[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.

Use of a fibrinogen-thrombin sponge in rhinoplasty.

BACKGROUND: Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial. OBJECTIVE: Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®. MATERIAL AND METHODS: In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively. RESULTS: In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections. CONCLUSION: The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

[Telescience : Feasibility studies, definition and a fair answer to the scientific brain drain]. / Telewissenschaft ­ Telescience : Machbarkeitsstudie, Definition und eine faire Antwort zum Wissenschafts-Braindrain.

BACKGROUND: What is telescience? Is it feasible to transfer academic information with the help of telematics to educate and teach young scientists over large distances? The term telescience has so far not been defined but covers a variety of possibilities, which could be successfully implemented worldwide. This article gives examples and highlights the feasibility analysis of telescience. METHODS: We have carried out feasibility analyses for neurological functional diagnostics, an epidemiological cross-sectional study as well as a laboratory study for detection of thrombocyte function during dengue fever with the help of telemedicine. The basis for all these projects was a telemedical transcontinental cooperation over a distance of 12,000 km. RESULTS: All performed studies demonstrated the feasibility. With the help of telematics the laboratory techniques, planning, conduction and interpretation of results as well as publication skills can be transferred. DISCUSSION: Telescience is feasible. Our studies showed that telescience is a very promising option to transfer knowledge, which will help to enable professional expertise to be transferred directly to the region/country without a brain drain. All too often young motivated scientists are enticed to move to well-known institutions, which involves the danger of a brain drain. Brain drain can be avoided in favor of local implementation of scientific projects. Our results illustrate that it is feasible to educate and guide scientists with the help of telematics infrastructures.

[Mission (im)possible : Setting up a neurological center 12,000 km away with telemedicine]. / "Mission (im)possible" : Aufbau eines neurologischen Zentrums 12.000 km entfernt mittels Telemedizin.

BACKGROUND: Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center. AIM: The aim of this project called to teach to treat - to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000 km. Treatment options were elucidated by teaching and taught by case examples. MATERIAL AND METHODS: The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site. RESULTS: In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed. CONCLUSION: The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.

[Therapy Goals for Children and Adolescents with ADHD and their Primary Caregivers. A Content Analysis and Examination of Agreement of ADHD Patients and their Primary Caregivers]. / Therapieziele von Kindern und Jugendlichen mit ADHS und ihren Hauptbezugspersonen. Eine inhaltsanalytische Auswertung und Prüfung der Übereinstimmung zwischen Betroffenen und Bezugspersonen.

OBJECTIVE: The aim of this study was to identify individual therapy goals (ITGs) of children and adolescents with ADHD and their primary caregivers. METHODS: Within the evaluation of the selective contract for children and adolescents with ADHD in Bremerhaven, Germany, ITGs of 42 study participants (aged 8-17) and their primary caregivers were collected with the psychotherapy basis documentation for children and adolescents (Psy-BaDo-KJ). ITGs were analysed following the classification of categories for individual therapy goals (KITZ) and their modification for children and adolescents. Analysis focused on the most frequently named ITGs and the agreement of patients and primary caregivers ITGs on the individual level. RESULTS: 235 ITGs were named. The greatest proportion of ADHD patients and their caregivers (47%) focused on interactional, psychosocial conflicts. In 19% of the cases (n=8) patients and their caregivers had the same main goal. 38% of patients and of caregivers (n=16) named the other ones main goal in one of his/her ITGs as well. CONCLUSIONS: ADHD patients and their primary caregivers both pursue ITGs related to ADHD symptoms. Few ITGs address medication related aspects. In case of differences in the ITGs of a patient and his/her primary caregivers, therapists should check whether differing ITGs address the same problem from different perspectives.

TV news and concerns about - the EHEC-outbreak 2011 in Germany.

