Investigation of liver-targeted peripheral focused ultrasound stimulation (pFUS) and its effect on glucose homeostasis and insulin resistance in type 2 diabetes mellitus: a proof of concept, phase 1 trial

BACKGROUND

Mechanical waves produced by ultrasound pulses have been shown to activate mechanosensitive ion channels and modulate peripheral nerves. However, while peripheral ultrasound neuromodulation has been demonstrated in vitro and in pre-clinical models, there have been few reports of clinical tests.

AIM

We modified a diagnostic imaging system for ultrasound neuromodulation in human subjects. We report the first safety and feasibility outcomes in subjects with type 2 diabetes (T2D) mellitus and discuss these outcomes in relation to previous pre-clinical results.

DESIGN

The study was performed as an open label feasibility study to assess the effects of hepatic ultrasound (targeted to the porta hepatis) on glucometabolic parameters in subjects with T2D. Stimulation (peripheral focused ultrasound stimulation treatment) was performed for 3 days (i.e. 15 min per day), preceded by a baseline examination and followed by a 2-week observation period.

METHODS

Multiple metabolic assays were employed including measures of fasting glucose and insulin, insulin resistance and glucose metabolism. The safety and tolerability were also assessed by monitoring adverse events, changes in vital signs, electrocardiogram parameters and clinical laboratory measures.

RESULTS AND CONCLUSION

We report post-pFUS trends in several outcomes that were consistent with previous pre-clinical findings. Fasting insulin was lowered, resulting in a reduction of HOMA-IR scores (P-value 0.01; corrected Wilcoxon signed-rank test). Additional safety and exploratory markers demonstrated no device-related adverse impact of pFUS. Our findings demonstrate that pFUS represents a promising new treatment modality that could be used as a non-pharmaceutical adjunct or even alternative to current drug treatments in diabetes.

Activity tracker-based intervention to increase physical activity in patients with type 2 diabetes and healthy individuals: study protocol for a randomized controlled trial

BACKGROUND

One relevant strategy to prevent the onset and progression of type 2 diabetes mellitus (T2DM) focuses on increasing physical activity. The use of activity trackers by patients could enable objective measurement of their regular physical activity in daily life and promote physical activity through the use of a tracker-based intervention. This trial aims to answer three research questions: (1) Is the use of activity trackers suitable for longitudinal assessment of physical activity in everyday life? (2) Does the use of a tracker-based intervention lead to sustainable improvements in the physical activity of healthy individuals and in people with T2DM? (3) Does the accompanying digital motivational intervention lead to sustainable improvements in physical activity for participants using the tracker-based device?

METHODS

The planned study is a randomized controlled trial focused on 1642 participants with and without T2DM for 9 months with regard to their physical activity behavior. Subjects allocated to an intervention group will wear an activity tracker. Half of the subjects in the intervention group will also receive an additional digital motivational intervention. Subjects allocated to the control group will not receive any intervention. The primary outcome is the amount of moderate and vigorous physical activity in minutes and the number of steps per week measured continuously with the activity tracker and assessed by questionnaires at four time points. Secondary endpoints are medical parameters measured at the same four time points. The collected data will be analyzed using inferential statistics and explorative data-mining techniques.

DISCUSSION

The trial uses an interdisciplinary approach with a team including sports psychologists, sports scientists, health scientists, health care professionals, physicians, and computer scientists. It also involves the processing and analysis of large amounts of data collected with activity trackers. These factors represent particular strengths as well as challenges in the study.

TRIAL REGISTRATION

The trial is registered at the World Health Organization International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (DRKS), DRKS00027064 . Registered on 11 November 2021.

Addressing barriers to mental health services: evaluation of a psychoeducational short film for forcibly displaced people

BACKGROUND

Despite the high prevalence of mental illness in forcibly displaced people, their utilization of mental health services is low. Major barriers to seeking mental health services include mental health self-stigma. To address this issue, the psychoeducational short film 'Coping with Flight and Trauma' was developed as a brief online intervention.

