[Radiation therapy for the treatment of macroscopic canine anal gland tumors - a retrospective study]. / Strahlentherapie zur Behandlung makroskopischer Analbeuteltumoren des Hundes ­ eine retrospektive Studie.

INTRODUCTION: Canine anal gland tumors are locally invasive and early metastasize to the loco-regional pelvic lymph nodes. Radiation therapy is a good method for loco-regional tumor control, especially in inoperable tumors. Since the organs in the pelvic area are sensitive to both acute and late radiation damage (chronic diarrhea, bleeding, strictures or intestinal perforations) and such damage mainly depends on the fraction size, we examined the radiation protocol used in this study with a reduced number of fractions (hypofractionated) regarding effectiveness and side effects. This retrospective study describes 13 dogs with macroscopic anal gland carcinoma that were irradiated with imaging-guided, intensity-modulated radiation therapy with a hypofractionated curative protocol of 12 × 3,8 Gy. Gross pathology was either in the region of the anal gland and/or in the sublumbar lymph nodes. Ten of the 13 dogs had advanced tumor diseases (stage 3a or 3b). The acute radiation reactions were mild to moderate and had been reported for some of the dogs in a previous study. The mean study time was 572 days (range 105-1292 days). Disease progression was observed or suspected in 7/13 dogs during the study period: local or loco-regional progression occurred in 3 dogs (23 %) and distant metastases in 4 dogs (31 %). Median progression-free survival was 480 days (95 %CI, 223-908), median survival was 597 days (95 %CI, 401-908). One year after treatment, 76,9 % (95 %CI, 53,5-100) of the dogs were still alive. The likelihood of tumor progression was lower with increasing age, otherwise none of the examined tumor or patient factors showed a prognostic influence on progression or survival time. No clinically relevant late side effects were observed apart from slight alopecia, pigmentation changes or dry, scaly skin, Medium to long-term tumor control can be expected in dogs with macroscopic anal gland tumors treated with a moderately hypofractionated radiation therapy protocol (12 × 3,8 Gy). During long-term monitoring no serious side effects or side effects requiring treatment were observed.

INTRODUCTION: Les tumeurs des glandes anales canines sont localement invasives et métastasent rapidement dans les ganglions lymphatiques loco-régionaux pelviens. La radiothérapie est une bonne méthode de contrôle des tumeurs loco-régionales, en particulier pour les tumeurs inopérables. Étant donné que les organes de la région pelvienne sont sensibles aux dommages aigus et tardifs de la radiation (diarrhée chronique, saignements, sténoses ou perforations intestinales) et que ces dommages dépendent principalement de la taille des fractions, nous avons étudié le protocole de radiations utilisé dans cette étude avec un nombre réduit de fractions (hypofractionné) en terme d'efficacité et d'effets secondaires. Cette étude rétrospective décrit 13 chiens atteints de carcinome macroscopique de la glande anale qui ont été traités par une radiothérapie à modulation d'intensité guidée par imagerie avec un protocole curatif hypofractionné de 12 × 3,8 Gy. La pathologie macroscopique se trouvait soit dans la région de la glande anale et/ou dans les ganglions lymphatiques sublombaires. Dix des 13 chiens présentaient des pathologies tumorales avancées (stade 3a ou 3b). Les réactions aiguës aux radiations étaient légères à modérées et avaient été signalées pour certains des chiens dans une étude précédente. La durée moyenne de l'étude était de 572 jours (fourchette 105­1292 jours). Une progression de la maladie a été observée ou suspectée chez 7/13 chiens au cours de la période d'étude : une progression locale ou loco-régionale est survenue chez 3 chiens (23 %) et des métastases à distance chez 4 chiens (31 %). La survie médiane sans progression était de 480 jours (95 %CI, 223­908), la survie médiane était de 597 jours (95 %CI, 401­908). Un an après le traitement, 76,9 % (95 %CI, 53,5­100) des chiens étaient encore en vie. La probabilité de progression de la tumeur était plus faible avec l'âge, mais aucun des facteurs examinés concernant la tumeur ou le patient n'a montré d'influence pronostique sur la progression ou la durée de survie. Aucun effet secondaire tardif cliniquement pertinent n'a été observé, hormis une légère alopécie, des changements de pigmentation ou une peau sèche et squameuse, On peut s'attendre à un contrôle tumoral à moyen et long terme chez les chiens atteints de tumeurs macroscopiques de la glande anale traités par un protocole de radiothérapie modérément hypofractionnée (12 × 3,8 Gy). Au cours du suivi à long terme, aucun effet secondaire grave ou nécessitant un traitement n'a été observé.

[Massive unresectable hepatocellular carcinoma in a dog treated with -intensity-modulated radiation therapy]. / Massives inoperables hepatozelluläres Karzinom bei einem Hund behandelt mittels intensitätsmodulierter Strahlentherapie.

INTRODUCTION: This case report describes a 12-year-old female spayed mixed-breed dog referred for treatment of a large, inoperable hepatocellular carcinoma. A computed tomography (CT) scan confirmed the previous ultrasonographic and laparoscopic findings of a large, lobulated, poorly defined mass on the left and central aspect of the liver. Multiple biopsies confirmed the diagnosis of hepatocellular carcinoma. Due to the large extent of the tumor, the vascular association to the Vena cava caudalis and the associated high risk of intraoperative bleeding, a resection of the mass was refrained from and a radiotherapeutic treatment was chosen. The dog underwent radiation therapy (RT) with a 6MV linear accelerator with 5×6 Gy, total dose 30 Gy. In the follow up examinations three months and one year after therapy, the dog presented in normal condition and had normal Alanine-amino-transferase (ALT) and alkaline phosphatase (AP). The tumor size measured in the CT-examinations decreased by 61% and 90%, respectively. Two years after radiation therapy the dog has a normal general condition and liver enzymes are within the normal limits.

INTRODUCTION: Ce rapport décrit le cas d'une chienne de race mixte, stérilisée, âgée de 12 ans et référée pour traitement d'un important carcinome hépatocellulaire inopérable. Une tomodensitométrie (TDM) a confirmé les résultats échographiques et laparoscopiques antérieurs, à savoir une grande masse mal définie sur la partie gauche et centrale du foie. De multiples biopsies ont confirmé le diagnostic de carcinome hépatocellulaire. En raison de l'étendue de la tumeur, de l'association à la veine cave caudale et du risque élevé associé d'hémorragies peropératoires, on a renoncé à une résection de la masse et un traitement radiothérapeutique a été choisi. Le chien a subi une radiothérapie (RT) avec un accélérateur linéaire de 6 MV avec 5 × 6 Gy, dose totale 30 Gy. Lors des examens de suivi, trois mois et un an après le traitement, le chien présentait un état normal et avait une alanine-amino­-transférase (ALT) et une phosphatase alcaline (PA) normales. La taille de la tumeur mesurée lors des examens tomodensitométriques avait diminué de 61% respectivement de 90%. Deux ans après la radiothérapie, le chien présente un état général normal et les enzymes hépatiques sont dans la norme.

[Influence of Teamwork on Wellbeing And Emotional Exhaustion of Staff in German Rehabilitation Clinics]. / Einfluss von Teamarbeit auf Wohlbefinden und emotionale Erschöpfung von Mitarbeitern in der medizinischen Rehabilitation.

AIM: In the context of high prevalence rates of mental and psychosomatic disorders in the medical staff, emotional exhaustion and wellbeing are often considered as important indicators. Teamwork can have a positive influence on wellbeing of staff members. In the sector of rehabilitation, however, this is not sufficiently investigated. The aim of this study was to investigate aspects of teamwork as predictors of wellbeing and emotional exhaustion in staff at rehabilitation clinics in Germany. METHODS: Data was collected in 10 rehabilitation clinics, 9 of them could be included in the data analysis (n=306, 70% female, 68% age 40-59). Data was analyzed with multiple linear regression analyses. RESULTS: Staff reported moderate rates of emotional exhaustion and good rates of overall wellbeing. Results of the regression analysis show that cohesion (ß=0.27, p<0,001), team organization (ß=0.19, p<0,01) and age (ß=0.13, p<0,05) could predict wellbeing (F[3, 244]=19.38, p<0,05). Emotional exhaustion was predicted by cohesion (ß=- 0.37, p<0,001, F[1, 244]=39.19). CONCLUSION: Consequences of interpersonal andstructural aspects of teamwork are discussed as well as the potential relevance of interventions to improve teamwork, in order to enhance wellbeing and counteract emotional exhaustion of staff members.

A patient-centred team-coaching concept for medical rehabilitation.

Team coaching enhances teamwork and subsequently improves patient-centredness in medical rehabilitation clinics. Even though interprofessional teamwork is regarded as a crucial factor in medical rehabilitation, to date no evaluated team-coaching approaches are available for improving interprofessional teamwork in medical rehabilitation in Germany. Based on a systematic literature search and interviews with staff, managers, and patients of rehabilitation clinics, we developed a team-coaching approach that is standardized in its process but based on the individual needs and requests of each clinic. It takes a systemic perspective and is goal-oriented and solution-focused. The approach mainly serves to provide impulses to make use of resources within the team and to support a self-directed organisational learning process. It is manualized and can, therefore, be used by professionals aiming to improve interprofessional teamwork in their clinic. A multi-centre, cluster-randomized controlled study that was conducted to evaluate the team-coaching approach showed positive results. Team organization, knowledge integration, and responsibility can be improved, and, therefore, the implementation of the patient-centred team-coaching approach in interprofessional rehabilitation teams can be recommended.

[Team Development in Medical Rehabilitation: Concept and Evaluation of a Team Intervention]. / Teamentwicklung in der medizinischen Rehabilitation: Konzept und Evaluation einer Teamintervention.

AIM OF THE STUDY: Interprofessional collaboration is a main precondition of successful treatment in rehabilitation. In order to improve interprofessional collaboration, a clinic-specific, goal- and solution-oriented and systemic team development approach was designed. The aim of the study is the evaluation of this approach. METHODS: A multi-centre cluster-randomized controlled study with staff questionnaires. RESULTS: The team development could be implemented successfully in 4 of 5 clinics and led to significant improvements in team organisation, willingness to accept responsibility and knowledge integration. The effects are small and are caused by the opposed development of intervention and control group. CONCLUSIONS: The team development approach can be recommended for rehabilitation practice. A train-the-trainer approach will be developed and further studies are planned in order to disseminate the approach and to investigate the conditions of implementation.

Expectations and requests regarding team training interventions to promote interdisciplinary collaboration in medical rehabilitation--A qualitative study.

BACKGROUND: Interdisciplinary teamwork and team interventions are highly valued in the rehabilitation sector because they can improve outcomes of care for persons with complex health problems. However, little is known about expectations and requests regarding team interventions, especially in medical rehabilitation. This study aimed to explore how clinical managers and health professionals within multidisciplinary rehabilitation teams describe their expectations and requests regarding team-training interventions in the field of medical rehabilitation. METHODS: Considering the methodology of qualitative research, data were collected using semi-structured interviews and focus groups at five rehabilitation clinics in Germany. We conducted face-to-face interviews with 5 clinical managers and 13 department heads of health care teams as well as five focus groups with a total of 35 members of interdisciplinary rehabilitation teams. Afterwards, the data were analyzed through qualitative content analysis encompassing data coding and using inductive thematic analysis. RESULTS: The exploration of team members' and clinical managers' descriptions showed that, to them, interdisciplinary team training programs should include a wide array of training contents. Seven common core themes emerged from the interviews, including participation of employees, leadership, communication, team meetings, team composition, coordination, and equal esteem. Additionally, 13 themes were identified by either managers or team members. The body of expectations regarding team training content in healthcare spans the continuum of changes on the team and organizational levels. On the organizational level, a number of structural factors were mentioned (e.g. improving the general conditions for team meetings, organized workshops to exchange interdisciplinary experiences, and leadership training), and on the team level, changes in procedural factors were listed (e.g. optimizing the consecutive planning and coordination of patient treatments, clarity with regard to roles and responsibilities of team members, and mutual esteem and appreciation between different professions). CONCLUSIONS: The synthesis underscores that there is meaningful heterogeneity in team training needs; training interventions should be locally adapted for each clinic in terms of training content and training strategies. Tailored team interventions are important for rehabilitation clinics. Future work should evaluate employed team training concepts over time as well as training contents, implementation strategies, and learning outcomes. This includes using robust study designs and evaluating team-training effects.

[Importance of multidetector CT imaging in multiple trauma]. / Stellenwert der Multidetektor-CT bei Polytrauma.

CLINICAL/METHODICAL ISSUE: Diagnostic imaging of complex multiple trauma remains a challenge for any department providing modern emergency radiology (ER) service. An early and comprehensive approach for ER imaging is crucial for a priority-oriented and timely therapy concept with the aim of identifying potentially life-threatening injuries early and initiating appropriate treatment. STANDARD RADIOLOGICAL METHODS: The basic diagnostic approach still consists of focused ultrasound using focused assessment with sonography for trauma (FAST) and conventional radiography (CR), usually limited to a single supine chest x-ray for triaging patients undergoing immediate operations. METHODICAL INNOVATIONS: Multidetector computed tomography (MDCT) has become established as early whole body CT (WBCT) as the undisputable diagnostic method. The detection rate of injuries by WBCT is outstanding and it improves the probability of survival by 20-25% compared with all other previous methods. At the same time, the spatial and temporal resolution of MDCT was improved resulting in considerably shortened examination times but WBCT is still associated with a significant radiation exposure, even in the acute single use setting. Using modern scanner and dose reduction technology, including iterative reconstruction, a dose reduction of up to 40% could be achieved. The substantial number of images in WBCT is another challenge; images must be processed priority-oriented, read and transferred to the picture archiving and communications system (PACS). For rapid diagnosis, volume image reading (VIR) offers additional options to keep the diagnostic process on time. ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS: Modern WBCT after multiple trauma is performed early, comprehensively and personalized so that WBCT improves the probability of survival by 20-25%.

[Facilitators and barriers to interprofessional collaboration in rehabilitation clinics--a survey of clinical executive managers]. / Förderfaktoren und Barrieren interprofessioneller Kooperation in Rehabilitationskliniken--Eine Befragung von Führungskräften.

PURPOSE: Interprofessional collaboration is an essential feature of quality and success in medical rehabilitation, a field which is influenced by a variety of factors. It is the objective of this study to identify beneficial factors that may promote team collaboration as well as barriers which may hinder it. METHODS: The facilitators and barriers of team collaboration were identified in a cross-sectional study. We conducted guided expert interviews with 18 managers aged between 36 and 62 years (M = 49.2) in a total of 5 inpatient rehabilitation clinics. Among the surveyed managers were 5 senior physicians and 13 department head managers of the health professionals (4 head nurses,6 head therapists and 3 heads of psychological departments). The qualitative analysis of interview transcripts was carried out according to Mayring's structured content analysis approach. RESULTS: From a total of 480 coded statements,337 are concerned with factors supporting interprofessional collaboration and 143 relate to barriers.The most common statements concerning supporting factors relate to the main category "Interprofessional Coordination of Treatment".Here, for example, the existence of an overall rehabilitation concept and planning of care services with rehabilitation goals in mind are regarded as facilitating. Variables such as interactive information exchange, multilateral communication,transparent team roles, defined tasks of the entire team or of individual team members play significant roles in this context. Hindering factors and barriers to interprofessional collaboration are mentioned in particular in relation to the organization.In terms of organization, heavy workload(time pressure, high treatment frequencies,altered severity of rehabilitation needs, considerable administration costs), inadequate pay Inter and insufficient time corridors to consult within the interprofessional team are rated as limiting factors. CONCLUSION: Influencing factors on interprofessional collaboration identified in our study are similar to those named in other studies. Facilitators and barriers of interprofessional collaboration should be taken into account when guiding and managing teams.

[The relevance of internal and external participation for patient satisfaction]. / Die Bedeutung der internen und externen Partizipation für die Patientenzufriedenheit.

AIM OF THE STUDY: Patient satisfaction is an essential quality and outcome criteria for patient-centered treatment of chronic diseases. For successful implementation of integrated patient-centered care it is important to take the needs and expectations of the patients into consideration in the treatment process and to involve them in decision-making (external participation), as well as establishing patient-centered collaboration within the team and organization (internal participation). This study examines in what respect patient satisfaction can be predicted through parameters that focus on the personal needs of the individual or internal and external participation. METHODS: To this end we used a multicenter cross-sectional study to collect evaluations from N=329 patients with different chronic diseases in 11 rehabilitation clinics. Patient satisfaction (ZUF-8) served as the criterion, and the predictors were external participation (PEF-FB-9), satisfaction with decision-making (Man-Son-Hing Scale) and internal participation (Internal Participation Scale), socio-demographic factors and rehabilitation status (IRES-24). The data were analyzed statistically using multiple linear regression. RESULTS: A high degree of variance of patient satisfaction could be explained by the parameters applied (Goodness-of-fit: R²corrected=47.3%). The strongest predictors of satisfaction were internal participation (Beta=0.44, p<0.001) and satisfaction with the decision-making (Beta=0.36, p<0.001). CONCLUSION: The study provides initial indications of the positive effects of internal and external participation. Further studies are necessary to substantiate the connection between internal and external participation and patient satisfaction.

The role of follow-up ultrasound and clinical parameters after abdominal MDCT in patients with multiple trauma.

BACKGROUND: Beside its value during the initial trauma work-up (focused assessment with sonography for trauma), ultrasound (US) is recommended for early follow-up examinations of the abdomen in multiple injured patients. However, multidetector CT (MDCT) has proven to reliably diagnose traumatic lesions of abdominal organs, to depict their extent, and to assess their clinical relevance. PURPOSE: To evaluate the diagnostic impact of follow-up US studies after MDCT of the abdomen and to identify possible clinical parameters indicating the need of a follow-up US. MATERIAL AND METHODS: During a 30-month period, patients with suspected multiple trauma were allocated. Patients with admission to the ICU, an initial abdominal MDCT scan, and an US follow-up examination after 6 and 24 h were included. Two patient cohorts were defined: patients with normal abdominal MDCT (group 1), patients with trauma-related pathologic abdominal MDCT (group 2). In all patients, parameters indicating alteration of vital functions or hemorrhage within the first 24 h were obtained by reviewing the medical charts. RESULTS: Forty-four of 193 patients were included: 24 were categorized in group 1 (mean age, 41.1 years; range, 21-90 years), 20 in group 2 (mean age, 36.6 years; range, 16-71 years). In group 1, US did not provide new information compared to emergency MDCT. In group 2, there were no contradictory 6- and 24-h follow-up US findings. In patients with positive MDCT findings and alterations of clinical parameters, US did not detect progression of a previously diagnosed pathology or any late manifestation of such a lesion. In none of the patients with negative abdominal MDCT and pathological clinical parameters US indicated an abdominal injury. CONCLUSION: Routine US follow-up does not yield additional information after abdominal trauma. In patients with MDCT-proven organ lesions, follow-up MDCT should be considered if indicated by abnormal clinical and/or laboratory findings.