BACKGROUND AND AIM: In the beginning of May 2011 and finally terminated on July 26th 2011 an outbreak of infections with enterohaemorrhagic Escherichia (E.) coli (EHEC) strain O104:H4 occurred in Germany. The aim of this study is to analyse whether media coverage of the outbreak influenced the number of patients presenting with diarrhoea to the emergency room of a tertiary centre and to evaluate the influence of information on perception and rating of symptoms. METHODS: Prospectively collected data in a tertiary centre on the number of patients presenting to the emergency room with diarrhea during the EHEC outbreak was correlated with retrospectively collected data about the media coverage of the outbreak on TV and compared to the number of patients that had presented with diarrhea during a comparative period in 2010. RESULTS: A total of 1,625 patients presented to our emergency room during the observation period in 2011 between May 31st and June 13th, including 72 patients (4.4%) presenting with the predominant symptom of diarrhoea, of whom six patients (0.4%) reported haemorrhagic diarrhoea. In the comparative period in 2010, between May 31st and June 13th, twelve patients (1.6%) presenting the symptom of diarrhea were treated in our emergency room. The analysis of the news reports in 2011 revealed a total of 1,150 reports broadcast in the ARD and a total of 173 reports broadcast in the regional news channel MDR between May 29th and June 11th. In 2010 not a single report regarding our search terms was broadcast in the corresponding time period. CONCLUSION: Our data suggest a clear positive correlation of the frequency of TV reports dealing with the epidemic disease outbreak and the rate of outpatient consultations in emergency rooms because of diarrhoea and could make an important contribution for future discussions.

Gastric stimulation in treatment in type 2 diabetes mellitus.

UNLABELLED: Metabolic surgery is a dynamic field providing a wide range of new techniques. The aim of our paper is to inform about gastric electrostimulation in the treatment of type 2 diabetes mellitus. Gastric electrostimulation in type 2 diabetes mellitus treatment is performed by means of implanting Tantalus system (Metacure). When triggered by food intake, the Tantalus system generates signals for the stomach to contract. Early after the food intake, thus before the stomach distends completely, the system increases spontaneous stomach contractions. Via afferent vagal signals, these increased contractions are evaluated by the central nervous system as a sign that satiety has been reached. Three pairs of electrodes connected with a stimulator are implanted laparoscopically. The system comes equipped with a battery as well. Laparoscopically implanted system of stomach electrostimulation presents a simple and easily regulated system without disturbing the integrity of gastrointestinal tract. It is a reversible system. In accord with preliminary results, Tantalus offers a safe and effective treatment of type 2 diabetes mellitus by reducing other cardiometabolical risky factors. The operation safety is comparable with that of similar minimally invasive surgical techniques. In order to improve our understanding of diabetes mellitus pathophysiology as well as of effects of gastric electrostimulation, more trials need to be performed. The surgical diabetes treatment represents an interesting chance for patients and it might become a common technique in the future (Fig. 1, Ref. 29). KEYWORDS: diabetes mellitus, obesity, gastric stimulation, pacemaker.

The role of laparoscopic Heller myotomy in the treatment of achalasia.

AIM: To evaluate the results of laparoscopic Heller myotomy in our group of patients. METHOD: A retrospective clinical trial was carried out to evaluate the indication, technique and controversies of laparoscopic Heller myotomy in the achalasia treatment. The following symptoms were evaluated prior and after Heller myotomy: dysphagia, heartburn, nausea/vomiting after meal and asthma/coughing. The patients were evaluated by the use of Likert score. Statistical analysis was performed by using Student t test. The intra-operative (operation time, intraoperative complications, blood loss, conversion rate), and peri-operative parameters (morbidity, mortality, hospital stay) were evaluated as well. The patients who underwent laparoscopic Heller myotomy were included in the trial. All patients were perioperatively managed by a multidisciplinary team. RESULTS: The evaluation of fourteen patients was performed (average age: 53.2 yrs., eleven men, two women, BMI 23.6 kg/m(2)). The patients were indicated for surgery in all of the stages (I-III). Previous semiconservative therapeutic modalities were performed in thirteen patients. The standard laparoscopic technique for Heller myotomy with semifundoplication was applied. All the observed symptoms were statistically improved after the surgery (p=0.05). The average operating time was 89 minutes. Intraoperative blood loss was below 20 ml. There was no conversion to open surgery. An average hospital stay was 4.3 days. Morbidity was 14.3 % and mortality 0 %. In one patient esophageal mucosa perforation was intra-operatively identified and sutured. Post-operative course in this patient was without any complications. CONCLUSION: The laparoscopic Heller myotomy has become the "gold standard" procedure for achalasia. It is an excellent method allowing precise operation technique with good visualization of the esophagogastric junction. The operation with this approach is safe, efficient, and with excellent reproducible operative results. The correct and early indication for surgery is crucial. The delayed diagnosis with a late indication for surgery is not an exemption (Tab. 2, Fig. 2, Ref. 36).

