[Quality in acute inpatient rheumatology 2021 : Current aspects of the KOBRA quality label of the Association of Rheumatological Acute Care Clinics]

Mit einer umfassenden gesundheitspolitischen Qualitätsoffensive ab 2021 sollen die Qualität und Transparenz in der Versorgung von Menschen mit Krankheiten in Krankenhäusern in Deutschland verbessert werden. Gesetzliche Vorgaben zu Mindestmengen und die Ausweitung von Qualitätsverträgen zwischen Kostenträgern und Krankenhäusern sowie die Verwendung von planungsrelevanten Qualitätsindikatoren für eine bedarfs- und qualitätsorientierte Weiterentwicklung der stationären Versorgung werden den Wettbewerb in der Versorgungsqualität zwischen den Krankenhäusern verstärken. Dem Thema „Entwicklung und Definition von Qualität in der Medizin“ hat sich auch der Verband der Rheumatologischen Akutkliniken e. V. (VRA) schon früh nach der Gründung im Jahr 1998 umfassend angenommen. Im Zentrum der akutstationären Qualitätssicherung stehen verbindlich festgelegte Strukturkriterien in Verknüpfung mit dem 2003 in der Rheumatologie gestarteten und bis heute kontinuierlich durchgeführten KOBRA-Projekt (Kontinuierliches Outcome Benchmarking in der Rheumatologischen Akutversorgung) mit der Messung von Prozess- und Ergebnisqualität. Auf der Basis dieses Rahmenkonzeptes (Erfüllung der Strukturkriterien und Durchführung des KOBRA-Projektes) können erfolgreich teilnehmende rheumatologische Einrichtungen für jeweils 2 Jahre das KOBRA-Label erwerben, welches von der Projektleitung – dem aQua-Institut – vergeben wird. Die herausragende Stellung des KOBRA-Projektes wird beispielhaft anhand von Datenauswertungen des Projektzyklus 2018 gezeigt mit Auswertungen zum Therapiestrategiewechsel bei aktiver rheumatoider Arthritis, Diagnosesicherung von Kollagenosen und Vaskulitiden während des stationären Aufenthaltes sowie zur partizipativen Entscheidungsfindung bei rheumatoider Arthritis. Auf den gesundheitspolitisch geforderten „Paradigmenwechsel – weg vom Bett, hin zu einer leistungs-, bedarfs- und qualitätsorientierten Planung“ – ist die akutstationäre Rheumatologie mit der Verankerung von Projekten zur Struktur‑, Prozess- und Ergebnisqualität sehr gut vorbereitet. Für die in der vom Gemeinsamen Bundesausschuss (G-BA) erstellten Richtlinie zu „Rheumatologischen Zentren“ geforderten Qualitätssicherung ist das KOBRA-Projekt ebenfalls eine sehr gute Voraussetzung.

[Future of acute inpatient rheumatology in Germany : Statement of the Boards of the German Society for Rheumatology and the Association of Rheumatological Acute Clinics on hospital planning North-Rhine/Westphalia 2019 for the discipline rheumatology]

Im September 2019 wurde vom Ministerium für Arbeit, Gesundheit und Soziales (MAGS) in NRW ein Gutachten zur Krankenhausplanung veröffentlicht. Hierin wurde eine grundlegende Reform der Krankenhausplanung empfohlen, indem zukünftig eine Bedarfsplanung auf der Grundlage einer detaillierten Ausweisung von Leistungsbereichen und Leistungsgruppen erfolgen soll. Nach Aufforderung durch das MAGS NRW hat auch die Deutsche Gesellschaft für Rheumatologie (DGRh) mit Unterstützung des Verbandes Rheumatologischer Akutkliniken (VRA) hierzu Stellung genommen.

Pulmonary hemodaynamic in obesity

Background

Higher prevalence of pulmonary hypertension exist in obesity subjects. Little known about pulmonary hemodynamics during exercise in obesity population.

Purpose

To assess and compare the response of pulmonary vascular resistance during exercise in obese subjects vs healthy controls.

Methods

Seventeen obesity subjects (gender: 25%men, age: 44±11 years, height: 1.7±0.1 m, weight: 111±17 kilogram, BMI: 38±4 kg/m2) were compared to twenty gender-, age-, height- and race-matched healthy control subjects (age: 46±12 years, height: 1.7±0.1 m, weight: 64±11 kilogram, BMI: 22±2 kg/m2). All subjects underwent an incremental exercise stress echocardiography with measurements of pulmonary artery pressure (PAP), cardiac output (CO), cardiac index (CI) and tricuspid annular plane systolic excursion (TAPSE) at rest and at increasing exercise intensities. Total pulmonary vascular resistance index (PVRi) was calculated as mean PAP/CI and right ventricular-arterial coupling as TAPSE/systolic PAP.

