Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research.

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

The relationship between sense of coherence and post-traumatic stress: a meta-analysis.

Background: Antonovsky's concept of sense of coherence (SOC) - as a global orientation reflecting an individual's feeling of confidence in both the predictability of their internal and external environment and their ability to cope with stressful and challenging situations in life - shows a negative association with symptoms of post-traumatic stress. However, single studies varying in study characteristics provide heterogeneous effect size estimations. Objective: The purpose of the current study is to investigate the relationship between SOC and post-traumatic stress disorder (PTSD) symptom severity for the first time on a meta-analytical level. Method: The random-effects meta-analysis is based on zero-order correlations (r) and consists of 47 independent samples out of 45 studies (N = 10,883). Results: After correcting for sampling error, the mean correlation between SOC and PTSD symptoms was M(r) = -.41 (excluding four outliers: -.39). However, this effect could not be generalized to all types of PTSD samples owing to substantial remaining heterogeneity. Subsequent moderator analyses investigating the influence of different SOC and PTSD measures, trauma type and duration, mean age and gender imbalances per sample did not reveal significant moderating effects. Conclusions: The meta-analysis reveals a substantial correlation between SOC and PTSD symptom severity: higher SOC levels are associated with lower symptom severity. Thus, future research should progress to the question of whether the relationship between SOC and post-traumatic stress is causal, and by which factors it is moderated. Abbreviations: CD, Cook's distance; DSM, Diagnostic and Statistical Manual of Mental Disorders; (G)RR, general (and specific) resistance resources; IES(-R), Impact of Event Scale (Revised); PDS, Posttraumatic Stress Diagnostic Scale; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PTSD, post-traumatic stress disorder; SDR, standard deleted residual; SOC, sense of coherence; SOC-R, Sense of Coherence Scale - Revised.

Antecedentes: El concepto de sentido de coherencia (SOC) de Antonovsky- como una orientación global reflejando el sentimiento de seguridad de un individuo, tanto en la previsibilidad de su ambiente interno y externo y su habilidad para enfrentar situaciones estresantes y desafiantes en su vida- muestra una asociación negativa con el estrés postraumático. Sin embargo, estudios individuales que varían en las características proporcionan estimaciones del tamaño del efecto heterogéneo.Objetivo: El propósito de este estudio es investigar la relación entre SOC y severidad de los síntomas de TEPT por primera vez a un nivel metaanalítico.Método: El metanálisis de efectos aleatorios se basa en correlaciones de orden cero (r) y consta de 47 muestras independientes de 45 estudios (N= 10.883).Resultados: Después de corregir por error de muestreo, la correlación media entre SOC y síntomas de TEPT fue M(r) =−.41 (excluyendo cuatro valores atípicos: −.39). Sin embargo, este efecto podría no ser generalizado a todos los tipos de muestras de TEPT debido a la importante heterogeneidad restante. Los siguientes análisis del moderador investigan la influencia de diferentes mediciones de SOC y TEPT, tipo de trauma y duración, edad media y desbalance de género por muestra no revela efectos moderados significativos.Conclusiones: El metanálisis revela una importante correlación entre SOC y severidad de los síntomas de TEPT: Niveles más altos de SOC están asociados con menor severidad de los síntomas. De este modo, las investigaciones futuras deberían progresar a la pregunta de si la relación entre SOC y estrés postraumático es causal, y por cuáles factores es moderada.

Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts.

