EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVES

To develop evidence based recommendations for the management of hand osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference.

RESULTS

Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise.

CONCLUSION

Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Basidiochrome – A Novel Siderophore of the Orchidaceous Mycorrhizal Fungi Ceratobasidium and Rhizoctonia spp

A novel trishydroxamate siderophore, named basidiochrome, was isolated as the principal siderophore from low-iron culture filtrates of Ceratobasidium and Rhizoctonia species which are known as mycorrhizal fungi associated with orchid roots. Ion-exchange chromatography and preparative HPLC yielded a pure compound which contained two components according to GC-MS analysis: L: -N(5)-hydroxy-ornithine and 3-methyl-2-cis-pentenedioic acid (3-methyl-cis-glutaconic acid). FTICR-ESI-MS of both the iron-free and ferric form indicated an elemental composition of C(33)H(47)N(6)O(16)Fe (MW = 839) for the ferric form of basidiochrome. The connectivity was further elucidated by 2D-NMR techniques (HSQC, HMBC, COSY, NOESY) indicating that basidiochrome is a novel linear tripeptide consisting of three L: -N(5)-hydroxy-ornithines each linked to 3-methyl-2-cis-pentenedioic acid residues.

Evidenzbasierte Bewertung der symptomatischen Therapie von Glucosamin

Meta-analyses can contribute to the field of evidence based medicine. In the systematic analyses so far published, the symptomatic efficacy of glucosamine was described to be moderate to large. The results of the individual clinical studies however do not support these findings unanimously. In the past couple of years, some new studies of high quality standard were published. This publication gives an overview and an evaluation of the current available studies for the symptomatic treatment of patients with gonarthrosis with glucosamine. It also compares the results of the individual studies with those of recent meta-analyses.

[Vaccine opponents and sceptics. History, background, arguments, interaction]

Scepticism and critical attitudes towards immunisation have prevailed since the introduction of the smallpox vaccine. In Germany the anti-vaccine movement is rather small (3-5% of the population). Nevertheless its influence on the acceptance of immunisation by the population may be substantial, as shown by the examples of smallpox vaccination and the recent discussion of the combined MMR vaccine in the UK. Modern societies facilitate networking and the dissemination of anti-vaccination ideas. The decline in the incidence of vaccine-preventable diseases has led to a reduced awareness of possible complications from infectious diseases and to an overestimation of the incidence of rarely occurring adverse events following immunisation. Proposals for managing the anti-vaccine movement must take into account changes in immunisation policies and draw on elements of risk communication.

[Influenza pandemic: A real threat ?]

An influenza pandemic is not merely a theoretical threat, but an historical fact. Reliable predictions of the timing of a new pandemic or its extent are, however, impossible. A pandemic poses a threat to society at large, which can be effectively prepared for by appropriate planning and investment in supplies of vaccine doses, antiviral medication and effective monitoring systems. During the interpandemic phase, general practitioners have an important role in raising the level of immunization and providing medical care to those contracting the disease when a pandemic does break out.

Ausgew�hlte Daten zum Impf- und Immunstatus in Deutschland

Up-to-date information on vaccination coverage and seroprevalence are the basis for enhancing the acceptance of vaccination and increasing vaccination coverage. In Germany these data are currently only available to a limited extent. Existent data sources only permit estimates of vaccination coverage or are not age appropriate, such as the representative data from the school entry examinations. Despite increasing vaccination coverage of children and adolescents in recent years, existent data indicate important coverage gaps for certain vaccines. In addition, the vaccination status in adults is often incomplete. Improved surveillance of vaccination coverage and seroprevalence could make an important contribution to closing gaps in vaccination coverage.

In vivo kinematic measurement during laparoscopic cholecystectomy

BACKGROUND

Despite the rapid development of computer-assisted surgery, studies on kinematic measurement for surgical innovation are rare. This study describes a system for kinematic measurement in real operating theater environments. Six laparoscopic cholecystectomies were recorded and analyzed. In addition to a demonstration of the feasibility of the method, basis data for the development of an actuated laparoscopic camera holder are evaluated.