Results

The results are described in the table 1. Pulmonary hemodynamic was not different at rest between two groups, but lower at maximal exercise in obesity subjects. In obesity subjects, identical exercise level was associated with a higher mean PAP and PVRi, and a lower TAPSE/systolic PAP ratio.

Conclusion

While pulmonary hemodynamic seems preserved at rest in obesity patients, pulmonary vascular resistance is increased and right ventricular coupling is decreased, particularly at exercise.

Funding Acknowledgement

Type of funding source: None

Prenatal prediction of postnatal large-for-dates neonates using a simplified MRI method: comparison with conventional 2D ultrasound estimates

OBJECTIVE

To evaluate the performance of a simple semi-automated method for estimation of fetal weight (EFW) using magnetic resonance imaging (MRI) as compared with two-dimensional (2D) ultrasound (US) for the prediction of large-for-dates neonates.

METHODS

Data of two groups of women with singleton pregnancy between March 2011 and May 2016 were retrieved from our database and evaluated retrospectively: the first group included women who underwent US-EFW and MRI-EFW within 48 h before delivery and the second group included women who had these evaluations between 35 + 0 weeks and 37 + 6 weeks of gestation, more than 48 h before delivery. US-EFW was based on Hadlock et al. and MRI-EFW on the formula described by Baker et al. For MRI-EFW, planimetric measurement of the fetal body volume (FBV) was performed using a semi-automated method and the time required for measurement was noted. Outcome measure was the performance of MRI-EFW vs US-EFW in the prediction of large-for-dates neonates, both ≤ 48 h and > 48 h before delivery. Receiver-operating characteristics (ROC) curves for each method were compared using the DeLong method.

RESULTS

Of the 270 women included in the first group, 48 (17.8%) newborns had birth weight ≥ 90^th centile and 30 (11.1%) ≥ 95^th centile. The second group included 83 women, and nine (10.8%) newborns had birth weight ≥ 95^th centile. Median time needed for FBV planimetric measurements in all 353 fetuses was 3.5 (range, 1.5-5.5) min. The area under the ROC curve (AUC) for prediction of large-for-dates neonates by prenatal MRI performed within 48 h before delivery was significantly higher than that by US (for birth weight ≥ 90^th centile, difference between AUCs = 0.085, standard error (SE) = 0.020, P < 0.001; for birth weight ≥ 95^th centile, difference between AUCs = 0.036, SE = 0.014, P = 0.01). Similarly, MRI-EFW was better than US-EFW in predicting birth weight ≥ 95^th centile when both examinations were performed > 48 h prior to delivery (difference between AUCs = 0.077, SE = 0.039, P = 0.045).

CONCLUSION

MRI planimetry using our purpose-designed semi-automated method is not time-consuming. The predictive performance of MRI-EFW performed immediately prior to or remote from delivery is significantly better than that of US-EFW for the prediction of large-for-dates neonates. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Limiting mechanisms of force production after repetitive dynamic contractions in human triceps surae

The influence of repetitive dynamic fatiguing contractions on the neuromuscular characteristics of the human triceps surae was investigated in 10 subjects. The load was 50% of the torque produced during a maximal voluntary contraction, and the exercise ended when the ankle range of motion declined to 50% of control. The maximal torque of the triceps surae and the electromyographic (EMG) activities of the soleus and medial gastrocnemius were studied in response to voluntary and electrically induced contractions before and after the fatiguing task and after 5 min of recovery. Reflex activities were also tested by recording the Hoffmann reflex (H reflex) and tendon reflex (T reflex) in the soleus muscle. The results indicated that whereas the maximal voluntary contraction torque, tested in isometric conditions, was reduced to a greater extent (P < 0.05) at 20 degrees of plantar flexion (-33%) compared with the neutral position (-23%) of the ankle joint, the EMG activity of both muscles was not significantly reduced after fatigue. Muscle activation, tested by the interpolated-twitch method or the ratio of the voluntary EMG to the amplitude of the muscle action potential (M-wave), as well as the neuromuscular transmission and sarcolemmal excitation, tested by the M-wave amplitude, did not change significantly after the fatiguing exercise. Although the H and T reflexes declined slightly (10-13%; P < 0.05) after fatigue, these adjustments did not appear to have a direct deleterious effect on muscle activation. In contrast, alterations in the mechanical twitch time course and postactivation potentiation indicated that intracellular Ca(2+)-controlled excitation-contraction coupling processes most likely played a major role in the force decrease after dynamic fatiguing contractions performed for short duration.

