[Internet-based self-management interventions : Quality criteria for their use in prevention and treatment of mental disorders]. / Internetbasierte Selbstmanagementinterventionen : Qualitätskriterien für ihren Einsatz in Prävention und Behandlung psychischer Störungen.

BACKGROUND: Internet-based self-management interventions are effective in the prevention and treatment of mental disorders; however, for those affected as well as treating clinicians and decision makers in the healthcare sector, it is difficult to identify safe and effective interventions. AIM: Development of quality criteria for self-management interventions. METHODS: Based on a non-specific assessment matrix, a task force from two scientific societies formulated specific quality criteria for self-management interventions for mental disorders. Patients and other relevant stakeholders were involved in the process. RESULTS: A total of 8 key criteria with 17 subordinate points were developed. These must be met for the certification of an intervention. The criteria focus on therapeutic quality requirements, patient safety, data protection and security as well as proof of efficacy in at least one randomized study. A further five criteria are only descriptive and are not required for certification. DISCUSSION: These quality criteria serve as a starting point for the establishment of a certification process. This could help to make internet-based self-management interventions for mental disorders part of routine care in the German healthcare system.

Assessment of cellular adequacy of fine needle aspiration biopsy for small solid renal tumors.

OBJECTIVE: Our aim was to evaluate the performance of fine needle aspiration (FNA) as a method for obtaining cellular material for the tissue diagnosis of small solid renal tumours. METHODS: Fifty-five patients with a small solid renal tumour (4 cm or smaller) underwent a FNA biopsy under computed tomography guidance. Direct smears and rinse of needle with Cytolyt® were prepared. The cellular adequacy was divided into three groups: satisfactory cellular material, scant cellular material and noncellular material. RESULTS: Postoperative pathological diagnosis showed 35 clear cell carcinomas, 10 papillary carcinomas, four chromophobe carcinomas, four oncocytomas, one adenoma and one metastatic carcinoma. A total of 21 (38.2%) FNA biopsies belonged to noncellular group. For clear cell carcinomas, the cellularity of satisfactory cellular group, scant cellular group and noncellular group was, respectively, seven (20.0%), nine (25.7%) and 19 (54.3%). Of the 10 papillary carcinomas, nine (90%) and all four chromophobe carcinomas (100%) had satisfactory cellular materials. The percentages of noncellular group among clear cell carcinoma, papillary carcinoma and chromophobe carcinoma were significantly different (P = 0.0020). Fifteen tumours were 2 cm or smaller and 40 tumours were larger than 2 cm. No significant difference was found in the percentage of noncellular material for the tumours 2 cm or less (40.0%) and for the tumours larger than 2 cm (37.5%; P > 0.05). CONCLUSIONS: The cellularity of FNA biopsy of small solid renal masses might correlate with the subtype of renal cancers. FNA biopsy was an effective method of tissue sampling for papillary and chromophobe renal carcinomas.

Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills?

BACKGROUND: Most original studies and all meta-analyses conducted to date converge on the conclusion that patients with schizophrenia display rather generalized neurocognitive deficits. For the present study, we reopen this seemingly closed chapter and examine whether important influences, such as lack of motivation and negative attitudes towards cognitive assessment, result in poorer secondary neuropsychological performance. METHOD: A sample of 50 patients with an established diagnosis of schizophrenia were tested for routine neurocognitive assessment and compared to 60 nonclinical volunteers. Before and after the assessment, subjective momentary influences were examined (e.g. motivation, concerns about assessment, fear about poor outcome) for their impact on performance using a new questionnaire called the Momentary Influences, Attitudes and Motivation Impact (MIAMI) on Cognitive Performance Scale. RESULTS: As expected, patients performed significantly worse than controls on all neurocognitive domains tested (large effect size, on average). However, patients also displayed more subjective momentary impairment, as well as more fears about the outcome and less motivation than controls. Mediation analyses indicated that these influences contributed to (secondary) poorer neurocognitive performance. Differences in neurocognitive scores shrank to a medium effect size, on average, when MIAMI scores were accounted for. CONCLUSIONS: The data argue that performance on measures of neurocognition in schizophrenia are to a considerable extent due to secondary factors. Poor motivation, fears and momentary impairments distinguished patients from controls and these variables heavily impacted performance. Before concluding that neurocognitive deficits in psychiatric patients are present, clinicians should take these confounding influences into account. Although patients with schizophrenia achieved, on average, worse test scores than controls, a large subgroup displayed spared performance.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]. / Internetbasierte Interventionen in der Behandlung psychischer Störungen : Überblick, Qualitätskriterien, Perspektiven.

