Routine Treatment of Cervical Cytological Cell Changes: Diagnostic Standard, Prevention and Routine Treatment of Cervical Cytological Cell Changes - An Assessment of Primary and Secondary Prevention and Routine Treatment Data in the Context of an Anonymous Data Collection from Practicing Gynaecologists; an Academic, Non-Interventional Study

Introduction: Diagnosis and treatment of vaginal and cervical cytological cell changes are described in European and national guidelines. The aim of this data collection was to evaluate the remission rates of PAP III and PAP III D cytological findings in patients over a period of 3-4 months. Method: The current state of affairs in managing suspicious and cytological findings (PAP III, and III D) in gynecological practice was assessed in the context of a data collection survey. An evaluation over a period of 24 months was conducted on preventative measures, the occurrence and changes to normal/suspect/pathological findings and therapy management (for suspicious or pathological findings). Results: 307 female patients were included in the analysis. At the time of the survey 186 patients (60.6 %) had PAP III and 119 (38.8 %) had PAP III D findings. The spontaneous remission rate of untreated PAP III patients was 6 % and that of untreated PAP III D patients was 11 %. The remission rates of patients treated with a vaginal gel were 77 % for PAP III and 71 % for PAP III D. Conclusion: A new treatment option was used in gynecological practice on patients with PAP III and PAP III D findings between confirmation and the next follow-up with excellent success.

Pretransplant NPM1 MRD levels predict outcome after allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia

The objective was to evaluate the prognostic impact of pre-transplant minimal residual disease (MRD) as determined by real-time quantitative polymerase chain reaction in 67 adult NPM1-mutated acute myeloid leukemia patients receiving allogeneic hematopoietic stem cell transplantation (HSCT). Twenty-eight of the 67 patients had a FLT3-ITD (42%). Median age at transplantation was 54.7 years, median follow-up for survival from time of allografting was 4.9 years. At transplantation, 31 patients were in first, 20 in second complete remission (CR) and 16 had refractory disease (RD). Pre-transplant NPM1 MRD levels were measured in 39 CR patients. Overall survival (OS) for patients transplanted in CR was significantly longer as compared to patients with RD (P=0.004), irrespective of whether the patients were transplanted in first or second CR (P=0.74). There was a highly significant difference in OS after allogeneic HSCT between pre-transplant MRD-positive and MRD-negative patients (estimated 5-year OS rates of 40 vs 89% P=0.007). Multivariable analyses on time to relapse and OS revealed pre-transplant NPM1 MRD levels >1% as an independent prognostic factor for poor survival after allogeneic HSCT, whereas FLT3-ITD had no impact. Notably, outcome of patients with pre-transplant NPM1 MRD positivity >1% was as poor as that of patients transplanted with RD.

Perception of Slope and Distance in Photographs and in the Real World

We report a series of experiments in which spatial judgments of the real world were compared with equivalent judgments of photographs of the real-world scenes. In experiment 1, subjects judged the angle from the horizontal of natural slopes. Judgments of slope correlated with true slope (r=0.88) but judgments were in general overestimates. Equivalent judgments of slope in photographs again correlated with true slope (r=0.91) but judgments tended to be overestimates for small angles (6°) and underestimates for larger angles (up to 25°). In experiment 2 slope judgments were made under laboratory conditions rather than in the natural world. The slopes, which were viewed monocularly, varied from 5° – 45°, and were either plain, or textured, or included perspective information (a rectangle drawn on the surface) or had both texture and perspective. Judgments were overestimates, but the correlation with true slope was high (r=0.97). Slopes with either texture or perspective were judged more accurately than plain slopes, but combining texture and perspective information conferred no further benefit. Judgment of the angle of the same slopes in photographs produced similar results, but the degree of overestimation (closer to the vertical) was greater than for the real slopes. In experiment 3, subjects either judged the distance of landmarks ranging from 200 m to 5000 m from the observation point, or judged distance to the landmarks in photographs. In both cases subjects' judgments were well described by a power function with exponents close to one. Although there are large individual differences, subjects' judgments of slope and distance are accurate to a scale factor, and photographs yield similar judgments to real scenes.

The Generalizability of the Paediatric Developmental Passport: A Multi-Site Randomized Controlled Trial

BACKGROUND: The Pediatric Developmental Passport (passport) is an innovative tracking tool for families of children with autism spectrum disorder (ASD). It provides a mechanism for clearly communicating appropriate regional developmental services, an opportunity track progress in accessing these developmental services and a valuable summary of the developmental care received by that child for pediatrician. A qualitative study with parents and health professionals (developmental pediatricians, developmental nurses, pediatricians) lead to the design and iterative review of the passport.