Recombinant mouse-human chimeric antibodies as calibrators in immunoassays that measure antibodies to Toxoplasma gondii

In the present study, we examined the feasibility of using recombinant antibodies containing murine variable regions and human constant regions as calibrators or controls in immunoassays. As a model system, we chose the Abbott IMx Toxo immunoglobulin M (IgM) and Toxo IgG assays designed to detect antibodies to Toxoplasma gondii. Two mouse monoclonal antibodies were selected based on their reactivity to the T. gondii antigens P30 and P66. Heavy- and light-chain variable-region genes were cloned from both hybridomas and transferred into immunoglobulin expression vectors containing human kappa and IgG1 or IgM constant regions. The constructs were stably transfected into Sp2/0-Ag14 cells. In the IMx Toxo IgG assay, immunoreactivity of the anti-P30 chimeric IgG1 antibody paralleled that of the positive human plasma-derived assay calibrators. Signal generated with the anti-P66 chimeric IgG1 antibody was observed to plateau below the maximal reactivity observed for the assay calibrator. Examination of the IgM chimeric antibodies in the IMx Toxo IgM assay revealed that both the anti-P30 and anti-P66 antibodies matched the assay index calibrator manufactured with human Toxo IgM-positive plasma. When evaluated with patient samples, the correlation between results obtained with the chimeric antibody calibrators and the positive human plasma calibrators was > or =0.985. These data demonstrate that chimeric mouse-human antibodies are a viable alternative to high-titer positive human plasma for the manufacture of calibrators and controls for diagnostic assays.

[Renal hemodynamics and proteinuria in chronic glomerulonephritis treated with beta-receptor blockers or ace inhibitors]

BACKGROUND AND OBJECTIVE

In patients with chronic glomerular nephropathy associated arterial hypertension and proteinuria are considered to be cardinal risk factors in the progressive deterioration of renal function. Treatment regimens which reduce proteinuria and hypertension improve prognosis. The effect of the new beta-receptor blockers compared to common ACE-Inhibitors is of special interest.

PATIENTS AND METHODS

The studied cohort consisted of 11 patients with CGN, hypertension and proteinuria > 400 mg/24 h. Four drugs were given for 4 weeks, doubly blinded and randomized according to a "Latin-square design": Celiprolol (beta-1-antagonist, beta-2-agonist, 200 mg/d), Atenolol (selective beta-1-antagonist, 50 mg/d), Ramipril (ACE-inhibitor, 2.5 mg/d) and placebo. There was a two-week wash-out phase between each of the four treatment phases. At the end of each treatment phase glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured by inulin and para-amino-hippuric acid (PAH) clearance. Proteinuria was determined in the course of a three-day collection period at the end of each treatment phase. During this period blood pressures were measured with a continuous 24-hour blood pressure monitor.

RESULTS

Mean arterial blood pressure (MAP) was significantly reduced, compared with placebo, by all three antihypertensives (108 +/- 9 mm Hg with placebo, 98 +/- 12 mg Hg with atenolol, 101 +/- 11 mm Hg with celiprolol and 98 +/- 8 mm Hg with ramipril; P < 0.01). Celiprolol produced a significant rise In ERPF (322 +/- 109 ml/min with placebo, 391 +/- 110 ml/min with celiprolol: P < 0.05). GFR was slightly, but not significantly, reduced by celiprolol and atenolol. Filtration fraction remained unchanged with atenolol and celiprolol, while it was slightly, but not significantly, reduced with ramipril. Compared with the placebo, all three drugs significantly reduced proteinuria (P < 0.05): 1.8 +/- 1.3 g/24 h with placebo, 1.2 +/- 1.2 g/24 h with atenolol, 1.2 +/- 1.1 g/24 h with celiprolol and 1.4 +/- 1.4 g/24 h with ramipril.

CONCLUSION

These data indicate that, in addition to ACE inhibitors, the new generation of beta-receptor blockers in particular, because of their vasodilator action, favourably influence proteinuria and renal blood flow in patients with CGN and arterial hypertension.