BACKGROUND: Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available. OBJECTIVE: The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions. METHODS: A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications. RESULTS: Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders. DISCUSSION: When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

Intraoperative Near-Infrared Fluorescence Imaging using indocyanine green in colorectal carcinomatosis surgery: Proof of concept.

PURPOSES: This study assesses the value of using Intraoperative Near Infrared Fluorescence Imaging and Indocyanine green to detect colorectal carcinomatosis during oncological surgery. In colorectal carcinomatosis cancer, two of the most important prognostic factors are completeness of staging and completeness of cytoreductive surgery. Presently, intraoperative assessment of tumoral margins relies on palpation and visual inspection. The recent introduction of Near Infrared fluorescence image guidance provides new opportunities for surgical roles, particularly in cancer surgery. METHODS: The study was a non-randomized, monocentric, pilot "ex vivo" blinded clinical trial validated by the ethical committee of University Hospital of Saint Etienne. Ten patients with colorectal carcinomatosis cancer scheduled for cytoreductive surgery were included. Patients received 0.25 mg/kg of Indocyanine green intravenously 24 h before surgery. A Near Infrared camera was used to detect "ex-vivo" fluorescent lesions. RESULTS: There was no surgical mortality. Each analysis was done blindly. In a total of 88 lesions analyzed, 58 were classified by a pathologist as cancerous and 30 as non-cancerous. Among the 58 cancerous lesions, 42 were correctly classified by the Intraoperative Near-Infrared camera (sensitivity of 72.4%). Among the 30 non-cancerous lesions, 18 were correctly classified by the Intraoperative Near-Infrared camera (specificity of 60.0%). CONCLUSIONS: Near Infrared fluorescence imaging is a promising technique for intraoperative tumor identification. It could help the surgeon to determine resection margins and reduce the risk of locoregional recurrence.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of obsessive-compulsive disorder : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung der Zwangsstörung : Normative Personalbedarfsermittlung.

BACKGROUND: Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV). OBJECTIVES: The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV. METHODS: Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care). RESULTS: The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV). CONCLUSIONS: The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.

A Psychometric Evaluation of the German Version of the Quick Inventory of Depressive Symptomatology (QIDS-SR16) in Outpatients with Depression.

BACKGROUND: The self-rated, 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16) is a well-established measure of depression severity. This study aimed to evaluate the psychometric properties of the German translation of the QIDS-SR16. METHODS: 332 depressed German adults awaiting psychotherapy were assessed with the German translations of the QIDS-SR16, the Beck Depression Inventory (BDI-II) and the 24-item Hamilton Rating Scale for Depression (HRSD-24). RESULTS: Internal consistency for the QIDS-SR16 was acceptable (Cronbach's alpha = .77). Corrected item-total correlations indicated adequate discriminatory power of all the items. The QIDS-SR16 highly correlated with the BDI-II (r = .810) but only moderately correlated with the HRSD-24 (r = .581). Regarding discriminant validity, the QIDS-SR16 discriminated between patients with and without a depressive episode but not between patients with and without panic disorder. CONCLUSION: The German translation of the QIDS-SR16 has adequate psychometric properties. Our results support the usefulness of the German version of the QIDS-SR16 as a brief depression rating scale in clinical and research settings.

[Resource use and financing of guideline-adherent psychotherapeutic inpatient care]. / Aufwand und Finanzierung leitliniengerechter, psychotherapeutischer Behandlung im Krankenhaus.

