Präoperative Physiotherapie vor viszeralen abdominalen Operationen digital umsetzen? – Eine qualitative Machbarkeitsstudie

Hintergrund Große Operationen am Bauchraum stellen die größte Gruppe der Operationen in Deutschland dar. Besonders Patient*innen mit Komorbiditäten zeigen ein hohes Risiko für die Entwicklung postoperativer respiratorischer Komplikationen und damit einhergehend postoperativer Einbußen der körperlichen Funktionsfähigkeit. