[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]. / Früh- und Screeningsprechstunden: Ein notwendiger Weg zur besseren Frühversorgung in der internistischen Rheumatologie? : Rheumatologische Früh- und Screeningsprechstundenmodelle in Deutschland.

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[Protein-losing enteropathy: a cause of hypoalbuminaemia in patients with systemic lupus erythematosus]. / Enteraler Proteinverlust als Ursache einer schweren Hypoalbuminämie bei systemischem Lupus erythematodes.

Lupus nephritis is the most common cause of extended edema and hypoalbuminemia in patients with systemic lupus erythematosus (SLE). However, the same immune complex mechanisms which lead to renal protein loss can also be active in the gastrointestinal tract, resulting in severe hypoproteinemia through enteral protein loss. The case of a young female patient with otherwise mild SLE and severe hypoproteinemia through bowel manifestation of the disease is presented here. No gastrointestinal symptoms such as diarrhoea were present, but immunohistology of the smaller and larger bowel showed severe immunocomplex disease with focus on the submucosa and the basal membrane. Other causes of hypoproteinemia were excluded. Treatment with prednisolone and azathioprine led to fast and durable resolution of symptoms.

[Current "off label use" of methotrexate for chronic inflammatory rheumatic diseases]. / "Off label use" von Methotrexat in der klinischen Rheumatologie.

Methotrexate (MTX) is probably the most commonly used off-label drug in rheumatology. It is used as an immunosuppressant for a wide range of chronic inflammatory rheumatic diseases. In most cases there is limited evidence from controlled studies for the efficacy of MTX in this off-label scenario. Only a few controlled clinical trials exist for different types of connective tissue diseases and vasculitis. In most indications, however, MTX could help to avoid using steroids and/or to prevent relapses. Thus, there is a great deal of experience with MTX in an off-label use and MTX is employed in the daily practice by most rheumatologists with success. A commonly used register indexing the off-label use of MTX and also of other disease-modifying antirheumatic drugs (DMARDs) and biologicals would help to improve the acceptance and the safety of MTX as an orphan drug.

Ward rounds: how prepared are future doctors?

INTRODUCTION: Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. The present study aimed to identify final year students' deficiencies in conducting ward rounds in order to aid the development of appropriate teaching tools. METHODS: 45 final year students participated in a simulated ward round session with three standardised patient scenarios: (1) myocardial infarction, (2) poorly controlled diabetes, and (3) acute fever in acute myeloid leukaemia. Videotaped sessions were rated by independent raters using binary item checklists which reflected predefined learning goals in five different domains: (I) information gathering, (II) communication with patient, (III) focused physical examination, (IV) chart reviewing/ prescription/ documentation and (V) team communication. RESULTS: For the three patient scenarios, 64.3% of the domain-specific learning goals were attained for the domain "information gathering", 79.4% for "communication with patient", 62.6% for "focused physical examination", 48.9% for "chart reviewing/ prescription/ documentation" and 86.0% for the domain "team communication". CONCLUSION: Final year students' ward round skills appear to be insufficient with a central deficit in reviewing charts and initiating appropriate prescriptions and documentation. Ward round training which eases the transition from observing ward rounds to conducting them on one's own is urgently required.

An innovative model for teaching complex clinical procedures: integration of standardised patients into ward round training for final year students.

OBJECTIVES: Ward rounds are an essential activity for doctors in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. However, although the need for ward round training is emphasized in the published literature, there are currently no reports of ward round training in a simulated setting with standardized patients. METHODS: 45 final year students participated in a ward round training session lasting two hours with three standardized patient scenarios and role-plays. Final year students assumed the role of either doctor, nurse or final year student with role-specific instructions and provided each other with peer-feedback during the training session. Training was assessed using final year student focus groups and semi-structured interviews of standardized patients. Written protocols of the focus group as well as the interviews of standardized patients were content analysed. RESULTS: In the course of five focus groups, 204 individual statements were gathered from participating final year students. Ward round training proved to be a feasible tool, well accepted by final year students. It was seen to offer a valuable opportunity for reflection on the processes of ward rounds, important relevant feedback from standardized patients, peer group and tutors. Semi-structured standardized patient interviews yielded 17 central comments indicating that ward rounds are a novel and exciting experience for standardized patients. CONCLUSION: Ward round training with standardized patients is greatly appreciated by final year students and is viewed as an important part of their education, easing the transition from observing ward rounds to conducting them on their own.

Use of a cocktail of probe substrates for drug-metabolizing enzymes for the assessment of the metabolic capacity of hepatocyte preparations.

A cocktail of the following probe substrates for human drug-metabolizing enzymes was used to characterize hepatocyte preparations: phenacetin (for CYP1A2), diclofenac (CYP2C9), diazepam (CYP2C19), bufuralol (CYP2D6), midazolam (CYP3A4/5) and 7-hydroxycoumarin (for glucuronidation and sulphation). The cocktail was incubated with cryopreserved human, dog or minipig hepatocytes or with freshly prepared rat hepatocytes. Sample analysis was performed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in an Open Access environment that allowed less experienced MS operators to login, submit and analyse sample sets using predefined settings without the immediate attendance of an experienced analyst. Intrinsic clearances (CLint) were calculated from the disappearance of the compounds from the incubations. Initially, the cocktail used for human, rat and dog hepatocyte incubations contained 7-ethoxycoumarin instead of 7-hydroxycoumarin. However, 7-ethoxycoumarin had an inhibitory effect on the metabolism of phenacetin. The highest CLint estimated with human and dog hepatocytes was observed for 7-hydroxycoumarin. For rat and minipig hepatocytes, the highest CLint was observed for bufuralol. In incubations with dog and minipig hepatocytes, the lowest CLint was seen with diclofenac, whereas for human and rat hepatocytes, the lowest value was observed with diazepam and phenacetin, respectively. When the cocktail was incubated together with human hepatocytes and 1 microM ketoconazole, the CLint of midazolam was decreased to about 7.5% of the control value, whereas the metabolism of the other cocktail compounds was virtually unaffected by this CYP3A inhibitor. It is suggested that a cocktail of specific human probe substrates for drug-metabolizing enzymes can be used routinely for the determination of the metabolic capacity of hepatocyte preparations in order to ensure the quality and reproducibility of experiments. Moreover, a cocktail of specific probe substrates can also be a useful tool for studies on enzyme inhibition.