Placental ABCA1 and ABCG1 expression in gestational disease: Pre-eclampsia affects ABCA1 levels in syncytiotrophoblasts.

INTRODUCTION: Transplacental feto-maternal lipid exchange through the ATP-binding cassette transporters ABCA1 and ABCG1 is important for normal fetal development. However, only scarce and conflicting data exist on the involvement of these transporters in gestational disease. METHODS: Placenta samples (n = 72) derived from common gestational diseases, including pre-eclampsia (PE), HELLP, intrauterine growth restriction (IUGR), intrahepatic cholestasis of pregnancy and gestational diabetes, were assessed for their ABCA1 and ABCG1 expression levels and compared to age-matched control placentas with qRT-PCR and immunohistochemistry. ABCA1 expression was additionally investigated with immunoblot in placental membrane vesicles. Furthermore, placental cholesterol and phospholipid contents were assessed. RESULTS: ABCA1 mRNA levels differed significantly between preterm and term control placentas (p = 0.0013). They were down-regulated in isolated PE and PE with IUGR (p = 0.0006 and p = 0.0012, respectively), but unchanged in isolated IUGR, isolated HELLP and other gestational diseases compared to gestational age-matched controls. Correspondingly, in PE, ABCA1 protein expression was significantly reduced in the apical membrane of the villous syncytiotrophoblast (p = 0.011) and in villous fetal endothelial cells (p = 0.036). Furthermore, in PE there was a significant increase in the placental content of total and individual classes of phospholipids which were partially correlated with diminished ABCA1 expression. Conversely, ABCG1 mRNA and protein levels were stable in the investigated conditions. CONCLUSIONS: In gestational disease, there is a specific down-regulation of placental ABCA1 expression at sites of feto-maternal lipid exchange in PE. At a functional level, the increase in placental lipid concentrations provides indirect evidence of an impaired transport capacity of ABCA1 in this disease.

RNA degradation differentially affects quantitative mRNA measurements of endogenous reference genes in human placenta.

It has been highlighted that RNA quality and appropriate reference gene selection is crucial for the interpretation of RT-qPCR results in human placental samples. In this context we investigated the effect of RNA degradation on the mRNA abundance of seven frequently used reference genes in 119 human placental samples. Combining RNA integrity measurements, RT-qPCR analysis and mathematical modeling we found major differences regarding the effect of RNA degradation on the measured expression levels between the different reference genes. Furthermore, we demonstrated that a modified RNA extraction method significantly improved RNA quality and consequently increased transcript levels of all reference genes.

Evaluation of a dedicated MDCT protocol using iterative image reconstruction after cervical spine trauma.

AIM: To evaluate radiation exposure for 64-row computed tomography (CT) of the cervical spine comparing two optimized protocols using filtered back projection (FBP) and adaptive statistical iterative reconstruction (ASIR), respectively. MATERIALS AND METHODS: Sixty-seven studies using FBP (scanner 1) were retrospectively compared with 80 studies using ASIR (scanner 2). The key scanning parameters were identical (120 kV dose modulation, 64 × 0.625 mm collimation, pitch 0.531:1). In protocol 2, the noise index (NI) was increased from 5 to 25, and ASIR and the high-definition (HD) mode were used. The scan length, CT dose index (CTDI), and dose-length product (DLP) were recorded. The image quality was analysed subjectively by using a three-point scale (0; 1; 2), and objectively by using a region of interest (ROI) analysis. Mann-Whitney U and Wilcoxon's test were used. RESULTS: In the FBP group, the mean CTDI was 21.43 mGy, mean scan length 186.3 mm, and mean DLP 441.15 mGy cm. In the ASIR group, the mean CTDI was 9.57 mGy, mean scan length 195.21 mm, and mean DLP 204.23 mGy cm. The differences were significant for CTDI and DLP (p < 0.001) and scan length (p = 0.01). There was no significant difference in the subjective image quality (p > 0.05). The estimated mean effective dose decreased from 2.38 mSv (FBP) to 1.10 mSv (ASIR). CONCLUSION: The radiation dose of 64-row MDCT can be reduced to a level comparable to plain radiography without loss of subjective image quality by implementation of ASIR in a dedicated cervical spine trauma protocol. These results might contribute to an improved relative risk-to-benefit ratio and support the justification of CT as a first-line imaging tool to evaluate cervical spine trauma.

[Evaluation of radiation dose in 64-row whole-body CT of multiple injured patients compared to 4-row CT]. / Evaluation der Strahlendosis bei Polytrauma-CT-Untersuchungen eines 64-Zeilen-CT im Vergleich zur 4-Zeilen-CT.