BACKGROUND: The financing of psychiatric psychotherapeutic care in Germany is determined by the German psychiatric staffing regulations which are unchanged since 1991. Psychotherapy was established after 1991 as an effective and indispensable treatment of mental and behavioral disorders. AIMS AND OBJECTIVES: The aim of this study was to empirically investigate the use of psychiatrists' and psychologists' working time for psychotherapy in guideline-adherent hospital care. A further aim was to compare these results to the resources defined by the German psychiatric staffing regulations and in the new prospective payment system for psychiatry and psychosomatics in Germany. MATERIAL AND METHODS: University hospitals for psychiatry and psychotherapy were asked to retrospectively provide data of patients for which guideline-adherent care was possible. Participating institutions provided both data describing the staff time utilization of psychotherapeutic services provided by psychiatrists and psychologists and patient classifications according to the German psychiatric staffing regulations and the new prospective payment system for psychiatry and psychosomatics. RESULTS: Resources defined by the German psychiatric staffing regulations covered a mean of only 71 min of psychotherapy per patient and week while the actual mean intensity of psychotherapeutic care provided by the participating hospitals was 194 min per patient and week. The associated use of staff time was 102 min per patient and week. Both figures increased during an inpatient episode. The resources defined by the German psychiatric staffing regulations covered only 70 % of medical and psychological personnel. The current configuration of the new prospective payment system for psychiatry and psychosomatics covered only 59 % of staff time. CONCLUSION: The results of this study provide another unambiguous recommendation to adjust the out-dated German psychiatric staffing regulations to the current evidence and S3 guidelines for psychiatric psychotherapeutic hospital care. In particular, more resources are required for the provision of psychotherapeutic care.

[Atypical genesis of anterior ischemic optic neuropathy]. / Atypische Genese einer anterioren ischämischen Optikusneuropathie.

BACKGROUND: This article presents a case of arteritic anterior ischemic optic neuropathy as a manifestation of granulomatosis with polyangiitis (GPA). CASE REPORT: A 52-year-old woman suffered acute unilateral vision loss. Besides a unilateral papillary edema, serological investigations revealed elevated inflammation parameters with a positive (cytoplasmic) anti-neutrophil cytoplasmic autoantibodies (c-ANCA) titer. In addition to the occurrence of pulmonary nodules and cavitary lesions this is indicative for the diagnosis of GPA. RESULTS: Treatment with cyclophosphamide and prednisolone led to a rapid regression of inflammation parameters but no visual improvement occurred.

Aluminum content of human semen: implications for semen quality.

A deterioration of human semen quality has been observed over recent decades. A possible explanation could be an increased exposure to environmental pollutants, including aluminum. Our aim was to measure the aluminum concentration in the semen of 62 patients and to carry out a preliminary evaluation on its impact on specific semen parameters. For each patient, semen analyses were performed according to WHO guidelines. A graphite furnace atomic absorption spectrometry method was used to determine semen aluminum concentration. A cytological analysis using an aluminum-specific fluor, lumogallion, was also performed. The mean aluminum concentration in human semen was 339 µg/L. Patients with oligozoospermia had a statistically higher aluminum concentration than others. No significant difference was observed for other semen parameters. Cytological analysis showed the presence of aluminum in spermatozoa. This study provided unequivocal evidence of high concentrations of aluminum in human semen and suggested possible implications for spermatogenesis and sperm count.

Dyscalculia, dysgraphia, and left-right confusion from a left posterior peri-insular infarct.

The Gerstmann syndrome of dyscalculia, dysgraphia, left-right confusion, and finger agnosia is generally attributed to lesions near the angular gyrus of the dominant hemisphere. A 68-year-old right-handed woman presented with sudden difficulty completing a Sudoku grid and was found to have dyscalculia, dysgraphia, and left-right confusion. Magnetic resonance imaging (MRI) showed a focus of abnormal reduced diffusivity in the left posterior insula and temporoparietal operculum consistent with acute infarct. Gerstmann syndrome from an insular or peri-insular lesion has not been described in the literature previously. Pathological and functional imaging studies show connections between left posterior insular region and inferior parietal lobe. We postulate that the insula and operculum lesion disrupted key functional networks resulting in a pseudoparietal presentation.

Is the severity of knee osteoarthritis on magnetic resonance imaging associated with outcome of exercise therapy?