BACKGROUND AND PURPOSE: Prominent space-occupying cerebral edema is a devastating complication occurring in some but not all patients with large MCA infarcts. It is unclear why differences in the extent of edema exist. Better knowledge of factors related to prominent edema formation could aid treatment strategies. This study aimed to identify variables associated with the development of prominent edema in patients with large MCA infarcts. MATERIALS AND METHODS: From the Dutch Acute Stroke Study (DUST), 137 patients were selected with large MCA infarcts on follow-up NCCT (3 ± 2 days after stroke onset), defined as ASPECTS ≤4. Prominent edema was defined as a midline shift of ≥5 mm on follow-up. Admission patient and treatment characteristics were collected. Admission CT parameters used were ASPECTS on NCCT and CBV and MTT maps, and occlusion site, clot burden, and collaterals on CTA. Permeability on admission CTP, and day 3 recanalization and reperfusion statuses were obtained if available. Unadjusted and adjusted (age and NIHSS) odds ratios were calculated for all variables in relation to prominent edema. RESULTS: Prominent edema developed in 51 patients (37%). Adjusted odds ratios for prominent edema were higher with lower ASPECTS on NCCT (adjusted odds ratio, 1.32; 95% CI, 1.13-1.55) and CBV (adjusted odds ratio, 1.26; 95% CI, 1.07-1.49), higher permeability (adjusted odds ratio, 2.35; 95% CI, 1.30-4.24), more proximal thrombus location (adjusted odds ratio, 3.40; 95% CI, 1.57-7.37), higher clot burden (adjusted odds ratio, 2.88; 95% CI, 1.11-7.45), and poor collaterals (adjusted odds ratio, 3.93; 95% CI, 1.78-8.69). CONCLUSIONS: Extensive proximal occlusion, poor collaterals, and larger ischemic deficits with higher permeability play a role in the development of prominent edema in large MCA infarcts.

Timing-Invariant CT Angiography Derived from CT Perfusion Imaging in Acute Stroke: A Diagnostic Performance Study.

BACKGROUND AND PURPOSE: Timing-invariant (or delay-insensitive) CT angiography derived from CT perfusion data may obviate a separate cranial CTA in acute stroke, thus enhancing patient safety by reducing total examination time, radiation dose, and volume of contrast material. We assessed the diagnostic accuracy of timing-invariant CTA for detecting intracranial artery occlusion in acute ischemic stroke, to examine whether standard CTA can be omitted. MATERIALS AND METHODS: Patients with suspected ischemic stroke were prospectively enrolled and underwent CTA and CTP imaging at admission. Timing-invariant CTA was derived from the CTP data. Five neuroradiologic observers assessed all images for the presence and location of intracranial artery occlusion in a blinded and randomized manner. Sensitivity and specificity of timing-invariant CTA and standard CTA were calculated by using an independent expert panel as the reference standard. Interrater agreement was determined by using κ statistics. RESULTS: We included 108 patients with 47 vessel occlusions. Overall, standard CTA and timing-invariant CTA provided similar high diagnostic accuracy for occlusion detection with a sensitivity of 96% (95% CI, 90%-100%) and a specificity of 100% (99%-100%) for standard CTA and a sensitivity of 98% (95% CI, 94%-100%) and a specificity of 100% (95% CI, 100%-100%) for timing-invariant CTA. For proximal large-vessel occlusions, defined as occlusions of the ICA, basilar artery, and M1, the sensitivity and specificity were 100% (95% CI, 100%-100%) for both techniques. Interrater agreement was good for both techniques (mean κ value, 0.75 and 0.76). CONCLUSIONS: Timing-invariant CTA derived from CTP data provides diagnostic accuracy similar to that of standard CTA for the detection of artery occlusions in acute stroke.

Predictors of reperfusion in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Ischemic stroke studies emphasize a difference between reperfusion and recanalization, but predictors of reperfusion have not been elucidated. The aim of this study was to evaluate the relationship between reperfusion and recanalization and identify predictors of reperfusion. MATERIALS AND METHODS: From the Dutch Acute Stroke Study, 178 patients were selected with an MCA territory deficit on admission CTP and day 3 follow-up CTP and CTA. Reperfusion was evaluated on CTP, and recanalization on CTA, follow-up imaging. Reperfusion percentages were calculated in patients with and without recanalization. Patient admission and treatment characteristics and admission CT imaging parameters were collected. Their association with complete reperfusion was analyzed by using univariate and multivariate logistic regression. RESULTS: Sixty percent of patients with complete recanalization showed complete reperfusion (relative risk, 2.60; 95% CI, 1.63-4.13). Approximately one-third of patients showed some discrepancy between recanalization and reperfusion status. Lower NIHSS score (OR, 1.06; 95% CI, 1.01-1.11), smaller infarct core size (OR, 3.11; 95% CI, 1.46-6.66; and OR, 2.40; 95% CI, 1.14-5.02), smaller total ischemic area (OR, 4.20; 95% CI, 1.91-9.22; and OR, 2.35; 95% CI, 1.12-4.91), lower clot burden (OR, 1.35; 95% CI, 1.14-1.58), distal thrombus location (OR, 3.02; 95% CI, 1.76-5.20), and good collateral score (OR, 2.84; 95% CI, 1.34-6.02) significantly increased the odds of complete reperfusion. In multivariate analysis, only total ischemic area (OR, 6.12; 95% CI, 2.69-13.93; and OR, 1.91; 95% CI, 0.91-4.02) was an independent predictor of complete reperfusion. CONCLUSIONS: Recanalization and reperfusion are strongly associated but not always equivalent in ischemic stroke. A smaller total ischemic area is the only independent predictor of complete reperfusion.