OBJECTIVE

The present study aims to evaluate the feasibility and acceptance of the newly developed 10 min film, and to assess changes in self-stigma and help seeking.

METHOD

The evaluation of the film was conducted using a mixed-methods design with an online survey including the Self-Stigma of Mental Illness Scale, help seeking, and mental health variables at baseline, postintervention, and 3 month follow-up, in addition to telephone interviews postintervention with a randomly selected volunteer subsample.

RESULTS

A total of 134 participants with a forced displacement history within the past 8 years took part in the study, of whom 66% scored as having probable post-traumatic stress disorder (PTSD), depression, and/or anxiety. The results revealed emotional, cognitive, and behavioural changes postintervention. Directly after watching the film, participants reported reduced self-stigma and increased openness towards accessing mental health services. At follow-up, precisely 3.8 months later, these changes were no longer significant, yet 11% of participants reported having started psychotherapy since watching the film. Probable PTSD was associated with higher self-stigma at all three time-points. The majority (90%) would recommend watching the film to other forcibly displaced people.

CONCLUSIONS

Self-stigma was shown to be a robust and persistent issue, which tends to be underestimated by individuals not affected by mental illness. Low-threshold psychoeducational online interventions may be a promising tool to reduce barriers to accessing mental health services for forcibly displaced people, e.g. by being implemented in stepped-care models.

HIGHLIGHTS

Mental health self-stigma was shown to be a persistent and underestimated burden in forcibly displaced people.Psychoeducational online interventions are promising for addressing the burden of self-stigma and reducing barriers to seeking mental health services.

POS0459 UNSUPERVISED CLUSTERING IDENTIFIES UNIQUE SUBSETS OF PATIENTS IN A RACIALLY AND ETHNICALLY DIVERSE RHEUMATOID ARTHRITIS COHORT

Background:

Single biomarkers have limited utility to date in guiding RA clinical care. Machine learning algorithms may better identify and stratify RA patients with differential outcomes.

Objectives:

To determine if unsupervised machine learning methods can be employed in a racially and ethnically diverse RA cohort to identify clusters of patients with different disease activity trajectories, as measured by DAS28ESR.

Methods:

Data are derived from the longitudinal, observational University of California, San Francisco RA Cohort. Along with routine labs, medications and disease activity assessments, a multiple biomarker of disease activity (MBDA) panel was obtained at each visit. The MBDA measures 12 serum biomarkers. Four patient clusters were identified by unsupervised K-prototype clustering after collapsing all observations into a cross sectional dataset. Plots were created to display longitudinal disease activity trajectories for each cluster. Lasso regression was applied to identify biomarkers associated with DAS28ESR.

Results:

We identified 4 distinct clusters in our cohort (Table 1) with visually different disease activity trajectories (Fig. 1). Cluster 1 (n=116) was older (63.6±9.7), had the highest proportion of Asian participants (n=73, 63%) with the most study visits and longest disease duration. Cluster 2 (n=70) had the highest mean DAS28ESR (5.5±0.7), and the highest mean dose of prednisone (8.6±4.9 mg/day). Cluster 3 had the lowest number of participants (n=14), study visits and lowest biologic use (28.6%). Cluster 4 was the largest cluster (n=173) with the shortest disease duration (4.9±3.8 years) and highest biologic use (61.3%). In the Lasso regressions, leptin was found to have significant positive associations with DAS28ESR in the whole group as well as Clusters 2 and 4. EGF had negative associations with DAS28ESR in the whole group, Cluster 1 and 4. CRP had positive associations with DAS28ESR in the whole group and Cluster 1. YKL40 and VCAM1 were found to have significant associations in Clusters 1 and 3, respectively.

Conclusion:

We identified 4 unique clusters of RA patients in a racially and ethnically diverse longitudinal cohort with different disease activity trajectories and biomarkers associated with disease activity. Although additional work is needed to explore longitudinal outcomes in each cluster, the application of machine learning methods may identify unique combinations of patient and disease characteristics influencing RA clinical outcomes.