OBJECTIVE: To evaluate associations between severity of knee osteoarthritis (OA) on magnetic resonance imaging (MRI) and treatment outcomes in knee OA patients treated with exercise therapy in an exploratory study. METHODS: Ninety-five participants with knee OA in a 12-week exercise program had obtained 3.0T MRI scans of the knee joint prior to treatment. MRI data were systematically assessed for OA severity of multiple features (cartilage integrity, bone marrow lesions, osteophyte formation, effusion/synovitis, and meniscal abnormalities) according to the Boston Leeds Osteoarthritis Knee Score method. Regression analyses were performed to analyze associations between OA severity on MRI (for the tibiofemoral and patellofemoral [PF] compartments) and outcome of exercise therapy, i.e., changes in activity limitations (Western Ontario and McMaster Universities Osteoarthritis Index physical function; primary outcome), pain and upper leg muscle strength, and treatment response (Outcome Measures in Rheumatology/Osteoarthritis Research Society International criteria). RESULTS: Improvements of 24%, 34%, and 21% on average in activity limitations, pain, and muscle strength, respectively, after 12-week exercise therapy were found (P < 0.001). Severity of abnormalities in PF cartilage integrity was significantly associated with fewer improvements in both activity limitations (P = 0.01) and muscle strength (P = 0.04). Severity of PF osteophyte formation was significantly associated with fewer improvements in muscle strength (P < 0.01). All other features on MRI were not associated with treatment outcome. CONCLUSION: Effectiveness of exercise therapy seems to be independent of OA severity on MRI, except for abnormalities in cartilage integrity and osteophyte formation, both in the PF compartment. Our study suggests that all grades of OA severity on MRI can benefit from professionally supervised exercise therapy, although the effects might be reduced in patients with advanced PF OA.

[Ocular cicatricial pemphigoid - state of the art in clinic and therapy for a problematic disease]. / Das okuläre vernarbende Pemphigoid - aktuelle Aspekte zu Klinik und Therapie einer problematischen Erkrankung.

The ocular cicatricial pemphigoid (OCP) belongs to a family of chronically progressive autoimmune disorders, predominantly affecting mucous membranes (mucous membrane pemphigoids). It is an immunopathologically heterogeneous group of disorders with variable phenotypes that share the unique feature of a subepidermal blistering, through disruption of the adhesion between epidermis and dermis. A key feature is the chronically active inflammation with consecutive fibrosis, leading to a partial or complete loss of function of the affected organ. The ocular disease as a chronic cicatrising conjunctivitis is a common manifestation of the mucous membrane pemphigoid. The identification of the subtle pathology and the prompt initiation of an appropriate therapy are of pivotal importance. One purpose is to prevent further vision loss due to extensive corneal scarring and life-threatening systemic complications, such as the formation of oesophageal or tracheal strictures. So far there are no prospective, randomised studies, regarding the therapy guidelines with an evidence level more than III. The autoimmune nature of the disease implies that systemic immunosuppression is the only effective treatment option, most notably in extended stages. The aim of our study is to give a guideline for a stage adjusted therapy with conventional immunosuppressants and to give a perspective for alternative therapies, especially for recalcitrant disease.

The association between reduced knee joint proprioception and medial meniscal abnormalities using MRI in knee osteoarthritis: results from the Amsterdam osteoarthritis cohort.

BACKGROUND: Osteoarthritis (OA) of the knee is characterized by pain and activity limitations. In knee OA, proprioceptive accuracy is reduced and might be associated with pain and activity limitations. Although causes of reduced proprioceptive accuracy are divergent, medial meniscal abnormalities, which are highly prevalent in knee OA, have been suggested to play an important role. No study has focussed on the association between proprioceptive accuracy and meniscal abnormalities in knee OA. OBJECTIVE: To explore the association between reduced proprioceptive accuracy and medial meniscal abnormalities in a clinical sample of knee OA subjects. METHODS: Cross-sectional study in 105 subjects with knee OA. Knee proprioceptive accuracy was assessed by determining the joint motion detection threshold in the knee extension direction. The knee was imaged with a 3.0 T magnetic resonance (MR) scanner. Number of regions with medial meniscal abnormalities and the extent of abnormality in the anterior and posterior horn and body were scored according to the Boston-Leeds Osteoarthritis Knee Score (BLOKS) method. Multiple regression analyzes were used to examine whether reduced proprioceptive accuracy was associated with medial meniscal abnormalities in knee OA subjects. RESULTS: Mean proprioceptive accuracy was 2.9° ± 1.9°. Magnetic resonance imaging (MRI)-detected medial meniscal abnormalities were found in the anterior horn (78%), body (80%) and posterior horn (90%). Reduced proprioceptive accuracy was associated with both the number of regions with meniscal abnormalities (P < 0.01) and the extent of abnormality (P = 0.02). These associations were not confounded by muscle strength, joint laxity, pain, age, gender, body mass index (BMI) and duration of knee complaints. CONCLUSION: This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee OA. The study highlights the importance of meniscal abnormalities in understanding reduced proprioceptive accuracy in persons with knee OA.

