[Retrospective analysis of falls in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases]. / Retrospektive Analyse von Stürzen und deren Ursachen in einem stationären Rehabilitationszentrum für Patienten mit Erkrankungen des Stütz- und Bewegungsapparates.

AIM: To analyse the frequency and circumstances of falls in an inpatient rehabilitation centre. METHODS: In a survey all falls reported to the Austrian accident insurance carrier were analysed and external circumstances of falls were evaluated. The survey covers a period of 64 months (Jan 2000 to April 2005): 10 820 inpatients (234 502 patient days); mean age 52.8 years; 1,252 patients aged >/= 70 years; 47 % male, 53 % female. RESULTS: Of 223 accidents registered, 140 (62.8 %) were falls. Of these, 17 patients had to be referred to a surgical unit for further treatment. In total, 1.29 % of all patients fell during their stay (with report to the accident insurance carrier), 0.16 % suffered major injuries from falls (with referral to surgical unit). Females fell more frequently than males. 39 % of the falls were associated with physical therapy. Most falls occurred in daytime. The location in the centre or the day of week showed no major influence on the frequency of falls. Falls occurred slightly more often in the first part of the three-week inpatient stay. CONCLUSION: The high total number of falls shows that falls are important in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases. The analysis did not reveal any special location inside the rehabilitation centre with an increased risk of falls calling for urgent interventions. The active and activating physical therapies do not seem to increase the number of falls significantly.

High positive predictive value of specific antibodies cross-reacting with a 28-kDa Drosophila antigen for diagnosis of ankylosing spondylitis.

OBJECTIVES: Diagnosis of ankylosing spondylitis (AS) can be difficult, and a specific laboratory test has not yet been introduced as a routine diagnostic tool. Our aim was to evaluate the diagnostic value of antibodies specifically binding to a recombinant 28-kDa antigen for the diagnosis of AS. METHODS: Blinded sera were tested for antibodies binding to the procaryotically expressed 28-kDa protein using an enzyme-linked immunosorbent assay (ELISA). This purified 28-kDa protein is produced by a specific clone from an embryonic Drosophila hydei Xgtl I c-DNA library and is bound by human antibodies cross-reacting with both a 36-kDa protein of chromosomes from Drosophila melanogaster and a 69-Da HeLa S3 protein potentially involved in signal transduction pathways. RESULTS: Serum concentrations of antibodies cross-reacting with this specific antigen were increased in 371 patients with AS compared with 37 healthy controls (39.5 vs 22.6 U/ml; P = 0.004). The positive predictive values of this ELISA test for AS were between 95.1% (95% confidence interval 90.6-97.9%) for a cut-off level of 50 U/ml and 97.4% (92.7-99.5%) for a cut-off level of 75 U/ml, and the sensitivities were between 42.1% (37.0-47.3%) for a cut-off level of 50 U/ml and 30.7% (26.1-35.7%) for a cut-off level of 75 U/ml. CONCLUSIONS: Serum ELISA tests for antibodies cross-reacting with the 28-kDa antigen show a high positive predictive value for AS of more than 95%.

Preferential type 1 chemokine receptors and cytokine production of CD28- T cells in ankylosing spondylitis.