Table 1.

Demographics and clinical characteristics of the RA cohort. Biomarkers significantly associated with DAS28ESR were determined by Lasso regression Values listed are per standard deviation of each biomarker.

Overall(N=373)Cluster 1 (N=116)Cluster 2 (N=70)Cluster 3 (N=14)Cluster 4 (N=173)Demographics:Age54.8 ± 3.663.6 ± 9.750.8 ± 14.958.2 ± 15.850.3 ± 12.1Female Sex318 (85%)101 (87%)57 (81%)11 (79%)149 (86%)Race: Hispanic/Latino181 (49%)22 (19%)47 (67%)5 (36%)107 (62%) Asian123 (33%)73 (63%)8 (11%)6 (43%)36 (21%) Black35 (9%)12 (10%)8 (11%)2 (14%)13 (8%) White & Other34 (9%)9 (7%)7 (10%)1 (7%)17 (10%)Clinical Characteristics:Rheumatoid Factor315 (85%)104 (90%)56 (80%)13 (93%)142 (82%)ACPA297 (80%)98 (85%)54 (77%)12 (86%)133 (77%)Disease Duration7.8 ± 7.613.7 ± 9.75.4 ± 4.66.7 ± 5.74.9 ± 3.8csDMARD344 (92%)108 (93%)63 (90%)13 (93%)160 (93%)Biologic DMARD185 (50%)45 (39%)30 (43%)4 (29%)106 (61%)Prednisone Dose6.7 ± 3.86.0 ± 4.08.6 ± 4.95.8 ± 1.46.3 ± 2.8Body Mass Index28.2 ± 4.526.6 ± 3.828.7 ± 3.828.0 ± 6.229.1 ± 4.7DAS28ESR4.2 ± 1.14.2 ± 1.05.5 ± 0.83.9 ± 0.83.7 ± 0.9Lasso Results:EGF-0.16*-0.41***-----0.20**Leptin0.15**--0.21*--0.21**c-reactive protein0.34**0.51***------VCAM1-------0.73*--YKL40--0.26*------

-EGF: epidermal growth factor; VCAM1: Vascular cell adhesion protein 1; YKL40: Chitinase-3-like protein 1.

-*p<0.05, **p<0.01, ***p<0.001

Figure 1.

DAS28ESR trajectory plots with 95%CIs for the whole cohort and by cluster.

Acknowledgements:

This work was supported by the Rheumatology Research Foundation Scientist Development Award.

Disclosure of Interests:

None declared

Non-motor symptoms and quality of life in subjects with mild parkinsonian signs

BACKGROUND

Mild parkinsonian signs (MPS) are frequent in the elderly population and associated with the presence of risk markers for Parkinson's disease (PD). Both MPS and non-motor signs may be present in prodromal PD and may significantly impair quality of life (QoL).

OBJECTIVE

To disentangle the contribution of motor impairment and extra-motor manifestations to QoL in subjects with MPS (n=63), manifest PD (n=69), disorders with motor symptoms due to non-neurodegenerative diseases (n=213) and healthy controls (n=258).

METHODS

Subjects with MPS, healthy controls, disease controls (patients with motor impairment due to, eg, arthrosis and spondylosis), and PD patients (total n=603) were selected from a large epidemiological longitudinal study, the EPIPARK cohort. Motor function was determined using the UPDRSIII protocol, and information on depressive symptoms, anxiety, sleep, and QoL was assessed via rating scales and data were analyzed.

RESULTS

Depressive symptoms, anxiety, and sleep problems were equally frequent in the MPS group and controls. Health-related QoL was slightly reduced in the MPS group. Motor impairment and its extent was comparable between the MPS group and disease controls (UPDRSIII 5-6 points). Higher motor dysfunction was associated with lower QoL. Depressive symptoms, but not anxiety and daytime sleepiness, was significant predictors of general QoL, independent of motor function.