Randomized controlled trial of ACE-inhibitors and beta-blockers with and without vasodilating activity in chronic glomerulonephritis

A prospective double-blind, randomized study was conducted to compare the effects of the beta 1 antagonist, beta 2 agonist celiprolol (200 mg daily) on renal hemodynamics and protein excretion with those of the beta 1 antagonist atenolol (50 mg daily), the ACE-inhibitor ramipril (2.5 mg daily), and placebo in 11 patients with proteinuria > 400 mg/24 h due to chronic glomerulonephritis. All 4 substances were given in a double-blind, randomized manner according to a latin-square design over a period of 4 weeks with a wash-out period of 2 weeks in between. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured by inulin and PAH clearance. Proteinuria was assessed by urine sampling at the end of each treatment period. Mean arterial pressure (MAP) was reduced significantly (p < 0.01) by all 3 drugs compared to placebo (108 +/- 9 mmHg placebo, 98 +/- 12 mmHg atenolol, 101 +/- 11 mmHg celiprolol, and 98 +/- 8 mmHg ramipril). Celiprolol induced a significant increase in ERPF compared to placebo (322 +/- 109 ml/min under placebo versus 391 +/- 110 ml/min under celiprolol, p < 0.05). GFR was slightly but insignificantly increased under atenolol and celiprolol. Filtration fraction (FF) remained unchanged in case of atenolol and celiprolol treatment and was slightly but not significantly reduced by ramipril. Proteinuria was significantly (p < 0.05) reduced compared to placebo by all 3 drugs (1.8 +/- 1.3 g/24 h under placebo, 1.2 +/- 1.2 g/24 h under atenolol, 1.2 +/- 1.1 g/24 h under celiprolol, and 1.4 +/- 1.4 g/24 h under ramipril). These data demonstrate that new beta-blocking agents show favorable effects on proteinuria and renal blood flow in patients with chronic glomerulonephritis and arterial hypertension. This may be attributed to their vasodilating properties.

Antigens produced by recombinant DNA technology

Some of the greatest beneficiaries of the revolutionary advances in biotechnology over the past 15 years have been producers of diagnostic reagents, especially for the cloning and expression of antigens, primarily of viral origin. Recombinant DNA technology provides methods for producing antigens for diagnostic assays that are more highly purified, more specific, and safer to produce than viral culture and that are significantly less expensive to manufacture. Antigens so produced can be used for production of antibodies or antisera for competition assays, as reagents for mapping epitopes, as affinity-chromatography ligands for purification of antibodies or protein, and as research reagents. Their initial use in some hepatitis B assays may be primarily a cost-reduction application, but in other applications (e.g., HIV diagnostic tests) they present the first opportunity to commercially produce an otherwise very expensive antigen. Recombinant-DNA-produced antigens are also being used to develop safer vaccines, but not, however, without some consideration of the structural nature of immunodominant epitopes and the adequacy of the immune response.

Antigens produced by recombinant DNA technology

Some of the greatest beneficiaries of the revolutionary advances in biotechnology over the past 15 years have been producers of diagnostic reagents, especially for the cloning and expression of antigens, primarily of viral origin. Recombinant DNA technology provides methods for producing antigens for diagnostic assays that are more highly purified, more specific, and safer to produce than viral culture and that are significantly less expensive to manufacture. Antigens so produced can be used for production of antibodies or antisera for competition assays, as reagents for mapping epitopes, as affinity-chromatography ligands for purification of antibodies or protein, and as research reagents. Their initial use in some hepatitis B assays may be primarily a cost-reduction application, but in other applications (e.g., HIV diagnostic tests) they present the first opportunity to commercially produce an otherwise very expensive antigen. Recombinant-DNA-produced antigens are also being used to develop safer vaccines, but not, however, without some consideration of the structural nature of immunodominant epitopes and the adequacy of the immune response.

Genomic organization of major sperm protein genes and pseudogenes in the nematode Caenorhabditis elegans

The major sperm proteins (MSPs) are a family of closely related, small, basic proteins comprising 15% of the protein in Caenorhabditis elegans sperm. They are encoded by a multigene family of more than 50 genes, including many pseudogenes. MSP gene transcription occurs only in late primary spermatocytes. In order to study the genomic organization of transcribed MSP genes, probes specific for the 3' untranslated regions of sequenced cDNA clones were used to isolate transcribed genes from genomic libraries. These and other clones of MSP genes were located in overlapping cosmid clones by DNA fingerprinting. These cosmids were aligned with the genetic map by overlap with known genes or in-situ hybridization to chromosomes. Of 40 MSP genes identified, 37, including all those known to be transcribed, are organized into six clusters composed of 3 to 13 genes each. Within each cluster, MSP genes are not in tandem but are separated by at least several thousand bases of DNA. Pseudogenes are interspersed among functional genes. Genes with similar 3' untranslated sequences are in the same cluster. The six MSP clusters are confined to only three chromosomal loci; one on the left arm of chromosome II and two near the middle of chromosome IV. Additional sperm-specific genes are located in one cluster of MSP genes on chromosome IV. The multiplicity of MSP genes appears to be a mechanism for enhancing MSP synthesis in spermatocytes, and the loose clustering of genes could be a result of the mechanism of gene duplication or could play a role in regulation.