Induction of M2-macrophages by tumour cells and tumour growth promotion by M2-macrophages: a quid pro quo in pancreatic cancer.

INTRODUCTION: More effective therapies are required to improve survival of pancreatic cancer. Possible immunologic targets include tumour associated macrophages (TAMs), generally consisting of M1- and M2-macrophages. We have analysed the impact of TAMS on pancreatic cancer in a syngeneic orthotopic murine model. METHODS: 6606PDA murine pancreatic cancer cells were orthotopically injected into C57BL6 mice. Tumour growth was monitored using MRI. Macrophages were depleted by clodronate liposomes. Tumours including microvessel density were evaluated using immunohistochemistry, immunofluorescence and/or cytometric beads assays. Naïve macrophages were generated employing peritoneal macrophages. In vitro experiments included culturing of macrophages in tumour supernatants as well as tumour cells cultured in macrophage supernatants using arginase as well as Griess assays. RESULTS: Clodronate treatment depleted macrophages by 80% in livers (p = 0.0051) and by 60% in pancreatic tumours (p = 0.0169). MRI revealed tumour growth inhibition from 221.8 mm(3) to 92.3 mm(3) (p = 0.0216). Micro vessel densities were decreased by 44% (p = 0.0315). Yet, MCP-1-, IL-4- and IL-10-levels within pancreatic tumours were unchanged. 6606PDA culture supernatants led to a shift from naïve macrophages towards an M2-phenotype after a 36 h treatment (p < 0.0001), reducing M1-macrophages at the same time (p < 0.037). In vivo, M2-macrophages represented 85% of all TAMs (p < 0.0001). Finally, culture supernatants of M2-macrophages induced tumour growth in vitro by 63.2% (p = 0.0034). CONCLUSIONS: This quid pro quo of tumour cells and M2-macrophages could serve as a new target for future immunotherapies that interrupt tumour promoting activities of TAMs and change the iNOS-arginase balance towards their tumoricidal capacities.

[The staple line in sleeve gastrectomy]. / Staplerová linie u sleeve resekce zaludku.

INTRODUCTION: Postoperative leak and bleeding from the staple line are potentially serious early complications following laparoscopic sleeve gastrectomy. AIM: This study aims to assess the significance of oversewing the staple line after laparoscopic sleeve gastrectomy in preventing leak and bleeding in our group of patients. MATERIAL AND METHODS: Patients after laparoscopic sleeve gastrectomy were included in the trial. Two different principles of oversewing the staple line (selective vs. mandatory) were analyzed. The design of the trial was retrospective-prospective, non-randomized. Postoperative complications were recorded. RESULTS: Between October 2006 and December 2011, 638 laparoscopic sleeve gastrectomies were carried out using standard laparoscopic technique. 297 of the patients belonged to the group with selective oversewing of the staple line. The remaining 341 patients belonged to the group in which the staple line was oversewn in all cases. Both groups of patients were comparable in the basic parameters. Early postoperative leak affected one patient in both groups, 0.30% versus 0.29% (p = 0.9203), respectively. The rates of postoperative bleeding were 2.7% (selective oversewing) versus 0% (mandatory oversewing) (p = 0.0023), respectively. CONCLUSION: Our study did not demonstrate the impact of oversewing the staple line on the occurrence of postoperative leak. The rates of postoperative bleeding from the resection site were statistically significantly lower in the group with the mandatory oversewing of the staple line.

[Topical cyclosporine A 0.05% in the treatment of keratoconjunctivitis sicca]. / Ciclosporin A 0,05 % Augentropfen zur Therapie der Keratokonjunktivitis sicca.