CONCLUSIONS

Quality of life is slightly decreased in an elderly population with MPS. QoL is associated with severity of motor impairment but also with non-motor aspects, ie, depressive symptoms. Follow-up studies in large cohorts are warranted to determine the natural course of MPS and its impact on QoL.

Abstract P3-11-05: Reliability and acceptance of e-based survey instruments for measuring patient reported outcomes (PRO) in breast cancer patients: First results of the ePROCOM study

Introduction

Especially in oncology patients, Patient Reported Outcomes (PRO) play an increasingly important role to measure subjectively perceived health status and treatment effects. At the moment, paper-based surveys of PRO still predominate (pPRO); in recent years, data on patient-relevant endpoints is being increasingly collected electronically (ePRO). The aim of the study was to analyze the acceptance of an ePRO-survey tool in breast cancer patients within the PRAEGNANT multicenter trial. Furthermore, it should be considered, whether differences in response behavior between pPRO and ePRO can be identified (reliability check).

Materials and Methods

ePROCOM (Patient Reported Outcomes and Compliance Anaysis) was conceptualized as a monocenter, randomized, parallel-group, cross-over study. Female patients with diagnosis breast cancer aged more than 18 years were included.We randomized the patients into one of two study arms. In study arm A the patients are first asked to use the electronic, web-based tool to document the patient questionnaire (EORTC QLQ C-30 and FACT-B). Afterwards the patients were asked to fill and evaluate the paper-based questionnaires accordingly, followed by evaluation of usability, acceptance and capability. In study arm B the course varies by meaning that paper-based evaluation will be followed by the assessment of electronic data capture.

Results

N=110 patients with breast cancer in adjuvant or neoadjuvant situation completing the study during an outpatient visit at the University Hospitals in Tuebingen and the National Cancer Centre Heidelberg (average age: 52.4). In most patients, there were no differences in terms of acceptance between pPRO and ePRO. Only in some older patients with a lower quality of life hurdles for ePRO could be identified, because of lower acceptance rates. We could not find significant differences in response behavior between pPRO and ePRO.

Discussion

Because no differences in response behavior could be identified, the tool can be define as reliable possibility to measure patient reported outcomes. E-PRO surveys appear to be suitable for use in breast cancer patients. However, there is a need of support in older and more ill patients, to participate form the technical capabilities of ePRO.

Citation Format: Wallwiener M, Simoes E, Hartkopf AD, Taran F-A, Keilmann L, Sickenberger N, Stevanovic S, Belleville E, Ladra C, Schneeweiss A, Wallwiener D, Brucker SY, Graf J. Reliability and acceptance of e-based survey instruments for measuring patient reported outcomes (PRO) in breast cancer patients: First results of the ePROCOM study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-11-05.

The flagellar master operon flhDC is a pleiotropic regulator involved in motility and virulence of the fish pathogen Yersinia ruckeri

AIMS

To investigate the function of the master flagellar operon flhDC in the fish pathogen Yersinia ruckeri and compare the effect of a constructed flhD mutation to a naturally occurring fliR mutation causing loss-of-motility in emergent biotype 2 (BT2) strains.

METHODS AND RESULTS

Yersinia ruckeri flhD and fliR mutants were constructed in a motile strain. Both mutations caused loss-of-motility, ablation of flagellin synthesis and phospholipase secretion, similar to naturally occurring BT2 strains. Transcriptome analysis confirmed flhDC regulation of flagellar, chemotaxis and phospholipase loci as well as other genes of diverse function. The flhD mutation confers a competitive advantage within the fish host when compared with its parent strain, while this advantage was not seen with the naturally occurring fliR mutation.

CONCLUSIONS

An intact flhD is necessary for expression of the flagellar secretion system as well as other diverse loci, consistent with a role for flhD as a pleiotropic regulator. The maintenance of the flhD locus in Y. ruckeri strains suggests its importance for aspects of Y. ruckeri biology other than virulence, since the flhD mutation conferred a competitive advantage during experimental challenge of rainbow trout.