OBJECTIVE: To examine serum levels of type 1 and type 2 chemokines and lymphocytic expression of chemokine receptors, and to compare the results with lymphocytic cytokine production in patients with ankylosing spondylitis (AS). METHODS: Twelve patients with AS (mean (SD) age 44.9 (14.7) years) and 27 healthy controls (46.4 (12.8) years) were enrolled into the study. The expression of chemokine receptors (CCR-5, CXCR-3, CCR-4) and cytokines (interferon gamma (IFNgamma), interleukin (IL)2, IL4, IL10, tumour necrosis factor alpha (TNFalpha)) on CD28(+) and CD28(-) T cell subtypes was analysed by a three colour FACS technique of peripheral blood samples. Serum ELISAs were performed to detect the CCR-5 ligands CCL-5, CCL-3; the CXCR-3 ligands CXCL-10, CXCL-9; and the CCR-4 ligand, CCL-17 before and after administration of the TNFalpha blocking agent infliximab. RESULTS: CD4(+)CD28(-) T cells had higher ratios of CXCR-3 to CCR-4 than CD4(+)CD28(+) T cells. Both, CD4(+) and CD8(+)CD28(-) T cells of patients with AS produced more IFNgamma, TNFalpha, and IL10 than their CD28(+) counterparts (p<0.05), and lacked the production of IL2 and IL4. Serum levels of CXCL-9 were increased in patients with AS to 59.2 pg/ml (34.1-730.5) compared with 32.5 pg/ml (20.0-79.5) in healthy controls (p = 0.016). The levels of both type 1 (CCL-5, CXCL-9) and type 2 chemokines (CCL-17) decreased under blockade of TNFalpha (p<0.05). CONCLUSIONS: The profile of chemokine receptor expression and cytokine production by CD28(-) T cells suggests a type 1 immune reaction in AS, although IL10 is frequently produced by CD28(-) T cells. Treatment with TNFalpha blocking antibodies decreased both types of chemokines in patients' sera.

[Quality assurance in the teaching of medical students illustrated by the example of spa therapy for rheumatic diseases]. / Qualitätssicherung in der Lehre von Medizinstudenten illustriert am Beispiel der Kurorttherapie bei rheumatischen Erkrankungen.

BACKGROUND: The currently employed methods for quality assurance in student education are frequently considered as being inadequate. In the present study the request to plan a budget for the treatment of patients with ankylosing spondylitis is presented as an additional method to assess the influence of a teaching course on the student's attitude towards certain interventions. How would medical students distribute financial resources for the treatment of patients with ankylosing spondylitis? Does a course 'Excursion to a Spa' lead to changes in budgeting by the student? MATERIAL AND METHODS: Before and after a 4-day excursion to Bad Gastein (health resort primarily for patients with rheumatic diseases) to become better acquainted with the local treatment modalities medical students in semester 8.4 +/- 3.8 (5th year in medical school) were asked how they would distribute a fixed sum of EUR 5,000.- (= 100%) for a prospective period of 5 years over 9 given forms of treatment in a patient with ankylosing spondylitis in order to provide optimal improvement of the disease and quality of life. RESULTS: Before the excursion the students distributed the budget as follows: drug therapy 15%, spa therapy 17%, physical therapy 14%, exercise therapy 19%, massage therapy 11%, unconventional therapies 5%, psychological therapy 7%, changes in the household environment 8%, private pleasure 4%. After the excursion to the spa the medical students assigned more financial means on spa therapy (p = 0.024, Wilcoxon test) and unconventional therapies (p = 0.015). CONCLUSION: Creating a budget for a defined disease appears to be a useful instrument for assessing the influence of a teaching course on medical students' attitude towards certain interventions and for detecting imbalances in the presentation of therapy procedures or discrepancies between the presentation and the aims of teaching.

[Retained and discontinued conventional and unconventional measures by patients with Bechterew disease for modifying the course of illness]. / Von Patienten mit Morbus Bechterew beibehaltene und aufgegebene konventionelle und unkonventionelle Massnahmen zur Beeinflussung der Erkrankung.

BACKGROUND: Patients with chronic rheumatic disease often seek relief in unconventional treatments, but many of them do not share this information with their physician. OBJECTIVE: To explore which conventional and unconventional interventions are used by patients with ankylosing spondylitis. Which of these do they continue to use and which do they give up? PATIENTS: One-hundred fifty patients (36 female, 114 male) with ankylosing spondylitis, who presented for radon thermal treatment at the Gasteiner Heilstollen Hospital (mean age 50 +/- 11 years; disease duration 24 +/- 11 years). METHOD: A previous investigation identified 75 interventions used by patients with AS to influence their disease. In a face-to-face, structured interview all these interventions (terms used by the patients) were now presented to 150 other patients with AS. They were asked to state whether they had already used (and given up) the respective intervention or whether they intend to continue using it and intend to use it in future. RESULTS: A summary of all interventions previously and still used by patients showed conventional interventions (67%) to out-number unconventional (33%) interventions. Of the 150 patients, 20 stated that they use or have used more than 15 different unconventional interventions. In addition to health resort medicine (interview at a health resort!), massage therapy, physiotherapy and physical exercise were the most commonly used of the conventional interventions. Of the unconventional interventions warm climate, sea bathing, self-applied psychotherapy, vitamin pills, repression, showering with alternating cold and warm water, and self-help groups were named most frequently. CONCLUSION: Some patients with ankylosing spondylitis use many different (33% unconventional) interventions. In the patient's view, even rather general interventions such as warm climate or sea bathing are regarded as relevant to the disease. An open doctor-patient discussion of unconventional interventions used by the patient appears reasonable. The results confirm that most patients suffering from chronic and incurable disease seek relief in unconventional therapies.