OBJECTIVES: The objective of this study was to determine the general-izability and effectiveness of the passport compared to placebo in a multi-site pragmatic randomized control trial.

DESIGN/METHODS: A pragmatic multi-site randomized controlled trial was conducted with families of children between 0-6 years of age diagnosed with ASD. Families from two different models of developmental care were enrolled into the study. One site was a sub-urban developmental consultation clinic and the second site was a shared-care model between developmental pediatricians and general pediatricians in an urban resource restricted area. All families included in the study were randomized to receive the passport or placebo (blank card). Agencies providing Autism specific behaviour therapy (ABA) within each site were contacted directly to obtain accurate contact and access status of recommended developmental services. To determine passport effectivenes a pearson’s chi square test was conducted using a significant p value of <0.05.

RESULTS: Forty children with ASD were included and followed in this study. The passport proved to be significantly more effective in aiding families to contact developmental services than the placebo (blank card). A significantly larger portion of families (90.5%) with the passport contacted agencies for ABA (applied behaviour analysis) therapy compared to families with the placebo (61.9%, (p value significant at <0.05). More families with the passport tended to contact ABA in less than 2 months (48%) than the placebo group (35%), but this was not statistically significant.

CONCLUSION: The pediatric developmental passport enables families of children newly diagnosed with Autism to contact necessary behavioural services more often than those who did not receive the passport after diagnosis.

A Retrospective Review of Service Documentation by Physicians Following Families of Children Diagnosed with Autism Spectrum Disorder: Identifying Gaps in Communication

BACKGROUND: Currently very little is reported on the best way for family physicians and pediatricians to manage children diagnosed with autism spectrum disorder (ASD). There is no standard way to monitor whether families manage to access services, how long they wait for services, and what they do if services are deferred/denied. Consequently, families are often left with limited guidance and support when accessing developmental services.

OBJECTIVES: To evaluate the documentation patterns in medical charts of children diagnosed with ASD between 0-6-years old, whose care is shared between general and developmental pediatricians working in an inner-city setting. In particular, to study how physicians document the timeline and access to medical investigations and community services recommended by physicians.

DESIGN/METHODS: A retrospective chart review of a random sample of approximately 40 patients diagnosed between 0-6-years old with ASD followed by general and developmental pediatricians is currently being conducted at St. Michael’s Hospital. A systematic review of referral pathway to diagnosis, medical investigations, procurement of financial support and access to community services will be performed. Details obtained for review include date of recommendation, parent contact date, date on wait list, start date, and end date.

RESULTS: Preliminary data from 30 patient medical records revealed inconsistencies in how services were documented by physicians. 80% of charts noted that Intensive Behavior Intervention (IBI), Applied Behaviour Analysis (ABA) and speech and language therapy (SLP) were recommended and/or accessed by families. However, the recorded timeline of access varied extensively, with start and end dates recorded in ≤ 20% of charts for ABA, ≤ 50% of charts for SLP and ≤ 70-80% of charts for IBI. ABA therapy appeared to be the most difficult to access, with uptake occurring in only 50% of recommendations. Medical investigation results were often present, however the dates for hearing and vision tests were inconsistently recorded by the pediatrician in the medical charts. Parent education and attendance to drop-in centres were not recommended or accessed in 50% and 25% of patient charts respectively.

CONCLUSION: Preliminary results demonstrate inconsistent patterns of documentation by pediatricians following children with ASD when monitoring medical and community services, especially when recording timelines. Advocating for timely involvement in appropriate services requires an awareness of patients’ past and current involvement in services. Thus, further research may be warranted to determine why certain services are less frequently documented, and how these gaps in communication can be improved to ensure optimal management.

Inner-City Fathers of Children Affected by Chronic Illness: A Systematic Scoping Review of Their Experiences

BACKGROUND: Childhood chronic illness often impacts not just the child but the whole family, particularly the parents. Parents from inner-city backgrounds (defined as low income/socioeconomic status, unemployed, immigrant, refugee, or ethnic minority, and living in an urban area) face additional challenges. Research has traditionally centred on the mother’s role in caring for a child with a chronic illness, but with the increasing role of fathers caring for these children, research has shifted its focus on paternal experience. However, the experiences of inner-city fathers remain largely unknown.

OBJECTIVES: This systematic scoping review aims to explore the experiences of fathers of children with disabilities or chronic health conditions from inner city families, using the Double ABCX model as a conceptual framework.