SIGNIFICANCE AND IMPACT OF THE STUDY

Yersinia ruckeri is the causative agent of enteric red mouth disease, an invasive septicaemia that affects farmed salmonid fish species. Disease outbreaks can cause severe economic losses in aquaculture. BT2 variants, which have independently emerged worldwide, are an increasing threat to farmed fish production. Knowledge of mechanisms involved in virulence, conserved functions and gene regulation among strains may be exploited for the development of novel disease control strategies to prevent pathogen growth or virulence phenotypes within aquaculture.

Health-related Quality of Life in Metastatic and Adjuvant Breast Cancer Patients

Introduction: When cancer patients have advanced disease and a primary cure is no longer possible, the focus is on maintaining the patient's quality of life. Recent therapeutic advances in breast cancer treatment mean that even patients with metastatic disease can remain stable for long periods of time. The aim of this study was to look at the health-related quality of life (HRQL) of these patients and compare it with data for the general population and to show the differences in outcomes for different survey instruments used to measure quality of life. Material and Methods: A total of 96 breast cancer patients with metastatic disesae or receiving adjuvant therapy were questioned about their quality of life. Patients were investigated using the established survey instruments EORTC QLQ-C30, EORTC QLQ-BR23, EQ-5D-5L and EQ VAS. All patients filled out questionnaires. Statistical analysis was done using MS Excel and SPSS. Results: Although the questionnaires were completed at the same time, the different questionnaires showed significant differences with regard to the level of stress experienced by the patient. When the EQ VAS questionnaire was used, the patient's current state of health was assessed as significantly better than with the EORTC QLQ-C30. Overall, all aspects of patients' quality of life were found to be in need of optimization and HRQL of patients was significantly poorer in all areas compared to the reference population. Conclusion: To improve the quality of life of patients with metastatic disease, it is necessary to continuously monitor the success of therapy. The choice of survey tools is highly relevant as assessments differ considerably depending on the choice of questionnaire.

Reliability of transpulmonary pressure-time curve profile to identify tidal recruitment/hyperinflation in experimental unilateral pleural effusion

The stress index (SI) is a parameter that characterizes the shape of the airway pressure-time profile (P/t). It indicates the slope progression of the curve, reflecting both lung and chest wall properties. The presence of pleural effusion alters the mechanical properties of the respiratory system decreasing transpulmonary pressure (Ptp). We investigated whether the SI computed using Ptp tracing would provide reliable insight into tidal recruitment/overdistention during the tidal cycle in the presence of unilateral effusion. Unilateral pleural effusion was simulated in anesthetized, mechanically ventilated pigs. Respiratory system mechanics and thoracic computed tomography (CT) were studied to assess P/t curve shape and changes in global lung aeration. SI derived from airway pressure (Paw) was compared with that calculated by Ptp under the same conditions. These results were themselves compared with quantitative CT analysis as a gold standard for tidal recruitment/hyperinflation. Despite marked changes in tidal recruitment, mean values of SI computed either from Paw or Ptp were remarkably insensitive to variations of PEEP or condition. After the instillation of effusion, SI indicates a preponderant over-distension effect, not detected by CT. After the increment in PEEP level, the extent of CT-determined tidal recruitment suggest a huge recruitment effect of PEEP as reflected by lung compliance. Both SI in this case were unaffected. We showed that the ability of SI to predict tidal recruitment and overdistension was significantly reduced in a model of altered chest wall-lung relationship, even if the parameter was computed from the Ptp curve profile.