METHODS

The positions of four receivers were recorded by an electromagnetic motion acquisition system. Analysis of the data was performed postoperatively with matlab. Parameters such as coordinates, velocities, angles, angular velocities, workspaces in typical phases of an operation, and subareas of the coordinate ranges were computed.

RESULTS

The workspace during the operation in situ before (II) and after (V) removal of the gallbladder at the upper camera end was as follows: (X, Y, Z; given in cm): II: 65.5 . 42.7 . 27.3 (subarea 90% = 8.3. 14.0.6.3); V: 57.4.33.3.26.2, (90% = 10.3.16.5.7.9). Workspaces at the lower camera end were smaller: II: 14.8.9.7.15.4; (90% = 3.5.3.1.4.3). During these operation phases, velocities up to 82.9 cm/s were documented. Most of the measured velocities were much smaller. The camera -tilt-angles in left/right (alphax) and head/ feet (alphay) direction were as follows: alphax: -69 degrees to +69 degrees and alphay: -74 degrees to +48 degrees.

CONCLUSION

This study demonstrates the feasibility of real-time kinematic measurement in the operation environment. The information might be of future value not only as basis data for the development of camera holders, but also for further investigations on robotics, ergonomics, and simulation.

[Severe limitation of mouth opening]

Limitation of mouth opening is a common source of referral to an orofacial pain clinic with a proposed diagnosis of Temporomandibular Joint Dysfunction (TMD). The word "trismus" is defined by the American academy of orofacial pain as: "Myospasm of masticatory muscles specifically causing limited jaw opening; early symptom of tetanus". Therefore, once trismus is suspected, TMD should be ruled out. However, it is not uncommon to find the usage of this term to describe severe limitation of opening by causes other than myospasm, therefore posing the risk of misdiagnosis. The purpose of this article is to describe the differential diagnosis of hard end limitation of opening with emphasis on the clinical tools used to differentiate between muscle source of hard end limitation and other sources of hard end limitation. Several cases of hard end limitation of mouth opening are presented and through them major principles of orofacial diagnosis are discussed.

Pseudomembranous tracheobronchial aspergillosis: a rare manifestation of invasive aspergillosis in a non-neutropenic patient with Hodgkin's disease

Pseudomembranous tracheobronchial aspergillosis coincident with systemic pulmonary aspergillosis represents a rare manifestation of fungal infection in immunocompromized hosts. We report on a patient with recurrent Hodgkin's disease, showing this infectious pattern after treatment with corticosteroids within the antineoplastic schedule, whereas neutropenia--the main risk factor for mold infections--had not occurred. An impaired number of helper T lymphocytes was merely detected as an additional, but hypothetical risk factor, when investigating the status of immunosuppression. Treated systemically with amphotericin B, the patient recovered quickly, although reported mortality rates are disastrous. What is crucial for the clinical management is an early diagnosis by bronchoscopy and cultural proof of the pathogen followed by an adequate antifungal treatment.

[The Child and Adolescent Health Survey as a source of data for assessment of the essential aspects of health care in childhood and adolescence]

The German National Health Survey for Children and Adolescents aims at collecting representative data on the health status of the population in the 0 to 18 years age bracket. Examination of about 18.000 participants is planned. In this cross-sectional study relevant data concerning health services will be gathered. These include parameters of health care demands, health insurance, vaccination status and drug utilisation. The data collection will start in the first quarter of 2003 and will probably be terminated in the last quarter of 2005. The study design has been tested in a pilot study for one year and was adapted to the demands of this specific health survey. The instruments used for data collection are a self-administered questionnaire as well as a standardised, computer-based medical interview.

Redox modification of proteins using sequential-parallel electrochemistry in microtiter plates

Redox modification of proteins has frequently been used to improve the electron-transfer properties in amperometric biosensors. One approach is the coordinative labelling of histidine residues with metal complexes like [Ru(bpy)2Cl2] and [Ru(bpy)2CO3]. Although the reaction depends on a variety of parameters no detailed optimisation of these modification procedures has been done, most probably due to the complexity of the parameter matrix and the expected differences for any individual protein. A multi electrode sequential analyser (MESA) system has been developed which allows one to follow in a sequential-parallel scheme a number of modification reactions by performing electrochemical measurements such as cyclic voltammetry or differential pulse voltammetry in individual wells of a conventional microtiter plate. Using this system, the ligand exchange reaction leading to the binding of the Ru-complex to histidine residues could be investigated with imidazole as a model compound. Furthermore, the selective labelling of soluble PQQ (pyrrolochinolinquinone)-dependent glucose dehydrogenase (sGDH) and glucose oxidase (GOx) with Ru complexes could be optimised and the electrochemical and biological properties of the obtained 'electroenzymes' were examined.