DESIGN/METHODS: A systematic scoping review was conducted between November 2014 and January 2015 using the Arksey and O'Malley framework. Seven databases were searched (Medline, PsycInfo, Embase, Web of Science, CINAHL, Scopus, and Social Work Abstracts). Titles and abstracts meeting inclusion and exclusion criteria were included in the full text review for further assessment. Qualifying articles were critically appraised and relevant data were extracted. The Double ABCX model was used to qualitatively evaluate the articles in terms of stressors, resources, perception, coping, and adaptation.

RESULTS: 5114 articles were initially identified and 14 articles met the inclusion criteria. Most of the included studies were conducted in the USA. Most articles discussed fathers from low income/SES backgrounds, while others discussed ethnic minority, immigrant/refugee, and unemployed fathers. Fathers' stressors included financial strain and barriers to accessing healthcare. Fathers' resources, or sources of support, ranged from immediate to extended family members, depending on ethnicity. In terms of perceptions, fathers had different approaches to reconciling the care-giver role with cultural gender norms. Inner-city fathers had more desire for information about their children’s health, but some were uncomfortable with asking physicians. Inner-city fathers were more at risk for coping difficulties and used different coping strategies compared to higher income fathers. Inner-city fathers were at higher risk for maladaptation, including depression, PTSD and less acceptance of the child.

CONCLUSION: Fathers from inner-city backgrounds caring for their children affected by chronic illnesses and disabilities have unique experiences requiring a comprehensive approach to providing and communicating care to these children and caregivers. Findings from this review can be used to guide pediatricians in advocating for resources to reduce stressors, enhance coping, and promote positive adaptation for inner-city fathers.

Consensus: soy isoflavones as a first-line approach to the treatment of menopausal vasomotor complaints

The association between an increased uptake of isoflavones and a reduced frequency of menopausal hot flushes was first described in 1992, based on a lower incidence of hot flushes in countries with a high consumption of soy. Since then, numerous clinical trials with various sources of isoflavones including soy and red clover have been presented, with practically all of the studies with adequate design delivering an outcome in favour of isoflavone supplementation. An in-depth risk assessment (EFSA 2015) concludes that the amply available human data does not indicate any suspected harmful effects from a potential interaction of isoflavones with hormone-sensitive tissues in the mammary gland, the uterus and the thyroid gland. Safety was ascertained with long-term intake of up to 150 mg isoflavones per day ingested for the duration of at least 3 years. Moreover, high isoflavone intake was found to have preventive effects with respect to breast cancer. Clinical findings indicate potential benefits of isoflavone exposure even during breast cancer treatment with tamoxifen or anastrozole.

[Decision aids for patients are widely accepted by German urologists : A survey among members of the German Society of Urology (DGU) and the Federation of German Urologists (BDU)]

BACKGROUND

Treatment decision making remains a complex task for localized prostate cancer. Decision aids for patients can support the medical consultation. However, it is not known if German urologists accept decision aids for patients. Comparative data exist from a current survey among american urologists and radio oncologists.

MATERIALS AND METHODS

From October through November 2014 we conducted an online survey consisting of 11 multiple-choice questions and an optional free text commentary among the members of DGU and BDU. All data was processed anonymously. We received 464 complete responses for a 6.6 % return rate. For group comparison we applied the Chi2-test.

RESULTS

Respondents' median age was 50 (range 26-87) years and 15 % were female. 7 % were residents, 31 % employed at a clinic, and 57 % in private practice. Due to the low response rate of younger colleagues the results were not representative for the basic population. Regardless of age (p = 0.2) and professional environment (p = 1) shared decision making was preferred by 89 %. When counseling their patients with localized prostate cancer 20 % relied exclusively on conversation. To support their conversation 63 % used print media, 49 % decision aids, 33 % contact offers to support groups, 24 % Internet resources and 13 % video material. From using decision aids 86 % expected positive effects for patients and 78 % for physicians (p = 0.017). 15 % expected a change of the treatment decision. 77 % would motivate their patients to use a decision aid.

CONCLUSIONS

In comparison to the opinion of american urologists and radio oncologists the acceptance of decision aids for patients among German urologists is significantly higher.

A new responder criterion (relative effect per patient (REPP) > 0.2) externally validated in a large total hip replacement multicenter cohort (EUROHIP)

OBJECTIVE

To validate a new method to identify responders (relative effect per patient (REPP) >0.2) using the OMERACT-OARSI criteria as gold standard in a large multicentre sample.

METHOD

The REPP ([score before - after treatment]/score before treatment) was calculated for 845 patients of a large multicenter European cohort study for THR. The patients with a REPP >0.2 were defined as responders. The responder rate was compared to the gold standard (OMERACT-OARSI criteria) using receiver operator characteristic (ROC) curve analysis for sensitivity, specificity and percentage of appropriately classified patients.