Willingness of Patients with Breast Cancer in the Adjuvant and Metastatic Setting to Use Electronic Surveys (ePRO) Depends on Sociodemographic Factors, Health-related Quality of Life, Disease Status and Computer Skills

Introduction: Because of the often unfavorable prognosis, particularly for patients with metastases, health-related quality of life is extremely important for breast cancer patients. In recent years, data on patient-relevant endpoints is being increasingly collected electronically; however, knowledge on the acceptance and practicability of, and barriers to, this form of data collection remains limited. Material and Methods: A questionnaire was completed by 96 patients to determine to what extent existing computer skills, disease status, health-related quality of life and sociodemographic factors affect patients' potential willingness to use electronics methods of data collection (ePRO). Results: 52 of 96 (55 %) patients reported a priori that they could envisage using ePRO. Patients who a priori preferred a paper-based survey (pPRO) tended to be older (ePRO 53 years vs. pPRO 62 years; p = 0.0014) and typically had lower levels of education (p = 0.0002), were in poorer health (p = 0.0327) and had fewer computer skills (p = 0.0003). Conclusion: Barriers to the prospective use of ePRO were identified in older patients and patients with a lower quality of life. Given the appropriate conditions with regard to age, education and current health status, opportunities to participate should be provided to encourage patients' willingness to take part and ensure the validity of survey results. Focusing on ease of use of ePRO applications and making applications more patient-oriented and straightforward appears to be the way forward.

[Why Strive after Clinical Social Medicine? From Epidemiological Association to Personalized Social Medicine: a Case of Breast Cancer Care]

Advances in biomedicine, especially molecular biology and genetics, gave rise to the concept of personalized medicine targeting the patient's individual characteristics and needs to ensure the best possible therapy and healthcare. This concept, however, can be successfully implemented only if due consideration is given to (psycho-)social factors, as is shown for instance by considerably reduced post-therapy survival rates among cancer patients in regions with lower socioeconomic status, How breast cancer patients, for instance, find their way back to daily life and work after initial treatment at a breast center is substantially determined by multiple factors going beyond pure medical care. These factors critically affect health status and therapy outcomes, but are missing in current research agenda. A profound expertise in social medicine is required to respond in ways tailored to the individual's healthcare needs that go beyond just medical therapy. This expertise comprises, in particular, knowledge of inequality of access to healthcare due to varying health competence that in turn, results in inequality of health outcome and care. Competence in social medicine both in the clinic and outpatient care can help to individually target negative factors that originate from the social environment as well as from deficits in communication and coordination in the healthcare system and have an effect on the health status of patients..This, however, requires institutionalization of (clinical) social medicine and in particular, better opportunities for advanced training in social medicine in clinical departments and outpatient units.

Dual roles of the adenosine A2a receptor in autoimmune neuroinflammation

BACKGROUND

Conditions of inflammatory tissue distress are associated with high extracellular levels of adenosine, due to increased adenosine triphosphate (ATP) degradation upon cellular stress or the release of extracellular ATP upon cell death, which can be degraded to adenosine by membrane-bound ecto-enzymes like CD39 and CD73. Adenosine is recognised to mediate anti-inflammatory effects via the adenosine A2a receptor (A2aR), as shown in experimental models of arthritis. Here, using pharmacological interventions and genetic inactivation, we investigated the roles of A2aR in experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis (MS).

METHODS

We used two independent mouse EAE variants, i.e. active immunization in C57BL/6 with myelin oligodendrocyte glycoprotein (MOG)35-55 or transfer-EAE by proteolipid protein (PLP)139-155-stimulated T lymphocytes and EAE in mice treated with A2aR-agonist CGS21680 at different stages of disease course and in mice lacking A2aR (A2aR(-/-)) compared to direct wild-type littermates. In EAE, we analysed myelin-specific proliferation and cytokine synthesis ex vivo, as well as inflammation and demyelination by immunohistochemistry. In vitro, we investigated the effect of A2aR on migration of CD4(+) T cells, macrophages and microglia, as well as the impact of A2aR on phagocytosis of macrophages and microglia. Statistical tests were Mann-Whitney U and Student's t test.