PURPOSE: To evaluate radiation exposure in whole-body CT (WBCT) of multiple injured patients comparing 4-row multidetector computed tomography (MDCT) to 64-row MDCT. MATERIALS AND METHODS: 200 WBCT studies were retrospectively evaluated: 92 4-row MDCT scans and 108 64-row MDCT scans. Each CT protocol was optimized for the particular CT system. The scan length, CT dose index (CTDI), and dose length product (DLP) were recorded and analyzed for radiation exposure. The mean effective dose was estimated based on conversion factors. Student's t-test was used for statistical analysis. RESULTS: The mean CTDIvol values (mGy) of the thorax and abdomen were significantly reduced with 64-row MDCT (10.2±2.5 vs. 11.4±1.4, p<0.001; 14.2±3.7 vs. 16.1±1.7, p<0.001). The DLP values (mGy×cm) of the head and thorax were significantly increased with 64-row MDCT (1305.9±201.1 vs. 849.8±90.9, p<0,001; 504.4±134.4 vs. 471.5±74.1, p=0.030). The scan lengths (mm) were significantly increased with 64-row MDCT: head 223.6±35.8 vs. 155.5±12.3 (p<0.001), thorax 427.4±44.5 vs. 388.3±57.5 (p<0.001), abdomen 520.3±50.2 vs. 490.8±51.6 (p<0.001). The estimated mean effective doses (mSv) were 22.4±2.6 (4-row MDCT) and 24.1±4.6 (64-row MDCT; p=0.001), resulting in a percentage increase of 8%. CONCLUSION: The radiation dose per slice of the thorax and abdomen can be significantly decreased by using 64-row MDCT. Due to the technical advances of modern 64-row MDCT systems, the scan field can be adapted to the clinical demands and, if necessary, enlarged without time loss. As a result, the estimated mean effective dose might be increased in WBCT.

Upgrade to iterative image reconstruction (IR) in abdominal MDCT imaging: a clinical study for detailed parameter optimization beyond vendor recommendations using the adaptive statistical iterative reconstruction environment (ASIR).

PURPOSE: To compare the image quality of dose-reduced 64-row abdominal CT reconstructed at different levels of adaptive statistical iterative reconstruction (ASIR) to full-dose baseline examinations reconstructed with filtered back-projection (FBP) in a clinical setting and upgrade situation. MATERIALS AND METHODS: Abdominal baseline examinations (noise index NI = 29; LightSpeed VCT XT, GE) were intra-individually compared to follow-up studies on a CT with an ASIR option (NI = 43; Discovery HD750, GE), n = 42. Standard-kernel images were calculated with ASIR blendings of 0 - 100 % in slice and volume mode, respectively. Three experienced radiologists compared the image quality of these 567 sets to their corresponding full-dose baseline examination (- 2: diagnostically inferior, - 1: inferior, 0: equal, + 1: superior, + 2: diagnostically superior). Furthermore, a phantom was scanned. Statistical analysis used the Wilcoxon - the Mann-Whitney U-test and the intra-class correlation (ICC). RESULTS: The mean CTDIvol decreased from 19.7 ±â€Š5.5 to 12.2 ±â€Š4.7 mGy (p < 0.001). The ICC was 0.861. The total image quality of the dose-reduced ASIR studies was comparable to the baseline at ASIR 50 % in slice (p = 0.18) and ASIR 50 - 100 % in volume mode (p > 0.10). Volume mode performed 73 % slower than slice mode (p < 0.01). CONCLUSION: After the system upgrade, the vendor recommendation of ASIR 50 % in slice mode allowed for a dose reduction of 38 % in abdominal CT with comparable image quality and time expenditure. However, there is still further dose reduction potential for more complex reconstruction settings.

PP141. The lipid transporters ABCA1 and ABCG1 are differentially expressed in preeclamptic and IUGR placentas.