RESULTS

With the criterion REPP>0.2 85.4% of the patients were classified as responders, applying the OARSI-OMERACT criteria 85.7%. The new method had 98.8% sensitivity, 94.2% specificity and 98.1% of the patients were correctly classified compared to the gold standard.

CONCLUSION

The external validation showed a high sensitivity and also specificity of a new criterion to identify a responder compared to the gold standard method. It is simple and has no uncertainties due to a single classification criterion.

Tools and instruments for needs assessment, monitoring and evaluation of health research capacity development activities at the individual and organizational level: a systematic review

BACKGROUND

In the past decades, various frameworks, methods, indicators, and tools have been developed to assess the needs as well as to monitor and evaluate (needs assessment, monitoring and evaluation; "NaME") health research capacity development (HRCD) activities. This systematic review gives an overview on NaME activities at the individual and organizational level in the past 10 years with a specific focus on methods, tools and instruments. Insight from this review might support researchers and stakeholders in systemizing future efforts in the HRCD field.

METHODS

A systematic literature search was conducted in PubMed and Google Scholar. Additionally, the personal bibliographies of the authors were scanned. Two researchers independently reviewed the identified abstracts for inclusion according to previously defined eligibility criteria. The included articles were analysed with a focus on both different HRCD activities as well as NaME efforts.

RESULTS

Initially, the search revealed 700 records in PubMed, two additional records in Google Scholar, and 10 abstracts from the personal bibliographies of the authors. Finally, 42 studies were included and analysed in depth. Findings show that the NaME efforts in the field of HRCD are as complex and manifold as the concept of HRCD itself. NaME is predominately focused on outcome evaluation and mainly refers to the individual and team levels.

CONCLUSION

A substantial need for a coherent and transparent taxonomy of HRCD activities to maximize the benefits of future studies in the field was identified. A coherent overview of the tools used to monitor and evaluate HRCD activities is provided to inform further research in the field.

[Operative therapy of spinal metastases from urological tumors]

The treatment of bone metastases from urological tumors represents a palliative form of therapy, apart from the resection of solitary metastases from renal cell carcinomas. Due to the high incidence of spinal metastases this can result in clinically significant symptoms and possible complications for patients, such as pain, spinal instability and compression of the spinal canal with corresponding neurological deficits. By the use of targeted diagnostics and induction of radiotherapeutic and/or surgical treatment, for the majority of patients an immediate reduction in pain as well as early mobilization and sometimes even regression of existing neurological deficits and therefore an improved quality of life can be achieved.

Body balance control deficiencies following ACL reconstruction combined with medial meniscus suture. A preliminary report

INTRODUCTION

Proprioception makes a critical contribution to body balance. The objective of this study was to evaluate static postural control after anterior cruciate ligament (ACL) reconstruction combined with medial meniscus (MM) suture, comparatively to healthy controls.

HYPOTHESIS

Body balance is adversely affected 2 months after ACL reconstruction combined with MM suture.

PATIENTS AND METHODS

Fifteen patients (12 males and 3 females) aged 20 to 35 years (mean, 26.4 ± 6.0 years) who underwent ACL reconstruction with MM suture were compared to 20 healthy, physically active controls (16 females and 4 males) aged 19 to 23 years (mean, 21.1 ± 1.8 years), most of whom were physiotherapy students. Mean age was not significantly different between the patients and controls. A balance platform was used to estimate static postural control parameters. Each participant performed four tests, two in normal bipedal stance and two in tandem stance; in each stance, one test was done with the eyes open and the other with the eyes closed. We analysed global scores on a standardised 100-point scale and mean centre of pressure (COP) displacement velocity in the sagittal and frontal planes.

RESULTS

Body balance was impaired 2 months after ACL reconstruction with MM suture. Thus, the patients had lower global scores and higher mean COP velocities in both the coronal and sagittal planes.

CONCLUSIONS

Proprioception is impaired after ACL reconstruction with MM suture. Lack of visual control significantly decreases the ability to maintain balance. A balance platform is a useful diagnostic tool for patients with ACL reconstruction and MM suture.

LEVEL OF EVIDENCE

Level II.