What Does Big Data Mean for Wearable Sensor Systems? Contribution of the IMIA Wearable Sensors in Healthcare WG.

OBJECTIVES: The aim of this paper is to discuss how recent developments in the field of big data may potentially impact the future use of wearable sensor systems in healthcare. METHODS: The article draws on the scientific literature to support the opinions presented by the IMIA Wearable Sensors in Healthcare Working Group. RESULTS: The following is discussed: the potential for wearable sensors to generate big data; how complementary technologies, such as a smartphone, will augment the concept of a wearable sensor and alter the nature of the monitoring data created; how standards would enable sharing of data and advance scientific progress. Importantly, attention is drawn to statistical inference problems for which big datasets provide little assistance, or may hinder the identification of a useful solution. Finally, a discussion is presented on risks to privacy and possible negative consequences arising from intensive wearable sensor monitoring. CONCLUSIONS: Wearable sensors systems have the potential to generate datasets which are currently beyond our capabilities to easily organize and interpret. In order to successfully utilize wearable sensor data to infer wellbeing, and enable proactive health management, standards and ontologies must be developed which allow for data to be shared between research groups and between commercial systems, promoting the integration of these data into health information systems. However, policy and regulation will be required to ensure that the detailed nature of wearable sensor data is not misused to invade privacies or prejudice against individuals.

Classification of exacerbation episodes in chronic obstructive pulmonary disease patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive disease affecting the airways, which constitutes a major cause of chronic morbidity and a significant economic and social burden throughout the world. Despite the fact that in COPD patients exacerbations are common acute events causing significant and often fatal worsening of symptoms, an accurate prognostication continues to be difficult. OBJECTIVES: To build computational models capable of distinguishing between normal life days from exacerbation days in COPD patients, based on physical activity measured by accelerometers. METHODS: We recruited 58 patients suffering from COPD and measured their physical activity with accelerometers for 10 days or more, from August 2009 to March 2010. During this period we recorded six exacerbation episodes in the patients, accounting for 37 days. We were able to analyse data for 52 patients (369 patient days), and extracted three distinct sets of features from the data, one set of basic features such as average, one set based on the frequency domain and the last exploring the cross-information among sensors pairs. These were used by three machine-learning techniques (logarithmic regression, neural networks, support vector machines) to distinguish days with exacerbation events from normal days. RESULTS: The support vector machine classifier achieved an AUC of 90% ± 9, when supplied with a set of features resulting from sequential feature selection method. Neu- ral networks achieved an AUC of 83% ± 16 and the logarithmic regression an AUC of 67% ± 15. CONCLUSIONS: None of the individual feature sets provided robust for reasonable classification of PA recording days. Our results indicate that this approach has the potential to extract useful information for, but are not robust enough for medical application of the system.

Predictive value of thrombus attenuation on thin-slice non-contrast CT for persistent occlusion after intravenous thrombolysis.