RESULTS

We found an upregulation of A2aR in the central nervous system (CNS) in EAE, predominantly detected on T cells and macrophages/microglia within the inflamed tissue. Preventive EAE treatment with A2aR-specific agonist inhibited myelin-specific T cell proliferation ex vivo and ameliorated disease, while application of the same agonist after disease onset exacerbated non-remitting EAE progression and resulted in more severe tissue destruction. Accordingly, A2aR-deficient mice showed accelerated and exacerbated disease manifestation with increased frequencies of IFN-γ-, IL-17- and GM-CSF-producing CD4(+) T helper cells and higher numbers of inflammatory lesions in the early stage. However, EAE quickly ameliorated and myelin debris accumulation was lower in A2aR(-/-) mice. In vitro, activation of A2aR inhibited phagocytosis of myelin by macrophages and primary microglia as well as migration of CD4(+) T cells, macrophages and primary microglia.

CONCLUSIONS

A2aR activation exerts a complex pattern in chronic autoimmune neurodegeneration: while providing anti-inflammatory effects on T cells and thus protection at early stages, A2aR seems to play a detrimental role during later stages of disease and may thus contribute to sustained tissue damage within the inflamed CNS.

Conflicting Priorities in Social Legislation and Medicine: Gynaeco-oncology Patients and their Right to Participate in Society

Due to the declining mortality rates, malignant diseases have gained a chronic character for many gynaeco-oncology patients. The patients can expect to participate in social life and to an increasing extent in professional life for longer lengths of time. Promotion of rehabilitation and participation is an issue of the German 9th Social Security Code that explicitly places a focus on women. This is mainly of relevance for tumour patients with regard to assessment of the degree of severe disability, to compensate for disease-induced impairments and the possibilities for improving the participation of the afflicted subjects, especially by means of protective rights in professional life. Indeed, tumour patients do sometimes find themselves confronted with conflicting priorities between the entitlements guaranteed by social legislation and the compensation conferred by the health-care services, which can then be avoided when the facts are sufficiently known. For this purpose, the physician must be fully aware of the legal situation. The present article provides an overview of the procedures and reference points for appraisals. Patients need partners among their responsible physicians to help in the assertion of their claims. From the physician's side it is necessary to classify the reported complaints within the ever increasing knowledge about the direct side effects and the long-term side effects of cancer therapies. Against the background of an often life-long mental stress and the uncertain risk of recurrence, it should also be considered whether the concept of healing probation is in support of the targets of long-term disease management and social reintegration, also in the interest of society in general.

[Actors in liver transplantation advocate greater transparency and systematic evaluations of transplant centres]

BACKGROUND

Following the introduction of the MELD score, the survival rates have worsened after liver transplantation (LTX) in Germany. Existing organ shortages, shorter survival rates after LTX, and failures in the liver allocation process provide true challenges. Facilitated by a structured questionnaire, the appropriate German liver transplantation actors were approached with regard to these challenges for the first time. The aim was to provide a balanced experts' view in an anonymous fashion thereby identifying areas for potential improvement.

METHOD

Data collection was performed by a structured, standardised, anonymous survey of all LTX centres in Germany.

RESULTS

We received 75 % replies of the questionnaires, 35 of 36 participants responded to more than 75 % of all questions. The following key points were highlighted. A minimum amount of LTX per centre was deemed important and monetary incentives must not exist. The ultimate goal of LTX is a prolongation of life and social as well as occupational reintegration. Quality management and transparent LTX registers are prerequisites for both adequate organ allocation and distribution of resources in order to achieve the best possible transplant outcomes.

CONCLUSION

The German liver transplant experts consider transparency of organ allocation and systematic evaluation of the quality of transplant centres and the transplantation process itself to be mandatory, however, executed in a participatory way. A scoring system to facilitate the decision making process in order to predict the likelihood of satisfactory LTX outcome thereby circumventing some of the ethical and constitutional doubts would be highly appreciated.

