exclusively degraded by Clostridium innocuum, belonging to the normal human intestinal microflora. C. innocuum probably synthesises a yet unknown enzyme that splits the glucose-urea bond. We suggest that the term glucoseureidehydrolase is the appropriate designation for this enzyme.

Uterine bleeding in postmenopausal women on continuous therapy with estradiol and norethindrone acetate. Endometrium Study Group.

OBJECTIVE: To investigate the incidence of uterine bleeding during 12 months of treatment with 17beta-estradiol (E2) 1 mg, unopposed or in combination with three doses of norethindrone acetate. METHODS: This study was a prospective, double-masked, randomized, multicenter trial. A total of 1176 healthy postmenopausal women age 45 years and older without evidence of endometrial abnormalities were randomly assigned to receive either unopposed E2 1 mg, or continuous-combined formulations of E2 1 mg and norethindrone acetate 0.1 mg, 0.25 mg, or 0.5 mg. Any spotting or bleeding episodes during the treatment period were recorded in a daily diary and reported by weekly telephone calls. RESULTS: The incidence of bleeding was low in the combination groups, even during the initial 3 months of treatment (24-28%), after which it decreased with increasing doses of norethindrone acetate. Conversely, the incidence of bleeding increased over time with unopposed E2 1 mg. After the initial 3 months, the incidence of bleeding among the combination groups was lowest in the norethindrone acetate 0.5 mg group. Among women initiating therapy close to menopause, fewer reported bleeding with norethindrone acetate 0.5 mg than with the other combination groups. There was a significantly (P<.05) lower discontinuation rate due to bleeding in the norethindrone acetate 0.5 mg group compared with all other treatment groups. CONCLUSION: Continuous-combined formulations of E2 1 mg with norethindrone acetate 0.1, 0.25, or 0.5 mg are associated with a low incidence of uterine bleeding. After the initial 3 months of treatment, bleeding profiles improved with increasing doses of norethindrone acetate.

Triglyceride oxidation in cystic fibrosis: a comparison between different 13C-labeled tracer substances.

BACKGROUND: For indirect evaluation of pancreatic lipase activity in cystic fibrosis, different 13C-labeled triglycerides may be used. METHODS: Triglyceride oxidation in patients with cystic fibrosis was investigated after administration of different 13C-labeled triglycerides by comparing 13CO2 breath exhalation. In the comparative study, five patients with cystic fibrosis (age, 8-15 years; body weight, 22.5-39.8 kg) were treated with Pangrol (individual dosages: 1-3 capsules per morning meal; Berlin-Chemie, Berlin, Germany). [1,1,1-13C3]Glyceryl tripalmitate and [1,1,1-13C3]glyceryl trioleate were administered as a single oral pulse at 8:00 A.M. (dosage, 4 mg/kg each) with the standard diet Fresubin (dosage, 10 ml/kg; Fresenius, Bad Homburg, Germany). Alternately, the same subjects were given the synthetic mixed triglyceride 1,3-distearyl, 2[13C]octanoyl glycerol (dosage, 12.5 mg/kg) contained in the standard diet Nutri-Mix (dosage, 10 ml/kg; Nutricia, Zoetemeer, The Netherlands). Breath samples were taken in 15- and 30-minute intervals over 8 hours. The 13CO2 enrichment was measured by continuous-flow isotope ratio mass spectrometry. RESULTS: After administration of the 13C-labeled tripalmitin-triolein mixture and the mixed triglyceride, mean maximum 13CO2 enrichments were 4.70 and 7.37 delta over baseline, occurring at 7.0 and 3.5 hours, respectively. The corresponding percentage cumulative 13CO2 exhalations were 12.25% and 29.19%, respectively, and differed significantly in the five paired subjects (p = 0.003). CONCLUSIONS: After using different 13C-labeled triglycerides the resultant 13CO2 exhalation reflected the triglyceride hydrolysis and subsequent oxidation. It is concluded that the different cumulative 13CO2 exhalations were mainly caused by the rate-limiting step of triglyceride hydrolysis to free fatty acids and 2-monoglycerides and by fat deposition. Noninvasive 13C breath tests using different 13C-labeled triglycerides can be used for evaluation of pancreatic lipase activity before and during enzyme supplementation.

[Persistent Lactobacillus casei subspecies rhamnosus bacteremia in a 14 year old girl with acute myeloid leukemia. A case report]. / Persistierende Lactobacillus casei subspecies rhamnosus-Bakteriämie bei einer 14-jährigen Patientin mit akuter myeloischer Leukämie. Eine Kasuistik.

The present clinical observation is related to a 14-year-old girl suffering from acute myeloid leukemia. The clinical course was complicated by episodes of severe enterocolitis, E. coli- septicemia, pancreatitis and pneumonia. In the course of continued cytostatic and antibiotic treatment a persistent asymptomatic Lactobacillus casei subsp. rhamnosus-bacteremia became detectable by a total of 18 blood cultures. Microbial cultures of the faeces revealed colony-forming unites of this germ in orders of 10(9)/g. Antibiotic eradication attempts according to the resistogram were not successful. The Lactobacillus-bacteremia disappeared only after 13 months when the cytostatic therapy was terminated. An adjuvant influence of the Lactobacillus infection on the outcome of the underlying disease cannot be excluded.