INTRODUCTION: The ATP-binding cassette (ABC) transporter A1 (ABCA1) and ABCG1 are highly expressed in the placenta in various compartments, including the villous syncytiotrophoblast (V-STB) and foetal endothelial cells. Among other not yet characterized functions, they play a role in the foeto-maternal transport of cholesterol and other lipophilic molecules. In humans, preliminary data suggest expressional changes of ABCA1 and ABCG1 in pathologic gestation, particularly under hypoxic conditions, but a systematic expression analysis in common human pregnancy diseases has never been performed. OBJECTIVES: The aim of the present study was to characterize ABCA1 and ABCG1 expression in a large series of pathologic placentas, in particular from preeclampsia (PE) and intrauterine growth restriction (IUGR) which are associated with placental hypoxia. METHODS: Placentas from 152 pathological pregnancies, including PE and/or HELLP (n=24) and IUGR (n=21), and 20 normal control placentas were assessed for their ABCA1 and ABCG1 mRNA and protein expression with quantitative RT-PCR and semi-quantitative immunohistochemical analysis, respectively. RESULTS: ABCA1 protein expression in the V-STB was significantly less extensive in PE compared with normal controls (<10% of V-STB stained for ABCA1 in 58% PE placentas vs. 25% controls; p=0.035). Conversely, it was significantly more wide-spread in IUGR (>75% of V-STB stained in 57% IUGR placentas vs. 15% controls; p=0.009). Moreover, there was an insignificant trend for increased ABCA1 expression in fetal endothelial cells of stem villi in PE (p=0.0588). ABCA1 staining levels in V-STB were significantly associated with placental histopathological features related with hypoxia: they were decreased in placentas exhibiting syncytial knotting (p=0.033) and decidual vasculopathy (p=0.0437) and increased in low weight placentas (p=0.015). The significant and specific alterations in ABCA1 protein expression found at a specific cellular level were not paralleled by changes in ABCA1 mRNA abundance of total placental tissue. ABCG1 staining was universally extensive in the V-STB of normal placentas, always affecting more than 90% of V-STB surface. In comparison, ABCG1 staining of the V-STB was generally often reduced in pregnancy diseases. In particular, less than 90% of V-STB exhibited ABCG1 staining in 26% of PE placentas (p=0.022) and 35% of IUGR placentas (p=0.003). Similarly to ABCA1, ABCG1 mRNA expression in total placental tissue was not significantly different between controls and PE or IUGR. CONCLUSION: ABCA1 and ABCG1 proteins are differentially expressed, with either down- or up-regulation, in the V-STB of placentas exhibiting features of chronic hypoxia, such as in PE and IUGR. This suggests that other factors in addition to hypoxia regulate the expression of placental lipid transporters. The specific changes on a cellular level were masked when only total tissue mRNA was analysed underlining the importance of cell specific expression analysis. The potential effects of decreased placental ABCA1 and ABCG1 expression on foetal nutrition and development remain to be elucidated.

[Patients as customers? The term "customer" in the perception of medical students at the end of their university training]. / Der Patient als Kunde? Zur Perzeption eines marktwirtschaftlich geprägten Begriffs bei Medizinstudierenden am Ende ihres Studiums.

In the preceding decades a new perspective on the role of patients in the health-care system has gained ground, considering patients not merely as "suffering persons" but additionally as "customers". Physicians, however, tend to disagree with this approach because of the economic connotation of the term customer. Until now, there is only poor evidence of whether students of medicine - who are going to work as physicians in the future - agree or disagree with that approach and whether they are ready to accept patients as customers. In the following study students of medicine were interviewed on their perspectives towards that approach, in particular on their attitudes towards the idea of "the patient as customer", the appropriateness of the term consumer in different clinical settings and sectors of health care, the implementation of consumer orientation in clinical routine, and their favoured model of physician-patient relationship.As the study could not build upon data of prior similar studies, a quantitative and qualitative cross-sectional study with a descriptive-explorative design was conducted. Using a semi-standardised questionnaire, 313 medical students (response rate: 95%) were interviewed in Spring 2010. At the time of the survey, the students were enrolled at the faculty of medicine at Freiburg University, Germany, and were in their last semester which immediately preceded their exam.The future physicians do not consider patients primarily as customers. More than 80% of the respondents "absolutely" or "largely" supported the idea that patients are considerably more than customers. The analysis of the qualitative data of the study shows different results. Here, more statements were made that patients could equally be seen as customers (449 students supported this idea, 298 did not). Statements contradicting the customer approach referred mostly to the asymmetry of the physician-patient relationship and the special role of the patient. The highest level of acceptance of the customer approach was found in classical service settings such as pharmacies, the lowest level in emergency medical aid. According to medical students, a consumer orientation has been realised in different health service areas in correspondingly different degrees: On top of the list are plastic surgery clinics, followed by private health insurances and homeopathic clinics. A minority of medical students predict the implementation of consumer orientation in the emergency medical aid. Future physicians consider their relationship to patients largely as a relationship between a healing person and a person seeking help rather than a relationship between a service provider and a customer.Considering recent developments in the organisation of medical services and health services in general, it becomes increasingly important to know what kind of 'service behaviour' patients expect from their doctors and other health providers. Obviously, it is not self-evident for medical students to perceive their future patients as customers and to act as customer-oriented 'service providers'. In view of this, the faculties of medicine at universities - which provide professional training to students of medicine - should be aware of the challenge to 'socialise' their students so that they can keep up with patients' expectations.

[Development of an interprofessional train-the-trainer programme to implement shared decision-making in medical rehabilitation clinics]. / Entwicklung eines interprofessionellen Train-the-Trainer-Programms zur Implementierung der partizipativen Entscheidungsfindung in Rehabilitationskliniken.