[Aerosinusitis. Part 2: Diagnosis, therapy and recommencement of flight duties]

Aerosinusitis more frequently affects the frontal sinus than the maxillary sinus and mostly occurs during descent. Sinonasal diseases and anatomic variations leading to obstruction of paranasal sinus ventilation favor the development of aerosinusitis. This Continuing Medical Education (CME) article is based on selective literature searches of the PubMed database (search terms: "aerosinusitis", "barosinusitis", "barotrauma" AND "sinus", "barotrauma" AND "sinusitis", "sinusitis" AND "flying" OR "aviator"). Additionally, currently available monographs and further articles that could be identified based on the publication reviews were also included. In part 2, diagnostic measures, drug therapy, balloon dilatation and endoscopic sinus surgery are presented, along with a discussion regarding when flight attendants and pilots are able to resume their work. Endoscopic surgery to expand the natural drainage pathways of the affected sinuses with minimal surgical trauma to the healthy mucous membranes is largely successful.

[Safety in intensive care medicine. Can we learn from aviation?]

Safety is of extraordinary value in commercial aviation. Therefore, sophisticated and complex systems have been developed to ensure safe operation. Within this system, the pilots are of specific concern: they form the human-machine interface and have a special responsibility in controlling and monitoring all aircraft systems. In order to prepare pilots for their challenging task, specific selection of suitable candidates is crucial. In addition, for every commercial pilot regulatory requirements demand a certain number of simulator training sessions and check flights to be completed at prespecified intervals. In contrast, career choice for intensive care medicine most likely depends on personal reasons rather than eligibility or aptitude. In intensive care medicine, auditing, licensing, or mandatory training are largely nonexistent. Although knowledge of risk management and safety culture in aviation can be transferred to the intensive care unit, the diversity of corporate culture and tradition of leadership and training will represent a barrier for the direct transfer of standards or procedures. To accomplish this challenging task, the analysis of appropriate fields of action with regard to structural requirements and the process of change are essential.

Racial and ethnic disparities in disease activity and function among persons with rheumatoid arthritis from university-affiliated clinics

OBJECTIVE

Health outcomes in rheumatoid arthritis (RA) have improved significantly over the past 2 decades. However, research suggests that disparities exist by race/ethnicity and socioeconomic status, with certain vulnerable populations remaining understudied. Our objective was to assess disparities in disease activity and function by race/ethnicity and explore the impact of language and immigrant status at clinics serving diverse populations.

METHODS

We examined a cross-sectional study of 498 adults with confirmed RA at 2 rheumatology clinics: a university hospital clinic and a public county hospital clinic. Outcomes included the Disease Activity Score in 28 joints (DAS28) and its components, and the Health Assessment Questionnaire (HAQ), a measure of function. We estimated multivariable linear regression models including interaction terms for race/ethnicity and clinic site.

RESULTS

After adjusting for age, sex, education, disease duration, rheumatoid factor status, and medication use, clinically meaningful and statistically significant differences in DAS28 and HAQ scores were seen by race/ethnicity, language, and immigrant status. Lower disease activity and better function was observed among whites compared to nonwhites at the university hospital. This same pattern was observed for disease activity by language (English compared to non-English) and immigrant status (US-born compared to immigrant) at the university clinic. No significant differences in outcomes were found at the county clinic.

CONCLUSION

The relationship between social determinants and RA disease activity varied significantly across clinic setting with pronounced variation at the university, but not at the county clinic. These disparities may be a result of events that preceded access to subspecialty care, poor adherence, or health care delivery system differences.

Innate and procured immunity inside the digestive tract of the medicinal leech

Especially when combined with unique biological adaptations, invertebrate animals provide important insights into innate immunity because the immune response is not complicated by adaptive immunity that vertebrates evolved. One such example is the digestive tract of the medicinal leech, Hirudo verbana, which is unusual in two aspects, it contains a simple microbial community and it stores large amounts of vertebrate blood for a several months. In this review we will discuss aspects of the innate immunity of the leech and from the ingested blood that we term procured immunity to differentiate it from the immunity encoded by the leech genome.