[Vertebral metastases of urogenital carcinomas: Diagnosis and conservative therapy]

The high incidence of bone metastases of urologic neoplasms and their morbidity, especially of vertebral metastases, requires exact diagnosis and consequent therapy. Conventional radiography plays an important role in the diagnosis of symptomatic bone lesions. Computed tomography can evaluate the stability of metastatic lesions and is indispensable for therapy planning. MRI and PET-CT have the highest diagnostic accuracy for the detection of bone metastases and MRI can evaluate their intra- and extraosseus components. PET-CT, PET-MRI, or SPECT-CT in combination with specific tracers - due to their high specificity and sensitivity - have the potential to replace conventional methods in the future. Conservative treatment basically consists of analgesic therapy, the administration of calcium and vitamin D3 and bisphosphonates or inhibitors of RANKL (denosumab). Moreover radium-223-dichloride can improve overall survival and the time to the first symptomatic skeletal event in castration-resistant prostate cancer patients with bone metastases.

[Structure of biobanks for urological research]

Biomedical research plays an important role in the development of novel diagnostic procedures, drugs and treatment strategies with regard to cancerous and chronic inflammatory diseases. Biobanks are essential tools in this process. The complex structures and benefits of biobanks are presented in this article.

Examination performances of German and international medical students in the preclinical studying-term--a descriptive study

INTRODUCTION

Medical students with a migration background face several specific problems during their studies. International surveys show first indications that this group of students performs worse in written, oral or practical exams. However, so far, nothing is known about the performance of international students in written pre-clinical tests as well as in pre-clinical State Examinations for German-speaking countries.

METHOD

A descriptive, retrospective analysis of the exam performances of medical students in the pre-clinical part of their studies was conducted at the Faculty of Medicine of Heidelberg in for the year 2012. Performance in written tests of the final exams in the second (N=276), third (N=292) and fourth semester (N=285) were compared between German students, students from EU countries and students from non-EU countries. Same comparison was drawn for the performance in the oral exam of the First State Examination in the period from 2009 - 2012 (N=1137).

RESULTS

German students performed significantly better than students with a non-EU migration background both in all written exams and in the oral State Examination (all p<.05). The performance of students with an EU migration background was significantly better than that of students with a non-EU background in the written exam at the end of the third and fourth semester (p<.05). Furthermore, German students completed the oral exam of the First State Examination significantly earlier than students with a non-EU migration background (<.01).

DISCUSSION

Due to its poorer performance in written and oral examinations and its simultaneously longer duration of study, the group of non-German medical students with a country of origin outside of the European Union has to be seen as a high-risk group among students with a migration background. For this group, there is an urgent need for early support to prepare for written and oral examinations.

Impaired cell death and mammary gland involution in the absence of Dock1 and Rac1 signaling

Throughout life, the tight equilibrium between cell death and the prompt clearance of dead corpses is required to maintain a proper tissue homeostasis and prevent inflammation. Following lactation, mammary gland involution is triggered and results in the death of excessive epithelial cells that are rapidly cleared by phagocytes to ensure that the gland returns to its prepregnant state. Orthologs of Dock1 (dedicator of cytokinesis 1), Elmo and Rac1 (ras-related C3 botulinum toxin substrate 1) in Caenorhabditis elegans are part of a signaling module in phagocytes that is linking apoptotic cell recognition to cytoskeletal reorganization required for engulfment. In mammals, Elmo1 was shown to interact with the phosphatidylserine receptor Bai1 and relay signals to promote phagocytosis of apoptotic cells. Still, the role of the RacGEF Dock1 in the clearance of dying cells in mammals was never directly addressed. We generated two mouse models with conditional inactivation of Dock1 and Rac1 and revealed that the expression of these genes is not essential in the mammary gland during puberty, pregnancy and lactation. We induced mammary gland involution in these mice to investigate the role of Dock1/Rac1 signaling in the engulfment of cell corpses. Unpredictably, activation of Stat3 (signal transducer and activator of transcription 3), a key regulator of mammary gland involution, was impaired in the absence of Rac1 and Dock1 expression. Likewise, failure to activate properly Stat3 was coinciding with a significant delay in the initiation and progression of mammary gland involution in mutant animals. By using an in vitro phagocytosis assay, we observed that Dock1 and Rac1 are essential to mediate engulfment in epithelial phagocytes. In vivo, cell corpses accumulated at late time points of involution in Dock1 and Rac1 mutant mammary glands. Overall, our study demonstrated an unsuspected role for Dock1/Rac1 signaling in the initiation of mammary gland involution, and also suggested a role for this pathway in the clearance of dead cells by epithelial phagocytes.

Evaluation of health research capacity strengthening trainings on individual level: validation of a questionnaire

RATIONALE, AIMS AND OBJECTIVES

In the field of global health, research capacity strengthening is becoming a common concept for defining and improving research competencies on individual, organizational, national and supranational level. However, HRCS activities often lack evaluation procedures to measure their impact and to ensure their quality. The aim of this study was to develop and validate a short questionnaire to evaluate trainings in the field of health research capacity strengthening (HRCS).