BACKGROUND: In stroke erythrocyte-rich thrombi are more sensitive to intravenous thrombolysis with recombinant tissue plasminogen activator (IV-rtPA) and have higher density on non-contrast CT (NCCT). We investigated the relationship between thrombus density and recanalization and whether persistent occlusions can be predicted by Hounsfield unit (HU) measurements. METHODS: In 88 IV-rtPA-treated patients with intracranial ICA or MCA occluding thrombus and follow-up imaging, thrombus and contralateral vessel attenuation measurements were performed on thin-slice NCCT. Mean absolute and relative HU were compared between patients with persistent occlusion (modified Thrombolysis in Cerebral Infarction system, grade 0/1/2a) and recanalization (grade 2b/3). Univariate and multivariate (adjusted for stroke subtype, clot burden score, occlusion site and time to thrombolysis) odds ratios for persistent occlusion were calculated. Additional prognostic value for persistent occlusion was estimated by adding HU measurements to the area under the curve (AUC) of known determinants and calculating optimal cut-off values. RESULTS: Patients with persistent occlusion (n = 19) had significant lower mean HU (absolute 52.2 ± 9.5, relative 1.29 ± 0.20) compared to recanalization (absolute 63.1 ± 10.7, relative 1.54 ± 0.23, both p < 0.0001). Odds ratios for persistent occlusion were 3.1 (95% confidence interval, CI 1.6-6.0) univariate and 3.1 (95% CI 1.7-5.7) multivariate per 10 absolute HU decrease and 3.2 (95% CI 1.6-6.5) univariate and 4.1 (95% CI 1.8-9.1) multivariate per 0.20 relative HU decrease. Attenuation measurements significantly increased the AUC (0.67) of the known determinants to 0.84 (absolute HU) and 0.86 (relative HU). Cut-off values of <56.5 absolute HU and <1.38 relative HU showed optimal predictive values for persistent occlusion. CONCLUSIONS: Thrombus density is related to recanalization rate. Lower absolute and relative HU are independently related to persistent occlusion and HU measurements significantly increase discriminative performances of known recanalization determinants.

The effect of pH and nitrite concentration on the antimicrobial impact of celery juice concentrate compared with conventional sodium nitrite on Listeria monocytogenes.

The objectives of this study were to evaluate the impact of pH and nitrite from celery juice concentrate (CJ) on the growth of Listeria monocytogenes in broth and on ham slices, and to evaluate the impact of pH and nitrite from CJ on quality attributes of the ham. The pH of both broth and ham were increased by the addition of CJ. The CJ was less effective than conventional nitrite at 100 mg/kg nitrite in broth, but in ham, the CJ treatments at both 100 and 200 mg/kg resulted in growth of L. monocytogenes (p>0.05) similar to that of the conventional nitrite at the same concentrations. Reducing the pH of CJ before addition to the ham had greater impact on L. monocytogenes growth at 200 mg/kg nitrite than at 100 mg/kg. Celery juice concentrate may increase meat product pH which could have implications for the antimicrobial impact of nitrite in some products.

Relationship between thrombus attenuation and different stroke subtypes.

INTRODUCTION: More insights in the etiopathogenesis of thrombi could be helpful in the treatment of patients with acute ischemic stroke. The aim of our study was to determine the relationship between presence of a hyperdense vessel sign and thrombus density with different stroke subtypes. METHODS: We included 123 patients with acute ischemic anterior circulation stroke and a visible occlusion on CT-angiography caused by cardioembolism (n = 53), large artery atherosclerosis (n = 55), or dissection (n = 15). Presence or absence of a hyperdense vessel sign was assessed and thrombus density was measured in Hounsfield Units (HU) on non-contrast 1 mm thin slices CT. Subsequently, occurrence of hyperdense vessel sign and thrombus density (absolute HU and rHU (=HU thrombus/HU contralateral)) were related with stroke subtypes. RESULTS: The presence of hyperdense vessel signs differed significantly among subtypes and was found in 45, 64 and 93 % of patients with cardioembolism, large artery atherosclerosis and dissection, respectively (p = 0.003). The mean HU and rHU (+95 % CI) of the thrombi in all vessels were respectively 56.1 (53.2-59.0) and 1.39 (1.33-1.45) in cardioembolism, 64.6 (62.2-66.9) and 1.59 (1.54-1.64) in large artery atherosclerosis and 76.4 (73.0-79.8) and 1.88 (1.79-1.97) in dissection (p < 0.0001). We found the same significant ranking order in the density of thrombi with hyperdense vessel signs (mean HU and rHU (+95 % CI), respectively): cardioembolism 61.3 (57.4-65.3) and 1.49 (57.4-65.3); large artery atherosclerosis 67.3 (64.9-69.7) and 1.65 (1.58-1.71); dissection 76.4 (72.6-80.1) and 1.89 (1.79-1.99, p < 0.0001). CONCLUSION: Presence of a hyperdense vessel sign and thrombus density are related to stroke subtype.