BACKGROUND AND AIMS: Until now, training programmes on shared decision-making (SDM) have been designed exclusively for medical decision-making and predominantly for physicians. How-ever, interprofessional treatment, such as in medical rehabilitation, is very important in the treatment of chronic diseases. This requires an extended understanding of shared decision-making. Therefore the aim of the study is to develop an interprofessional training (IPT) for implementation of shared decision-making (SDM) in rehabilitation clinics. METHODS: The needs and preferences of the persons undergoing rehabilitation were collected in 4 focus groups, with frequency of answers analyzed by means of inductive category formation. The providers' preferences and requirements concerning a training programme on shared decision-making were assessed through an expert survey and underwent a mainly descriptive-explorative evaluation as well as a partial content analysis. RESULTS: 36 patients took part in the focus groups. Besides the wish for more participation in treatment decisions, they expressed further needs, such as more time and respect. The -experts of the 4 clinics (n=34, rate of response: 71%) also assessed these aspects of the patient-provider interaction as relevant. However, they saw the highest training need in the area of interdisciplinary team interactions. CONCLUSION: The interprofessional training programme "Fit for SDM" was developed on the basis of these results, and consists of 2 modules for the implementation of shared decision-making in medical rehabilitation. Module 1 focuses on external participation (provider-patient interaction), Module 2 on internal participation (team interaction). Module 2 was additionally used for preparing executives in their role as multipliers in the team. The training is currently being evaluated in a cluster-randomized multicentre study.

Expression and localization pattern of ABCA1 in diverse human placental primary cells and tissues.

The ATP-binding cassette transporter A1 (ABCA1) mediates the transport of cholesterol, phospholipids, and other lipophilic molecules across cellular membranes. Recent data provide evidence that ABCA1 plays an important role in placental function but the exact cellular sites of ABCA1 action in the placenta remain controversial. To clarify this issue, we analyzed the cellular and subcellular localization of ABCA1 with immunocytochemistry, immunofluorescence and subsequent confocal or immunofluorescence microscopy in different types of isolated primary placenta cells: cytotrophoblast cells, amnion epithelial cells, villous macrophages (Hofbauer cells), and mesenchymal cells isolated from chorionic membrane and placental villi. After 12 h of cultivation, primary cytotrophoblast cells showed intensive membrane and cytoplasmic staining for ABCA1. After 24 h, with progressive syncytium formation, ABCA1 staining intensity was markedly reduced and ABCA1 was dispersed in the cytoplasm of the forming syncytial layer. In amnion epithelial cells, placental macrophages and mesenchymal cells, ABCA1 was predominantly localized at the cell membrane and cytoplasmic compartments partially corresponding to the endoplasmic reticulum. In these cell types, the ABCA1 staining intensity was not dependent on the cultivation time. In conclusion, ABCA1 shows marked expression levels in diverse placental cell types. The multitopic localization of ABCA1 in diverse human placental cells not all directly involved in materno-fetal exchange suggests that this protein may not only participate in transplacental lipid transport but could have additional regulatory functions.

Identification of ABCA1 and ABCG1 in milk fat globules and mammary cells--implications for milk cholesterol secretion.

The ATP-binding cassette (ABC) transporters ABCA1 and ABCG1 play an important role in cellular cholesterol homeostasis, but their function in mammary gland (MG) tissue remains elusive. A bovine MG model that allows repeated MG sampling in identical animals at different functional stages was used to test whether 1) ABCA1 and ABCG1 protein expression and subcellular localization in mammary epithelial cells (MEC) change during the pregnancy-lactation cycle, and 2) these 2 proteins were present in milk fat globules (MFG). Expression and localization in MEC were investigated in bovine MG tissues at the end of lactation, during the dry period (DP), and early lactation using immunohistochemical and immunofluorescence approaches. The presence of ABCA1 and ABCG1 in MFG isolated from fresh milk was determined by immunofluorescence. The ABCA1 protein expression in MEC, expressed as arbitrary units, was higher during the end of lactation (12.2±0.24) and the DP (12.5±0.22) as compared with during early lactation (10.2±0.65). In contrast, no significant change in ABCG1 expression existed between the stages. Throughout the cycle, ABCA1 and ABCG1 were detected in the apical (41.9±24.8 and 49.0±4.96% of cows, respectively), basal (56.2±28.1 and 54.6±7.78% of cows, respectively), or entire cytoplasm (56.8±13.4 and 61.6±14.4% of cows, respectively) of MEC, or showed combined localization. Unlike ABCG1, ABCA1 was absent at the apical aspect of MEC during early lactation. Immunolabeling experiments revealed the presence of ABCA1 and ABCG1 in MFG membranes. Findings suggest a differential, functional stage-dependent role of ABCA1 and ABCG1 in cholesterol homeostasis of the MG epithelium. The presence of ABCA1 and ABCG1 in MFG membranes suggests that these proteins are involved in cholesterol exchange between MEC and alveolar milk.