Radon progeny activity on skin and hair after speleotherapeutic radon exposure.

The objective of present investigation was to measure radon progeny activity on hair and skin (forehead, paraumbilical, paravertebral) and its decrease after speleotherapeutic radon exposure in the gallery of the Gasteiner Heilstollen. Radon progeny activity was measured by means of a halogen-quenched Geiger-Mueller tube with a mica window (density 1.5-2.0 mg/cm2) and an effective diameter of 45 mm; beta efficiency 32% (210Bi), alpha efficiency 18% (241Am). Results are in counts per minute (cpm). All 17 patients were being treated for rheumatic disease in the galleries of the Gasteiner Heilstollen Hospital. The following activity (mean +/- standard error of the mean) was measured 25 (+/- 5) min after leaving the treatment area: on hair of the head, 1235+/-141 cpm; forehead, 503+/-78 cpm; paraumbilical 460+/-85 cpm; paravertebral, 270+/-39 cpm. Taking a shower did not significantly reduce radon progeny activity. Speleotherapeutic radon exposure causes a considerable increase in radon progeny activity on skin. The large surface of hair causes much greater activity on hair than on skin. Owing to their high adhesive properties, radon progenies are not reduced by taking a shower.

Vascular endothelial growth factor (VEGF) in ankylosing spondylitis--a pilot study.

INTRODUCTION: Angiogenesis is important for the pathogenesis of chronic inflammatory diseases in joints. Inflammation itself may upregulate the expression of VEGF in rheumatic diseases. Angiogenesis may become a new target for therapeutic intervention in inflammatory joint disease. AIM OF THE STUDY: To examine plasma levels of VEGF in AS patients and to test a possible correlation with serological and/or clinical parameters. PATIENTS AND METHODS: Sixteen consecutive patients with definite AS were recruited from the Gasteiner Heilstollen Hospital and compared to eight healthy probands as controls. VEGF was determined in EDTA plasma samples by using an ELISA kit. Data are given as mean values (+/- SEM). The Spearman two-sided test was used to test possible correlations. RESULTS: EDTA-plasma levels of VEGF were 75.3 +/- 19.0 pg/ml, compared to 13.8 +/- 4.7 pg/ml measured in the control group (P = 0.001). A significant correlation was found between plasma VEGF of AS patients and the BASMI score (r = 0.665, P = 0.013). Whereas VEGF was elevated in patients without treatment or NSAIDs (88.9 +/- 24.2 pg/ml), lower levels up to 43.8 pg/ml were found in patients treated with corticosteroids (34.7 +/- 4.0 pg/ml, P = 0.039). CONCLUSIONS: Disease status of AS appears to be associated with elevated VEGF plasma levels. Whether this reflects inflammation or a truly angiogenic pathomechanism requires further investigation.

Prospective controlled evaluation of the influence of an excursion to a health resort on medical students' opinion about chances for outpatient rehabilitation at a health resort.

OBJECTIVE: To assess the influence of an excursion to a health resort on students' opinion on the chances for outpatient rehabilitation at a health resort for cardiac and rheumatic diseases. METHODS: A group of 17 medical students went on a 1-day excursion to Bad Orb (near Frankfurt/M.) where mainly patients with heart diseases are treated. Another group of 44 students went on a 5-day excursion to Bad Gastein (Austria) where mainly patients with rheumatic diseases are treated. Before and after the excursion students completed a questionnaire asking their opinion on the chances for outpatient rehabilitation at a health resort for acute and chronic cardiac and rheumatic diseases. RESULTS: Students judged the chances for beneficial effects of outpatient rehabilitation at a health resort for chronic rheumatic diseases to be significantly better after the excursion to Bad Gastein than before, whereas there was no difference after the excursion to Bad Orb. CONCLUSION: Students' opinion of chances for outpatient rehabilitation at a health resort can be influenced by an excursion to a spa, but a single 1-day excursion may not be sufficient.

Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial.

OBJECTIVE: To determine the efficacy of combined spa-exercise therapy in addition to standard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis (AS). METHODS: A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 +/- 10 years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria; group 2 (mean age 49 +/- 9 years; male:female ratio 28:12) in a spa resort in Arcen, The Netherlands. The control group (mean age 48 +/- 10 years; male:female ratio 34:6) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises, walking, correction therapy (lying supine on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or sauna (Netherlands). After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks. Primary outcomes were functional ability, patient's global well-being, pain, and duration of morning stiffness, aggregated in a pooled index of change (PIC). RESULTS: Analysis of variance showed a statistically significant time-effect (P < 0.001) and time-by-treatment interaction (P = 0.004), indicating that the 3 groups differed over time with respect to the course of the PIC. Four weeks after start of spa-exercise therapy, the mean difference in PIC between group 1 and controls was 0.49 (95% confidence interval [CI] 0.16-0.82, P = 0.004) and between group 2 and controls was 0.46 (95% CI 0.15-0.78, P = 0.005). At 16 weeks, the difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P = 0.002) and between group 2 and controls was 0.34 (95% CI--0.05-0.73; P = 0.086). At 28 and 40 weeks, more improvement was found for group 1 compared with controls (P = 0.012 and P = 0.062, respectively) but not for group 2 compared with controls. CONCLUSION: In patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug treatment and weekly group physical therapy alone, provides beneficial effects. These beneficial effects may last for at least 40 weeks.

[Symptoms, effects on quality of life, judgement and expectations of treatment in active ankylosing spondylitis: the patient's view]. / Aktiver Morbus Bechterew: Symptomatik, Einschränkung der Lebensqualität, Therapiebeurteilung und Therapieerwartung aus Sicht des Patienten.

Symptoms, Effects on Quality of Life, Judgement and Expectations of Treatment in Active Ankylosing Spondylitis: The Patient's View.In ankylosing spondylitis uncertainty prevails among rheumatologists on how to define and measure activity. In the present study the patient's view of activity was evaluated. What does active ankylosing spondylitis mean for the patient? In a standardized interview the patient was asked to describe, from his own experience, what active ankylosing spondylitis means, what bothers him most, what helps most, and what he expects from therapy. For the patient, active ankylosing spondylitis means pain (99 responses), mobility restriction (19), muscle tension (10), inability to stay supine (6), restriction in chest mobility (5) and dyspnea (5). Fatigue was mentioned by two patients. In active states patients are mainly bothered by pain (77), mobility restriction (55), consequences for social life (20) and work (18), disturbed sleep (17) and difficult breathing (16). Drugs (84) and physical activity (42) were judged the best treatments during active ankylosing spondylitis. It was no surprise that pain and mobility restriction were cited most often by the patients. Breathing difficulties were cited rather often, whereas fatigue seems not to play an important role for most patients. The results suggest that modern rheumatology may have underestimated the relevance of difficult breathing and paid too much attention to fatigue.

[Physical exercise, nutrition and sunshine exposure for the prevention of osteoporosis]. / Körperliche Belastung, Ernährung und Sonnenexposition zur Prävention der Osteoporose.

BACKGROUND: Social and economic impact of osteoporosis is growing. Prevention deserves more attention than at present. Since previous reviews on prevention of osteoporosis by the author, many original papers and reviews on the subject have been published. Which interventions are effective? METHODS: A MEDLINE search was performed using the search terms 'osteoporosis' and 'calcium' or 'vitamin D' or 'ultraviolet' or 'sunshine' or 'nutrition' or 'exercise' or 'hormone'. Additionally, references of recent publications were searched for significant contributions. Relevant publications as assessed by the author were included into the present review. RESULTS AND CONCLUSIONS: Regular high-impact physical exercise, a daily allowance of at least 1000 mg calcium, a sufficient supplementation with vitamin D through UVB-exposure of the skin or oral supplementation, and hormonal replacement therapy in deficiency states are the fundamentals of prevention of osteoporosis.