[Hydro-MRI in inflammatory bowel diseases: a comparison with colonoscopy and histology]

PURPOSE

To compare hydro-MRI with colonoscopy and biopsy specimen regarding the assessment of inflammatory activity and the differentiation of inflammatory bowel diseases.

MATERIAL AND METHODS

After an oral bowel opacification using 1000 ml of a 2.5% mannitol solution and a rectal bowel opacification using 250-500 ml of a 0.9% saline solution, axial and coronal breath-hold sequences +/- Gd-DTPA (HASTE-["half-Fourier acquisition single-shot turbo spin echo"] and dynamic FLASH-["fast low angle shot"]) were acquired in 27 patients with inflammatory bowel disease. The enhancement of the bowel wall as well as morphological MRI findings were correlated with colonoscopy and biopsy specimens. By means of the MRI findings, Crohn's disease (CD) and ulcerative colitis (UC) should be differentiated.

RESULTS

In CD, a significant correlation between the contrast enhancement of the inflamed bowel wall (delta SI) and the endoscopic/histopathologic indices could be established (r = 0.52; p = 0.02 and r = 0.72; p = 0.001). In UC, no correlations between delta SI and the endoscopic/histopathologic indices could be found. The correct diagnosis of CD and UC by MRI findings was possible in 22/27 patients (81%).

CONCLUSION

Hydro-MRI with dynamic studies is suitable for the assessment of disease activity in CD, but unreliable in UC. Hydro-MRI provides useful information for the differentiation of CD and UC.

Influence of circadian time and age on glomerular angiotensin II receptors in normotensive Sprague-Dawley and transgenic hypertensive TGR(mREN2)27 rats

In male heterozygous transgenic hypertensive rats, TGR(mREN2)27 (TGR), exhibiting an inverse blood pressure profile and in normotensive Sprague-Dawley (SPRD) controls, the density and affinity of angiotensin II receptors were determined at six circadian times in glomeruli of animals 11 weeks old kept under light-dark 12h:12 (LD 12:12) conditions. Angiotensin II receptors were also studied in rats 18-20 weeks old of both strains at 2h after light onset. As a measure of renal excretory functions, diuresis, creatinine, and protein excretion were monitored using metabolic cages. The expression of angiotensin II receptor mRNA was determined in renal arteries 2h-4h after light onset. The following results were obtained: (1) Renal excretory functions showed significant daily variation, with higher excretion rates in the dark span in both TGR and SPRD rats. (2) No circadian phase dependency was found in the glomerular angiotensin II receptors in both rat strains. However, receptor density was significantly lower in TGR than in SPRD rats. In both strains, receptor number increased with aging. (3) In renal arteries, the angiotensin II receptor mRNA of the main receptor subtype AT1A was neither strain nor age dependent, AT1B- and AT2-receptor mRNAs were significantly lower in TGR than SPRD rats. In conclusion, the results demonstrate that the overactive renin-angiotensin system in TGR rats led to a down-regulation of glomerular angiotensin II receptors that was not accompanied by a down-regulation of the mRNA of the dominant AT1A- receptor subtype. Circadian short-term variations in blood pressure in both TGR and SPRD rats are not reflected by daily variation in angiotensin II receptor density of renal glomeruli or by variation in receptor expression in renal vascular tissue.