[Multimorbidity and successful aging: the population-based KORA-Age study]. / Multimorbidität und erfolgreiches Altern: Ein Blick auf die Bevölkerung im Rahmen der KORA-Age-Studie.

BACKGROUND: The objective of the KORA-Age research consortium is to assess the determinants and consequences of multimorbidity in the elderly and to look into reasons for successful aging in the general public. PATIENTS AND METHODS: In the KORA-Age cohort study 9,197 persons were included who where born in the year 1943 or before and participants of previous KORA cohort studies conducted between 1984 and 2001 (KORA: Cooperative Health Research in the Region of Augsburg). The randomized intervention study KORINNA (Coronary infarct follow-up treatment in the elderly) tested a nurse-based case management program with 338 patients with myocardial infarct and included an evaluation in health economics. RESULTS: A total of 2,734 deaths were registered, 4,565 participants submitted a postal health status questionnaire and 4,127 participants were interviewed by telephone (response 76.2% and 68.9% respectively). A gender and age-stratified random sample of the cohort consisting of 1,079 persons took part in a physical examination (response 53.8%). CONCLUSION: The KORA-Age consortium was able to collect data in a large population-based sample and is contributing to the understanding of multimorbidity and successful aging.

Right middle lobe torsion: evaluation with CT angiography.

A case of right middle lobe torsion occurring after a right upper lobectomy is described. HR-CT angiography was successful in identifying the obstructed right middle lobe bronchus and the avascular nature of the infected and displaced right middle lobe. This detailed information, obtainable from present day multislice HR-CT scanners with the right CT protocols, seems to diminish the need for further confirmation by other methods.

Informatics and medicine--from molecules to populations.

OBJECTIVES: To clarify challenges and research topics for informatics in health and to describe new approaches for interdisciplinary collaboration and education. METHODS: Research challenges and possible solutions were elaborated by scientists of two universities using an interdisciplinary approach, in a series of meetings over several months. RESULTS AND CONCLUSION: In order to translate scientific results from bench to bedside and further into an evidence-based and efficient health system, intensive collaboration is needed between experts from medicine, biology, informatics, engineering, public health, as well as social and economic sciences. Research challenges can be attributed to four areas: bioinformatics and systems biology, biomedical engineering and informatics, health informatics and individual healthcare, and public health informatics. In order to bridge existing gaps between different disciplines and cultures, we suggest focusing on interdisciplinary education, taking an integrative approach and starting interdisciplinary practice at early stages of education.

Establishing an international reference image database for research and development in medical image processing.

INTRODUCTION: The lack of comparability of evaluation results is one of the major obstacles of research and development in Medical Image Processing (MIP). The main reason for that is the usage of different image datasets with different quality, size and Gold standard. OBJECTIVES: Therefore, one of the goals of the Working Group on Medical Image Processing of the European Federation for Medical Informatics (EFMI WG MIP) is to develop first parts of a Reference Image Database. METHODS: Kernel of the concept is to identify highly relevant medical problems with significant potential for improvement by MIP, and then to provide respective reference datasets. The EFMI WG MIP has primarily the role of a specifying group and an information broker, while the provider user relationships are defined by bilateral co-operation or license agreements. RESULTS: An explorative database prototype has been implemented using the MySQL database software on the Web. Templates for provider user agreements have been worked out and already applied for own 'pre-RID-MIP' co-operations of the authors. DISCUSSION AND CONCLUSION: First steps towards a comprehensive reference image database have been done. Issues like funding, motivation, management, provision of Gold standards and evaluation guidelines are to be solved. Due to the interest from research groups and industry the efforts will be continued.

[Current prescription practice of CSE inhibitors at clinic discharge after acute myocardial infarct]. / Aktuelle Verordnungspraxis von CSE-Hemmern bei Entlassung aus der Klinik nach akutem Myokardinfarkt.