Serum 25-hydroxyvitamin D and parathyroid hormone in patients with ankylosing spondylitis before and after a three-week rehabilitation treatment at high altitude during winter and spring.

Does a sojourn at high altitude during the winter and spring improve vitamin D status (and possibly suppress parathyroid hormone [PTH]) in patients with ankylosing spondylitis (AS)? In 73 patients with AS, serum concentrations of 25-hydroxy-vitamin D [25(OH)D] and PTH were determined before and after a three-week rehabilitation treatment at Bad Gastein (1000 m above sea level). At the first examination, serum 25(OH)D was median (25th, 75th percentile) 15.5 ng mL-1 (10.0 ng mL-1, 20.6 ng mL-1). Thirteen patients (18%) had a 25(OH)D concentration below 8 ng mL-1. In 53 patients (73%) the level was below 20 ng mL-1. After the sojourn, 25(OH)D significantly (p = 0.02) increased to 19.7 (11.3, 24.6) ng mL-1. PTH did not change significantly, being 32 (22.4, 43.9) pg mL-1 before and 30.3 (24.1, 39.9) pg mL-1 after the sojourn. Analysing different periods of sojourn, a significant (p < 0.001) increase in 25(OH)D was found in April but not in the other months. Patients with ankylosing spondylitis may have extremely low levels of 25(OH)D. The results of the present study suggest that a sojourn at high altitude in early spring is liable to reduce vitamin D deficiency.

Speleotherapy for asthma.

BACKGROUND: Speleotherapy, the use of subterranean environments, is a therapeutic measure in the treatment of chronic obstructive airways diseases. It is virtually unknown in the UK or the US, but has considerable widespread use in some Central and Eastern European countries. OBJECTIVES: To review evidence for the efficacy of speleotherapy in the treatment of asthma. SEARCH STRATEGY: We searched electronic databases (Medline, Embase, Cochrane Airways group database), contacted speleotherapy centres and experts in the field, hand searched proceedings, and checked bibliographies of articles obtained to identify possible relevant publications. SELECTION CRITERIA: We included controlled clinical trials (i.e., both randomized and those not reporting the method of allocation) that compared clinical effects of speleotherapy with another intervention or no intervention in patients with chronic asthma. DATA COLLECTION AND ANALYSIS: Information concerning patients, interventions, results, and methodology were extracted in standardized manner by two independent reviewers and summarized descriptively. MAIN RESULTS: Three trials including a total of 124 asthmatic children met the inclusion criteria, but only one trial had reasonable methodological quality. Two trials reported that speleotherapy had a beneficial short-term effect on lung function. Other outcomes could not be assessed in a reliable manner. A further search was conducted in July 2000. One further paper was excluded (see excluded studies) REVIEWER'S CONCLUSIONS: The available evidence does not permit a reliable conclusion as to whether speleo-therapeutic interventions are effective for the treatment of chronic asthma. Randomized controlled trials with long-term follow-up are necessary.

Is chronic lymphocytic leukemia a contraindication for radon and thermotherapy?--a case report.

A growing number of patients presenting for radon-thermotherapy have a history of malignant disease. The question as to whether malignancies in general are a contraindication for radon treatment or mild hyperthermia during spa therapy is still a subject of controversy. We report a patient with osteoarthritis and a frozen shoulder who repeatedly underwent speleotherapeutic radon and hyperthermia treatment in the gallery of the Gasteiner Heilstollen, Austria, despite concomitant chronic lymphocytic leukemia (B-CLL, Rai stage 0). After nine courses of radon-thermotherapy over eight years, no apparent negative impact on CLL was noted. The purpose of this case report is to encourage discussion as to whether CLL or other past or present malignancies must be considered a contraindication for spa treatment such as radon-thermotherapy.