BACKGROUND: The current understanding of the pathogenesis of dry eye disease has proceeded to recognition of inflammation as the key pathogenetic mechanism. The purpose of this study was to evaluate the effect of cyclosporine 0.05% eye drops on subjective symptoms and objective signs of patients with keratoconjunctivitis sicca. PATIENTS AND METHODS: In this clinical trial 62 patients with severe keratoconjunctivitis sicca (DEWS grade 3) were included. Over a time period of 3 months all patients received treatment with preservative-free hyaluronic acid artificial tears at one drop 5 times per day and in addition 31 patients received one drop of cyclosporine 0.05% twice daily. Screening parameters were LIPCOF, tear break-up time (BUT), fluorescein and rose bengal staining, the intraocular pressure (IOP) and the OSDI score. RESULTS: In the cyclosporine A group BUT, Jones test and OSDI score improved significantly after 3 months in contrast to the controls. Moreover the values of BUT and Jones test in the cyclosporine A group were significantly higher after 3 months compared to the healthy controls. Fluorescein and rose bengal staining improved only in the cyclosporine A group after 3 months. CONCLUSION: Anti-inflammatory therapy with cyclosporine A 0.05% eye drops as off label use significantly improves subjective symptoms and objective signs in patients with severe dry eye disease providing a good safety profile. These findings suggest a widespread use of cyclosporine A 0.05% eye drops in patients with moderate to severe keratoconjunctivitis sicca.

[Retroperitoneoscopic adrenalectomy with dorsal approach]. / Retroperitoneoskopická adrenalektomie dorzálním prístupem.

UNLABELLED: INTRODUSTION: Various surgical mininvasive approaches for adrenalectomy have been established over the last two decades. We are evaluating the retroperitoneoscopic adrenalectomy with dorsal approach. MATERIAL AND METHODS: The prospective open clinical trial was carried out to evaluate intra-operative (operations time, intraoperative complications, blood loss, conversion rate) and peri-operative parameters (morbidity, mortality, hospital stay). Patients who underwent retroperitoneoscopic adrenalectomy with dorsal approach were included in the trial. A tumor size above 12 cm or BMI higher than 35 kg/m2 were considered asexclusion criteria. All the patients were perioperatively managed by a multidisciplinary team. RESULTS: A total of 81 patients were assessed (average age: 45.7 yrs, 37 males, 44 females, BMI 27.8 kg/m2). The average operating time was 61 minutes. The intraoperative blood loss was below 20 ml. The mean hospital stay was 2.1 days. Morbidity was 2.7% and mortality 0%. CONCLUSION: Retroperitoneoscopic adrenalectomy with dorsal approach is considered a method of choice in our hospital. The use of this approach is safe, efficient, with excellent reproducible operative results and impressive patient recovery.

Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample.

BACKGROUND: Numerous longitudinal studies have identified risk factors for the onset of most eating disorders (EDs). Identifying women at highest risk within a high-risk sample would allow for focusing of preventive resources and also suggests different etiologies. METHOD: A longitudinal cohort study over 3 years in a high-risk sample of 236 college-age women randomized to the control group of a prevention trial for EDs. Potential risk factors and interactions between risk factors were assessed using the methods developed previously. Main outcome measures were time to onset of a subthreshold or full ED. RESULTS: At the 3-year follow-up, 11.2% of participants had developed a full or partial ED. Seven of 88 potential risk factors could be classified as independent risk factors, seven as proxies, and two as overlapping factors. Critical comments about eating from teacher/coach/siblings and a history of depression were the most potent risk factors. The incidence for participants with either or both of these risk factors was 34.8% (16/46) compared to 4.2% (6/144) for participants without these risk factors, with a sensitivity of 0.75 and a specificity of 0.82. CONCLUSIONS: Targeting preventive interventions at women with high weight and shape concerns, a history of critical comments about eating weight and shape, and a history of depression may reduce the risk for EDs.

Nissen versus Dor fundoplication for treatment of gastroesophageal reflux disease: a blinded randomized clinical trial.