METHOD

The questionnaire was developed by an interdisciplinary research team and tested in four different training settings at the Mbeya Medical Research Center and Mbeya Referral Hospital, Tanzania. Construct validity of the questionnaire was tested based on 97 responses of the participants of four trainings.

RESULTS

Iterative checking of Cronbach's alpha of the subscales and exploratory factor analysis revealed a four-factor solution that differed from the original structure and subscales of the questionnaire. The instrument was adapted accordingly and consists now of four subscales with 19 items, three global impression items, and open questions for participants' comments and recommendations.

CONCLUSIONS

The result of the study is a short, validated questionnaire for the evaluation of HRCS trainings on the individual level. The tool can be applied both to measure the short-term effects of international health research capacity trainings and to ensure their quality. In the future, after collecting larger sample sizes, a confirmatory factor analysis should be done to further support the four factors.

[Removal of the primary tumor in hematogenous metastatic tumor disease: reasons against]

Primarily treating metastatic malignancies systemically was an untouchable dogma for decades. Accordingly local therapy was reserved for localized disease only. However, in some oncological entities this apodictic principle could be disproved. In metastatic renal cell carcinoma cytoreductive nephrectomy is the current standard of care for appropriately selected patients but there is a lack of robust data for radical prostatectomy in patients with hematogenous spread from prostate cancer. Therefore, surgical treatment is not recommended outside clinical trials for the latter indication.

[Structured assessment for orthopaedic patients - method, results, and diagnostic potential]

BACKGROUND

Review of medical records demonstrates a moderate to low correlation (r = 0.57 to 0.22) between daily limitations and symptoms based upon patient history. This correlation could be improved with the ideal questionnaire which would assess patients using the same questions with the same response options in the same order. Therefore, a simple patient questionnaire for orthopaedic patients was developed and validated to assess 10 symptoms, 12 limitations of daily life and patients' well-being. The concept was to provide a universal questionnaire that could be used for all patients and provide the basis for a structured assessment that would then provide standardised and comparable patient information. Additional localisation of symptoms would allow a differential diagnosis. For example, pain in the groin/thigh while standing and walking may be caused by osteoarthritis of the hip or osteochondrosis of the lumbar spine. Further physical investigation and diagnostic imaging may lead to the diagnosis.

PATIENTS AND METHODS

This method was employed as part of routine quality control from November 2006 to October 2008 by two orthopaedic surgeons in their outpatient clinic in a tertiary health care hospital. Structured assessment was performed in all patients regardless of their pathology (hip, knee, shoulder, cervical spine, lumbar spine, foot) or situation (before/after surgery, conservative therapy). The completeness, symptom score, daily limitation score, and well-being as well as the relationships between symptom score, daily limitation score, and well-being were calculated. Answers regarding walking capacity and effective walking capacity could be compared. Several patients with combined orthopaedic pathologies were closely analysed.

RESULTS

Data of 2642 structured assessments in 1777 patients (957 women, 53.9 %) were evaluated. The average age was 64.4 years. The data completeness on the front page was 96.2 and 86.3 % on the back page. The mean value for symptoms (daily limitations) was 34.31 (27.45), and the median was 32.5 (25.0). The distributions of the symptom score and daily limitation score were asymmetrical; 80 % of the patients were below 50 and 38, respectively. Well-being was excellent in 21.4 %, good in 24 %, moderate in 24.2 %, poor in 11.4 %, and very poor in 16.7 %. The main symptom was pain on movement/walking, with an average of 60.32. The symptom score, daily limitation score, and well-being were found to have a correlation to each other (Spearman's r between 0.55 and 0.63). Thirty-nine patients reported an inability to walk, although 36 could walk in the office (1 had paraplegia and 2 had paraparesis caused by lumbar stenosis). Combined pathologies in orthopaedic patients were found for cervical-shoulder, lumbar-hip, and lumbar-knee pathologies.

CONCLUSIONS

A routine structured assessment can be performed with extra effort. A structured assessment provides patient information in a standardised form so that such information can be compared as well as allow a differential diagnosis. It is possible that answers to the questionnaire represent patients' subjective assessment rather than reality.

Circuit topology and control principle for a first magnetic stimulator with fully controllable waveform

Magnetic stimulation pulse sources are very inflexible high-power devices. The incorporated circuit topology is usually limited to a single pulse type. However, experimental and theoretical work shows that more freedom in choosing or even designing waveforms could notably enhance existing methods. Beyond that, it even allows entering new fields of application. We propose a technology that can solve the problem. Even in very high frequency ranges, the circuitry is very flexible and is able generate almost every waveform with unrivaled accuracy. This technology can dynamically change between different pulse shapes without any reconfiguration, recharging or other changes; thus the waveform can be modified also during a high-frequency repetitive pulse train. In addition to the option of online design and generation of still unknown waveforms, it amalgamates all existing device types with their specific pulse shapes, which have been leading an independent existence in the past years. These advantages were achieved by giving up the common basis of all magnetic stimulation devices so far, i.e., the high-voltage oscillator. Distributed electronics handle the high power dividing the high voltage and the required switching rate into small portions.