Conservation in the 5' flanking sequences of transcribed members of the Caenorhabditis elegans major sperm protein gene family

The major sperm proteins (MSPs) are encoded in the Caenorhabditis genome by a multigene family with more than 50 genes dispersed in small clusters at three chromosomal loci. In spite of their dispersed locations, all of the MSP genes appear to be expressed at the same time exclusively in the testis, indicating co-ordinate temporal and spatial regulation of these dispersed genes. Many of the MSP genes must be transcribed, because RNA hybridization with gene-specific probes showed that individual genes each contribute less than 3% to the total poly(A)+ RNA, and 13 out of 14 sequenced cDNAs came from different genes. Primer extension assays from MSP mRNA showed that most of the MSP mRNAs must be initiated at position -35 from the translation start codon. Extensive similarity was found in the first 100 nucleotides of genomic sequence flanking the start codons of ten MSP genes from different chromosomal locations. All MSP genes contained a consensus ribosome binding site, a consensus TATA homology 27 nucleotides distal to the site of mRNA initiation, and ten highly conserved nucleotides adjacent to the site of initiation. All the MSP genes contained the sequence AGATCT located approximately 65 nucleotides upstream from the transcriptional start, but little or no similarity was found more distal to this. Some of these conserved sequences may be cis-acting control elements that ensure the cell and temporal specificity of transcription of these co-ordinately regulated genes.

Expression of chimeric genes in Caenorhabditis elegans

We have shown the expression of transformed genes in the nematode Caenorhabditis elegans using a new gene fusion system. Vectors consisting of the flanking regions of a collagen gene (col-1) or a major sperm protein gene of C. elegans fused to the Escherichia coli uidA gene, encoding beta-glucuronidase, were microinjected into worms and found to be propagated as high-copy extrachromosomal tandem arrays. We have detected beta-glucuronidase activity in transformed lines, and have shown that the activity is dependent upon the correct reading frame of the construction and on the presence of the worm sequences. The enzyme activity was shown to be encoded by the chimeric beta-glucuronidase gene by co-segregation analysis and by inactivation with specific antisera. Expression is at a very low level, and seems to be constitutive. We have used histochemical techniques to visualize the enzyme activity in embryos.

Age-correlated changes in the DNA template in the nematode Caenorhabditis elegans

Analysis of DNA from the nematode Caenorhabditis elegans demonstrated a number of significant age-correlated changes. The number of single-strand breaks as assayed by an in vitro assay procedure using Escherichia coli DNA polymerase I increased significantly with age. There was also an exponential increase in the amount of 5-methylcytosine in C. elegans DNA as the worm matured and aged. Furthermore, DNA isolated from older worms exhibited reduced transcriptional capacity when assayed in a HeLa cell in vitro transcription system. Finally, a biological assay to determine age-correlated changes in the DNA of aging sperm demonstrated a significant reduction in the capacity of the sperm to support zygotic development as the age of the male increased. These findings demonstrated significant age-correlated alterations and modifications occurring in the DNA template of the nematode, and their implications to the aging process are discussed.

Changes in the DNA synthesis pattern of paramecium with increased clonal age and interfission time

The clonal age in paramecia refers to the total number of vegetative divisions a clone has undergone since its origin at autogamy (self-fertilization). As clonal age increases, the interfission time usually increases. The DNA synthesis pattern of cells of different ages was compared by autoradiographic analysis of the DNA synthesis of synchronized cells at various time intervals during the cell cycle (from one division to the next). The study showed that the G(1) period (the lag in DNA synthesis post division) was constant, irrespective of interfission time or clonal age; but the duration of the DNA synthesis period increased with increased interfission time or clonal age. Therefore, we have shown for the first time that the G(1) period is fixed, and the S period is increased in a eukaryotic unicellular organism as a function of interfission time and clonal age.

Parental Age and Life Span Versus Progeny Life Span in Paramecium

It has been possible to investigate for the first time at the cellular level, the influence of parental age on progeny life span, using Paramecium. As parental age increased, progeny life span decreased. The process of generating progeny clones from aging parents yielded paramecia with different life spans, allowing the study of the influence of parental life span on progeny life span. We found that parental life span was also a significant variable in the progeny life span. The theoretical basis for cellular aging and rejuvenation (the reinitiation of the life cycle) in paramecia is discussed in relation to the present data and previous studies.