INTRODUCTION: Fundoplication techniques for treatment of gastroesophageal reflux are discussed concerning impairments and success. This randomized trial was conducted to compare Nissen's wrap and the anterior partial technique (Dor) concerning patients' quality of life (QoL) and functional data after a mid-term follow-up. METHODS: In a 24-month period, 64 patients were equally randomized into group A (Nissen's fundoplication) and group B (180° anterior partial fundoplication). After a mean follow-up of 18 months, all patients were examined and interviewed using standardized QoL questionnaires (Gastrointestinal Quality of Life Index), Visick score, 24-hour pH-metry and esophageal manometry. Data of 57 patients (group A: 27, group B: 30) could be analyzed. RESULTS: After partial fundoplication, 9 patients (30%) stated the operative results were worse than perfect. Only 2 patients (7%) evaluated the outcome after Nissen's fundoplication as unsuccessful (p = 0.04). However, postoperative Gastrointestinal Quality of Life Index showed no differences between groups (p = 0.5). Additionally, functional data were not different (DeMeester 10 vs. 12, p = 0.17, and lower esophageal sphincter pressure 13 vs. 12 mm Hg, p = 0.5). CONCLUSION: The anterior partial fundoplication technique did not lead to disadvantages in postoperative QoL, physiological function and reflux control when compared to Nissen's approach in a mid-term follow-up.

[Inflammation of the eye in systemic inflammatory disorders: keratitis]. / Augenentzündungen bei entzündlichen Systemerkrankungen: Keratitis.

Systemic inflammatory diseases are associated with keratitis. In addition to the much less frequently occurring non-ulcerative keratitis, ulcerative inflammation of the corneal periphery is common in systemic inflammatory diseases. Significant systemic inflammatory diseases in this context are autoimmune connective tissue diseases (including rheumatoid arthritis, systemic lupus erythematosus or primary vasculitides such as polyarteritis nodosa or Wegener's granulomatosis), systemic autoimmune dermatological disorders (such as the cicatrising pemphigoid or Stevens-Johnson syndrome) and autoimmune diseases of the lacrimal system (such as the lacrimal gland involvement in primary Sjogren's syndrome or in graft-versus-host disease). In severe cases of peripheral ulcerative keratitis intensive topical therapy is initially combined with a systemic high-dose steroid therapy. In further progressing ulceration, surgery may help to preserve or restore the integrity of the eye and may suppress the autoimmune response by shielding the corneal antigens from blood and the lymphatic system. Systemic immune modulating therapy has to be done in close consultation with the rheumatologist.

[Screening questionnaire for documentation of medical history and diagnostic findings in dry eye disease]. / Erhebungsbogen zur Anamnese und Diagnostik des trockenen Auges.

Keratoconjunctivitis sicca is one of the most common ocular diseases world-wide. These patients suffer from severe symptoms which lead to an extremely reduced quality of life. Dry eye syndrome constitutes a major diagnostic and therapeutic challenge to all ophthalmologists because there is often a discrepancy between objective ocular signs and subjective symptoms of the patients. Furthermore, there exist only few causal therapeutic options. The physician-patient relationship plays an outstanding role in this condition. For the treatment of moderate to severe dry eye syndrome, special dry eye clinics have proved to be extremely useful. For follow-up measurements as well as the realisation of evidence-based medicine and quality control, it is a fundamental necessity to document symptoms, signs and therapy of these patients in order to optimise therapeutic strategies. For this purpose, we have developed special forms and standardised questionnaires for the individual documentation of medical history and diagnostic findings. To objectively assess the patient's complaints we use the "ocular surface disease index" (OSDI score). Only the establishment of standardised diagnostic and therapeutic algorithms with the help of special forms and questionnaires can help in the long run to improve the treatment of these severely affected patients.

Adaptation and evaluation of an Internet-based prevention program for eating disorders in a sample of women with subclinical eating disorder symptoms: a pilot study.

OBJECTIVE: Women reporting subclinical eating disorder (ED) symptoms are at higher risk for the development of an ED. Preventive interventions should therefore be specifically tailored for this subgroup. Accordingly, the aim of this pilot study was to test the feasibility of the adapted Internet-based prevention program "Student Bodies™" for women with subclinical ED and to obtain effect size and sample size estimates for a subsequent randomized controlled trial. METHOD: Twenty-two women with subclinical ED participated in the 8-week intervention; pre-post data are available for 12 women. Measures of ED symptoms and established risk factors, such as weight and shape concerns, were assessed at preand post-intervention. RESULTS: Completers' adherence and appraisal of the program were good. At post-intervention, completers reported significantly fewer ED symptoms and reduced weight and shape concerns. Pre-post-effect sizes ranged from medium to large. CONCLUSION: The pilot study showed the feasibility of the adapted online intervention and gave indications for its effectiveness.