[Relative effect per patient (REPP)--outcome groups for total hip replacement and total knee replacement]

BACKGROUND

The outcome of orthopaedic surgery such as total hip replacement (THR) or total knee replacement (TKR) is commonly given by the change in mean scores on patient-reported outcome measures (Prom's). This may give the impression that all enrolled patients have experienced an improvement. But the Swedish hip registry and other studies report a reduction of complaints in 80-85 % of patients ("responders"), with the remainder (approximately one in six) remaining unchanged or reporting worse complaints ("non-responders"). According to Cohen, the degree of success in the "responders" group can be subdivided into excellent, good and moderate. For a given treatment, a total of 5 different outcome groups can therefore be defined: excellent, good, moderate, unchanged and worse. Allocation to the groups is based on the "relative effect per patient" (REPP). The REPP is calculated as the base-line score minus the post-treatment score divided by the baseline score. The maximum possible REPP is 1; a REPP of 0 means no effect and a negative REPP means deterioration. Allocation to the outcome groups is as follows: excellent 0.95 to 1 REPP, good 0.5 to 0.95 REPP, moderate over 0.2 to 0.5 REPP, unchanged -0.2 to 0.2 REPP and worse below -0.2 REPP.

PATIENTS AND METHODS

Our local arthroplasty register was used to evaluate the 1-year outcomes of THR and TKR patients operated between March 2003 and November 2008, using WOMAC scores and EuroQoL scores. Only patients with complete data sets and unilateral THR/TKR were included. The success rate given by the REPP method was compared with that of the "responder rate" method defined by the OMERACT-OARSI criteria.

RESULTS

With the WOMAC questionnaire, outcomes were as follows (THR/TKR): excellent 29/14 %, good 51/54 %, moderate 11/13 %, unchanged at 5/12 %, worse 4/7 %. The corresponding values for the EuroQoL were (THR/TKR): excellent 16/6 %, good 41/42 %, moderate 25/28 %, unchanged 12/16 %, worse 6/8 %. For THR, success rates were 92 % using the "responder rate" method (OMERACT-OARSI criteria) and 91 % using the REPP method with the WOMAC.

CONCLUSION

Calculation of the REPP and the subsequent allocation to outcome groups is simple. The distribution of outcomes depends on the intervention (THR results better than TKR) and the patient questionnaire used (better results with a condition-specific than a generic questionnaire). The proportion of "unchanged" and "moderate" outcomes was greater with the generic questionnaire than with the condition-specific questionnaire, while the proportion of "worse" outcomes was similar for the two instruments. Partitioning of the degree of success into sub-groups, based on the REPP, provides more information for both the patient and the orthopaedic surgeon.

What are effects of a spaced activation of virtual patients in a pediatric course?

BACKGROUND

Virtual patients (VPs) have a long tradition in the curriculum of the medical faculty at the Ludwig-Maximilians-University (LMU) Munich. However, the pediatric VPs were not well integrated into the curriculum and hardly used by students.

METHODS

Therefore we created and implemented a self-contained E-learning module based on virtual patients (VPs), which was embedded into the pediatric curriculum.Students taking this course were divided into two groups. For Group A the virtual patients were activated in a timed order ("spaced activation"), whereas Group B could work on all VPs from the beginning.We investigated the performance of these two groups concerning usage pattern including number of sessions and session duration, score on questions integrated into the VP and results of the intermediate exam.

RESULTS

The integration of the VPs into the pediatric course was successful for both groups. The usage pattern for the spaced activation turned out to be more balanced, however we did not find any significant differences in the results of the intermediate exam, the score on questions included in the VPs nor in the time students spent working on the VPs.

CONCLUSIONS

Our study showed that the spaced activation led to a more balanced VP usage pattern with a lower peak of sessions at the end of the course. Further studies will have to investigate whether a spaced activation of VPs leads to favorable long-term learning outcomes.