Testicular biodistribution of 450 nm fluorescent latex particles after intramuscular injection in mice.

The significant expansion in the use of nanoparticles and submicron particles during the last 20 years has led to increasing concern about their potential toxicity to humans and particularly their impact on male fertility. Currently, an insufficient number of studies have focused on the testicular biodistribution of particles. The aim of our study was to assess the distribution of 450 nm fluorescent particles in mouse testes after intramuscular injection. To this end, testes were removed from 5 groups of 3 mice each at 1 h (H1), 4 days (D4), 21 days (D21), 45 days (D45) and 90 days (D90) after the injection of 7.28 × 109 particles in the tibialis anterior muscles of each mouse. We examined histological sections from these samples by epifluorescence microscopy and confocal microscopy and identified testicular biodistribution of a small number of particles in groups H1, D4, D21, D45 and D90. Using CD11b immunostaining, we showed that particles were not carried into the testis by macrophages. The intratesticular repartition of particles mainly followed testicular vascularization. Finally, we found some particles in seminiferous tubules but could not determine if the blood-testis barrier was crossed.

Identification by random forest method of HLA class I amino acid substitutions associated with lower survival at day 100 in unrelated donor hematopoietic cell transplantation.

The identification of important amino acid substitutions associated with low survival in hematopoietic cell transplantation (HCT) is hampered by the large number of observed substitutions compared with the small number of patients available for analysis. Random forest analysis is designed to address these limitations. We studied 2107 HCT recipients with good or intermediate risk hematological malignancies to identify HLA class I amino acid substitutions associated with reduced survival at day 100 post transplant. Random forest analysis and traditional univariate and multivariate analyses were used. Random forest analysis identified amino acid substitutions in 33 positions that were associated with reduced 100 day survival, including HLA-A 9, 43, 62, 63, 76, 77, 95, 97, 114, 116, 152, 156, 166 and 167; HLA-B 97, 109, 116 and 156; and HLA-C 6, 9, 11, 14, 21, 66, 77, 80, 95, 97, 99, 116, 156, 163 and 173. In all 13 had been previously reported by other investigators using classical biostatistical approaches. Using the same data set, traditional multivariate logistic regression identified only five amino acid substitutions associated with lower day 100 survival. Random forest analysis is a novel statistical methodology for analysis of HLA mismatching and outcome studies, capable of identifying important amino acid substitutions missed by other methods.

[Early in-the-bag spontaneous intraocular lens dislocation of hydrophilic acryl single piece lenses following uncomplicated phacoemulsification]. / Subluxationsserie eines hydrophilen Kunstlinsentyps nach umkomplizierter Phakoemulsifikation.

BACKGROUND: As techniques for cataract surgery have evolved, spontaneous intraocular lens (IOL) dislocation in patients with no ocular pathology arises less frequently. We present seven consecutive cases of uncomplicated cataract surgery with early in-the-bag spontaneous intraocular lens dislocation for which the same type of hydrophilic single piece lens was used. MATERIAL AND METHODS: A retrospective analysis was conducted on seven cases involving patients with IOL dislocation who underwent uncomplicated cataract surgery within a period of 4 months (October 2010 to January 2011) using the same type of single piece IOL. The median age of the 7 patients was 73 years and IOL repositioning was performed after an average of 10 weeks. RESULTS: Sulcus repositioning could be carried out in only five of the seven patients and IOL repositioning within the capsule was achieved in one patient. A second patient exhibited IOL dislocation after yttrium aluminium garnet (YAG) laser capsulotomy. Explantation of the IOL and sulcus implantation of another IOL type (Acrysof MA50 MB) was necessary for a third patient. A fourth case presented an angled IOL haptic and dislocation of the IOL in the sulcus position. DISCUSSION: Even after uncomplicated cataract surgery, spontaneous in-the-bag IOL dislocation in patients with no ocular pathology may occur due to a hydrophilic lens material which induces stronger anterior capsular phimosis (ACP) in comparison to alternative materials. In combination with a thin lens design this may result in angled IOL haptics and IOL dislocation. CONCLUSIONS: Careful selection of suitable lens design and material according to individual predisposing factors is necessary. This retrospective case study demonstrates that the combination of hydrophilic lens material and a thin lens design may result in early spontaneous IOL dislocation. Furthermore, as established in one case, YAG laser capsulotomy may induce IOL dislocation if the lens design cannot withstand capsular fibrosis.