Laparoscopic management of spontaneous intraperitoneal perforation of urinary bladder.

The authors present two cases of spontaneous intraperitoneal perforation of urinary bladder. The first case was a 56-year old female patient with history of urothelial cancer with partial urinary bladder resection and subsequent radiotherapy six years ago. The diagnostic laparoscopy was indicated because of the clinical signs of peritonitis. The diagnostic laparoscopy revealed a perforation of urinary bladder and the management of perforation was done laparoscopically. The histological examination of specimen revealed urothelial cancer. The postoperative course was uncomplicated and the patient underwent further oncologic treatment. The second patient was a 61-year old man admitted with abdominal pain lasting for one day after excessive alcohol intake. An indication to diagnostic laparoscopy was done according to the clinical signs of peritonitis. Also in this case, perforation of urinary bladder was identified and laparoscopic management was carried out. The postoperative course was uncomplicated. Both patients denied any trauma. The diagnosis of urinary bladder perforation was not done preoperatively. The diagnosis of spontaneous perforation of urinary bladder is difficult. The case history data with no trauma do not lead to this diagnosis. It is important to consider this diagnosis in case of acute abdomen. The treatment of urinary bladder perforation is based on the identification of the defect, lavage of the peritoneal cavity, excision of the defect, reconstruction of the bladder with intact blood supply, bladder drainage supporting the defect healing, and exclusion of malignancy. The laparoscopic treatment of spontaneous perforation according to literature is not common, however very effective (Fig. 1, Ref. 41).

[Ophthalmological complications in Sjögren's syndrome]. / Ophthalmologische Komplikationen beim Sjögren-Syndrom. Diagnostik und Therapie.

BACKGROUND: Ocular complications are typical sequels of primary and secondary Sjögren's syndrome. Since these can lead to blindness in the case of insufficient therapeutic steps, diagnostic tools and therapeutic options in Sjögren-syndrome associated ocular diseases are outlined. METHODS: Literature review from PubMed and own clinical and experimental results. RESULTS: Numerous ocular complications can occur both in primary and secondary Sjögren's syndrome. The main problems involve tear film disturbances leading to severe forms of dry eye. CONCLUSION: Early and close cooperation between rheumatologist and ophthalmologist can avoid long-term complications in patients with Sjögren's disease and ocular complications.

[Return to work following work-related orthopaedic rehabilitation: a cluster randomized trial]. / Berufliche Wiedereingliederung nach einer medizinisch-beruflich orientierten orthopädischen Rehabilitation: Eine clusterrandomisierte Studie.

BACKGROUND: Since the 1990s work-related programmes became more important in orthopaedic rehabilitation. However, in Germany orthopaedic rehabilitation initially focussed on improvements in evaluating functional capacity and on the development of appropriate modules of exercise therapy while psychosocial work demands have been less considered in the rehabilitation process so far. OBJECTIVE: Aims of the study were implementation and efficacy evaluation of an intensified multimodal work-related programme following a cognitive behavioural approach. METHODS: Participants were patients with substantial work-related problems. Included patients were randomized in groups either to the work-related programme or to the common orthopaedic rehabilitation (cluster randomization). Primary outcome was return to work. Analyses were based on post-treatment data and data after six months. RESULTS: 236 (86.8%) patients consented to participate. Questionnaires at post-treatment were completed by 155 (65.7%) persons and after six months by 169 (71.6%) persons. The medical performance evaluation given in the discharge letters documented a better performance of the intervention group (positive capacity: p=0.037; negative capacity: p=0.016). This evaluation was also reflected by the patients' evaluation at post-treatment. Participants of the intervention group reported higher work-related self-efficacy (p<0.001) and felt that they are better prepared for the time after their rehabilitation (p=0.006). After six months participants of the intervention group had a 2.4-fold higher chance (p=0.007) of returning to work, reported a better mental condition (HADS depression: p=0.014; SF-36 Mental Health Index: p=0.026) and a more salutary work-related behaviour (AVEM striving for perfection: p=0.012). Regarding physical outcomes both groups achieved moderate to high effects. CONCLUSIONS: Results of the trial confirm that an intensified work-related programme with a well-defined multimodal composition like the one presented here is able to enhance the chances of participation in working life for patients with substantial work-related problems.