Immune reactions to Listeria monocytogenes in the brain

Listeria monocytogenes (LM) is a common pathogen of cerebral infections. Experimental studies in mice have revealed that epithelial cells of the choroid plexus, ependymal cells, macrophages/microglia, and neurons are the target cells of LM. For the intracerebral pathogenesis of LM cell-to-cell spread via phospholipase C was particularly important. However, phospholipase C-deficient LM were not completely attenuated and, therefore, other virulence factors may also contribute to the intracerebral spread of LM. In general, all mice suffering from cerebral listeriosis rapidly succumbed to the disease. Active systemic immunization prior to intracerebral infection reduced the mortality rate to 40%. The favorable prognosis of immunized mice correlated with a reduced intracerebral bacterial load, an increased recruitment of protective CD4+ and CD8+ T cells as well as an upregulated mRNA production of protective cytokines.

Curriculum renewal in child psychiatry

OBJECTIVE

To ensure uniform design and evaluation of a clerkship curriculum for child and adolescent psychiatry teaching common disorders and problems in an efficient manner across 5 teaching sites and to include structures for continuous improvement.

METHOD

The curriculum committee selected for course inclusion disorders and problems of child psychiatry that were commonly encountered by primary care physicians. Instruction methods that encouraged active student learning were selected. Course coordination across sites was encouraged by several methods: involving faculty, adopting a centralized examination format, and aligning teaching methods with examination format. Quantitative and qualitative methods were used to measure students' perceptions of the course's value. These evaluative results were reviewed, and course modifications were implemented and reevaluated.

RESULTS

The average adjusted student return rate for course evaluation questionnaires for the 3-year study period was 63%. Clerks' ratings of course learning value demonstrated that the course improved significantly and continually across all sites, according to a Scheffé post-hoc analysis. Analysis of student statements from focus-group transcripts contributed to course modifications, such as the Brief Focused Interview (BFI).

CONCLUSIONS

Our curriculum in child psychiatry, which focused on common problems and used active learning methods, was viewed as a valuable learning experience by clinical clerks. Curriculum coordination across multiple teaching sites was accomplished by including faculty in the process and by using specific teaching and examination strategies. Structures for continuous course improvement were effective.

GLP-1 release in man after lower large bowel resection or intrarectal glucose administration

BACKGROUND

This study addresses the question whether the insulinotropic gut hormone, glucagon-like peptide-1 (GLP-1), is released from the lower large bowel upon oral or rectal glucose uptake.

METHODS

It was evaluated whether rectum or sigmoid colon resection alters glucose homeostasis or the plasma levels of the insulinotropic gut hormone, gastric inhibitory polypeptide (GIP), or GLP-1. Six men and 3 women (age 63 +/- 8 years, BMI 25.4 +/- 4.0 kg/m2) with normal preoperative fasting glucose values were treated before and after resection of large bowel segments. Fasting oral glucose tolerance (OGT, 75 g glucose/300 ml) tests were performed both before and 10 days postoperatively. Another approach aimed to clarify whether luminal glucose stimulation in the rectum/sigmoid colon increases GLP-1 plasma levels. Ten healthy volunteers (4 males, 6 females, age 25 +/- 2 years, BMI 22.1 +/- 2.4 kg/m2) received enemas with both saline and, 7 days later, 1 g/kg body weight glucose (70% glucose solution) intrarectally.

RESULTS

Neither rectum nor sigmoid colon resection led to significant changes in the pre- and postoperative glucose responses to OGT testing, or insulin, GIP and GLP-1 release. Intrarectal glucose instillation increased blood glucose by about 10 mg/dl with parallel small elevations in immunoreactive insulin and immunoreactive C peptide. However, plasma GLP-1 levels remained unaltered.

CONCLUSION

Our data make it unlikely that GLP-1 derived from the lower large bowel contributes significantly to maintain normal glucose tolerance.

Children's attitudes toward peers with disabilities: the Israeli perspective

Attitudes toward peers with disabilities were compared in two groups of elementary school children, Israeli (2845 children) and Canadian (1831 children), using the Chedoke-McMaster Attitudes Toward Children with Handicaps (CATCH) scale. Israeli children expressed significantly more positive general attitudes (P=0.0001). The more favourable attitudes were seen in both areas evaluated by the CATCH, the cognitive and the affective-behavioural. In both groups, children who had had previous experience with a disabled person expressed more positive attitudes (P=0.001). An effect of gender was seen in the Canadian but not in the Israeli children. Cultural factors appear to play a role in modelling children's attitudes toward their disabled peers and therefore should be considered before educational programmes are implemented.