Pain management with flunixin meglumine at dehorning of calves

Dehorning (DH) of calves is a common procedure on commercial dairy farms. Pain management of calves has been investigated in several studies. It is generally accepted that the use of local anesthesia before DH is essential for pain management. Postoperative inflammatory pain should be treated by using a nonsteroidal antiinflammatory drug. The objective of this controlled, randomized, and blinded clinical trial was to determine the effects of the nonsteroidal antiinflammatory drug flunixin meglumine before DH on cortisol concentrations in sera of 5- to 9-wk old calves. Furthermore, selected behavioral characteristics and heart and respiratory rate were examined to assess pain in the hours after dehorning. A total of 80 calves were allocated to 4 groups. In each of 20 replicates, 4 calves were randomly assigned to the following groups: in 3 treatment groups, calves received a local anesthetic (10 mL of procain hydrochloride) and a first treatment (i.v.) with flunixin meglumine or a placebo 20 min before hot-iron dehorning, and a second treatment with flunixin meglumine or a placebo (0.9% saline) 3 h after DH. Calves in the control (CON) group were not dehorned and did not receive any treatment. Groups received 2.2 mg of flunixin meglumine/kg followed by a placebo (FP), 2.2 mg of flunixin meglumine/kg for both treatments (FF), or a placebo for both treatments (PP). Blood samples were collected from all calves, including CON calves, 20 min before restraint in a headlock for DH, 2 min after DH, as well as 30 min and 1, 2, 4, 6, and 8 h after DH. Samples were analyzed for concentration of cortisol by enzyme immunoassay. It was found that concentration of cortisol, calculated as area under the curve, was greater in PP compared with FF and tended to be greater compared with FP. Significant differences between PP and FF were detected at 30 min and 2 h after DH. Throughout the observation period, cortisol concentrations were in both flunixin meglumine-treated groups at a similar level as in the CON group. The heart and respiratory rates showed neither difference between the CON group and the 3 dehorned groups nor between the treatment groups.

The association between popliteal vein compression and deep venous thrombosis: results of a pilot study

Objective:

A pilot study to clarify the association between popliteal vein compression (PVC)and deep venous thrombosis (DVT).

Method:

It is assumed that PVC and the associated change in blood flow increases the likelihood of DVT. We have selected patients who were referred to a vascular laboratory for a DVT duplex and scanned for both DVT and PVC. Duplex criteria for the diagnosis of a DVT were lack of flow and inability to compress the vein. The study was performed over 12 weeks.

Results:

Of the 54 eligible patients, 16 had a DVT. Five of 18 patients with PVC had a distal DVT (27.7%), while five of 36 patients without PVC had distal DVT (16.7%). The difference was statistically significant (relative risk 2.9, P < 0.05).

Conclusion:

There appears to be an association between the presence of PVC and an increased likelihood of developing a DVT. If confirmed in larger studies, this will have strong implications for patient positioning in theatres, as there is a high incidence of PVC in supine anaesthetized patients.

[Operative therapy for stress urinary incontinence in men--from sling to artificial sphincter]

Radical prostatectomy is the most common cause of male urinary incontinence. Up to 90% of the patients are incontinent in the early postoperative phase. This rate reduces to 3-23% approximately 12 months after prostatectomy. Male slings and the ProACT™-Ballon system are preferred minimal invasive therapeutic options for mild to moderate incontinence. Mid-term continence rates of 50-80% can be achieved with bone anchored and adjustable slings or the adjustable ProACT™-Ballon system. The results after radiation therapy are significantly poorer. Randomised controlled trials with longer follow-ups are necessary in order to evaluate the effectiveness of these options for continence therapy. Considering the high continence rates of 73-92% in long-term follow-ups, the artificial urinary sphincter (AUS) still remains the gold standard in the therapy for incontinence in men with normal dexterity and mental status. In cases where continence cannot be achieved by implantation of an AUS, a urinary diversion can be taken into consideration.

[Urology needs health services research: the case of small renal tumours]

The central tasks of health services research include the description and analysis of health care under everyday conditions as well as the development and evaluation of new concepts. As a first step, the reality of the health services' situation should be assessed using representative data. For that, registries, claims data of health insurance funds or observational studies are suitable. To investigate specific patterns or decisions, qualitative methods are of importance. To evaluate the effectiveness of health care concepts or structures, pragmatic randomized, controlled trials are considered to provide the best evidence. In this paper we discuss these questions on the basis of treatment for patients with small renal masses. Although recent guidelines recommend nephron-sparing surgery instead of radical nephrectomy for these patients, international studies suggest that there is a significant underuse of nephron-sparing procedures. However, national data describing the situation in Germany are necessary to analyse reasons and to develop new concepts which subsequently have to be tested in randomized trials. Therefore, the aim of health services research is to create a scientific basis for continuous improvements in health care. Urology needs health services research and we should find ways to overcome barriers to improve quality of care.