We investigated the use of statins in clinical practice in patients with acute myocardial infarction in Germany in 17,732 consecutively included patients of the registries MIR-1 and MITRA-1. A clinical follow-up has been performed in the MITRA-1 study after a mean period of 18 months. In total 30% of all patients with acute myocardial infarction received statins at discharge. From 1994 to 1998 the use of statins increased from 6% to 44%; however in 1998 still less than half of the patients with acute myocardial infarction received statins at discharge. In a logistic regression model, concomittant diseases as renal failure (OR 0.7), heart failure (OR 0.7) and diabetes mellitus (OR 0.9) were associated with a lower use of statins. Age > 70 years (OR 0.5) was also associated with a lower use of statins at hospital discharge. Patients with statins at discharge had a lower long-term mortality of 5.8% versus 12.9% in patients without statins. After adjustment to age and comorbidity, use of statins at discharge was associated with a borderline significant reduction of long-term mortality (multivariate OR 0.7, 95% CI 0.4-1.0). In a subgroup analysis of therapeutic benefit, measured by the "number needed to treat" (NNT), the number of patients to treat with statins to save one life, patients with cardiovascular risk factors, as heart failure (NNT 7.5), diabetes mellitus (NNT 7.8) and age > 70 years (NNT 13.8) had a larger therapeutic benefit as patients without these risk factors (NNT 345). However, these high-risk patients received less often statins than patients without risk factors (use of statins 11.8% versus 19.8%).

Learning tumor diagnostics and medical image processing via the WWW--the case-based radiological textbook ODITEB.

New Internet technologies offer excellent chances to build high-quality on-line learning media for the education in medicine. Especially, the teaching of diagnostics with medical imaging as well as medical image processing can be supported by the excellent visualization and interaction capabilities. In cooperation with three radiological departments at German universities in Munich, Erlangen and Würzburg, the case-based open distributed Internet text book (ODITEB) for tumor diagnosis of the GI-tract, liver, pancreas and thorax has been developed at the Institut für Medizinische Statistik und Epidemiologie (IMSE) of the Technische Universität München. It offers a big collection of clinical tumor cases located on servers at the provider sites Munich, Erlangen and Würzburg, visualization and interaction similar to a real CT or MRI console, original DICOM data, X-rays and endoscopic and endosonographic videos, and expert-guided tours through the cases. In a first evaluation in summer 1998, 32 medical students graded the application with 1.9 ('good') on a scale from 1 ('very good') to 5 ('very bad'). The textbook supports German language, an English version is in preparation. In a second part, it contains lessons in medical image processing for students of medical informatics. An ODITEB release 2 with several improvements will be finished until February 2000. The use of the textbook is free of cost.

Effect of variation in the common "a" determinant on the antigenicity of hepatitis B surface antigen.

Antibody to the common "a" determinant of hepatitis B surface antigen (HBsAg) protects against infection with hepatitis B virus. A number of variant surface antigens with amino acid substitutions within the "a" determinant have been described in patients around the world. Both wild type and variant HBsAgs were expressed in the yeast Pichia pastoris and the antigens were semi-purified and quantitated. The effect on antigenicity of these changes was investigated in a quantitative fashion using four monoclonal antibodies known to bind to different epitopes within the common "a" determinant. The results suggest that amino acid substitution of T131I, K141E and G145R and insertion of 3 amino acids between residues 123 and 124 markedly affect the antigenic structure of HBsAg. These substitutions and insertions in the viral envelope may lead to evasion of the virus neutralizing antibody response and also to reduce efficiency of detection by immunoassays used for diagnosis and blood-bank screening.

The teleconsultation service ENDOTEL. Implementation and first experiences.

The multimedia teleconsultation service ENDOTEL launches in May 2000 with its asynchronous component. In the initial phase, three hospitals and four general practitioners use the service to consult a specialist in the domain of gastroenterology and endoscopy. By validation of the patient information, i.e. videos, voice clips, still images and text, the experts can decide the further proceeding, for example, whether a patient shall be transported to a specialized hospital or not (cost-saving). We report about the experiences during the initiation and the first months of operation.