The significance of tryptophan in infant nutrition.

In the newborn, tryptophan (Trp) and its metabolites are essential to brain maturation and to the development of neurobehavioral regulations of food intake, satiation and sleep-wake-rhythm. Due to the high Trp concentration in human milk in relation to the total of neutral amino acids, the blood-brain transfer of tryptophan as a precursor of its metabolites serotonin and melatonin is optimal. In contrast, commercial infant formulas are lower in Trp and higher in neutral amino acid levels resulting in comparatively lower Trp serum concentrations. alpha-lactalbumin enriched, protein-reduced formulas adapted to 2.2% Trp were shown to be capable of producing Trp serum values that did not differ from those in breast-fed infants.

Analysis of factors affecting outcome after hepatectomy of patients with liver cirrhosis and small hepatocellular carcinoma.

OBJECTIVE: To review our policy of screening patients at risk of developing hepatocellular carcinoma (HCC), and to present 10 years' experience of hepatic resection for small HCC (< 5 cm). DESIGN: Retrospective study. SETTING: Teaching hospital, Germany. SUBJECTS: 861 patients with hepatic cirrhosis and oesophageal varices of whom 151 (18%) had HCC confirmed histologically; 30 of these tumours (20%) were less than 5 cm in diameter and suitable for resection. INTERVENTIONS: Segmentectomy (n = 14) bisegmentectomy (n = 10), and oncologically defined wedge resection (n = 6). MAIN OUTCOME MEASURES: Mortality, morbidity, and survival. RESULTS: 4 patients died within 30 days of liver failure and sepsis (n = 20, liver failure (n = 1), and bronchopneumonia (n = 1). The main beneficial prognostic factors were Child classification, donation of autologous blood, and an encapsulated tumour. The main indicators of a poor prognosis were invasion of the liver, venous invasion, invasion of the resection margin, and the presence of microsatellite tumours and nodules. 12 of the 26 survivors developed recurrences during the first five years postoperatively (46%). Kaplan-Meier survival curves showed that survival at 1 year was 80%, at 3 years 65%, and 5 years 50%, and at 10 years 30%. CONCLUSION: Hepatic resection is a useful treatment for small HCC, but its success depends on early detection and careful selection of patients.

[Comparison of gastric emptying, blood glucose, and oro-cecal transit times after a conventional morning meal and a Kollath breakfast]. / Vergleichende Messungen von Magenentleerung, Blutglukose und orozökaler Transitzeit nach einer konventionellen Morgenmahlzeit und einem Kollath-Frühstück.

Blood glucose kinetics and intestinal transit times were investigated in 12 adult volunteers aged 28 to 52 years after ingestion of a conventional morning meal made up of white flour rolls, butter, marmalade, and coffee with sugar as compared with an isocaloric Kollath-breakfast consisting of whole wheat flakes as a basis. For estimation of gastric emptying time the sodium-[13C]acetate breath test technique was used. Oro-coecal transit time and gastric emptying were determined by simultaneous administration of lactose-[13C]ureide and consecutive drawings of breath samples in intervals of 15, 30, and 60 min through 12 h. The 13CO2-excess of the breath test samples was measured by continuous flow isotope ratio mass spectrometry. The postprandial rise in blood glucose following the ingestion of the Kollath-breakfast was lower as compared with the conventional morning meal, showing significant differences between the 90 min values and the area below the blood glucose curve. The half time of gastric emptying was not different between the two breakfast versions (1.7 vs. 1.6 h). The oro-coecal transit time averaged out at 4.2 h after the Kollath-breakfast and 5.3 h following the conventional morning meal. Likewise, there were no significant differences in the coecal retention time nor in the cumulative percentage of 13CO2-exhalation between the two breakfast versions. Concerning the blood glucose kinetics the differences in the nutritional physiology between the breakfast based on whole wheat flakes and the conventional breakfast as claimed by Kollath were only detectable in outlines in our study. Gastric emptying time showed no differences between the two breakfast versions.

Metabolism of glycosyl ureides by human intestinal brush border enzymes.

13C-labeled glycosyl ureides were recently proposed as a new marker of the orocecal transit time: after passing the small bowel the sugar-urea bond is split by bacterial allantoicase. Further degradation results in 13CO2 which can be measured in the exhaled breath. The aim of this study was to detect an eventual allantoicase-like activity in the human gut and to elucidate the metabolism of glycosyl ureides by human intestinal brush border enzymes. Biopsies of 15 duodenal specimen and 6 colon specimen were homogenised and incubated with several disaccharides and their corresponding disaccharide ureides under various experimental conditions. Hydrolysis of the sugar-urea bond could not be observed neither in the small bowel nor in the colon. However, the conjugation between the two sugars was split. In a modified Dahlqvist assay lactase showed the same kinetics with lactose and lactose ureide as substrates whereas maltose showed a significantly 2.6-fold higher affinity to maltase than maltose ureide (P < 0.001). No major difference between these two substrates could be detected when total maltase activity was inhibited by acarbose. In summary, the human gut tissue possesses no allantoicase-like activity. Therefore, glycosyl ureides seem to be appropriate substances to test the orocecal transit time.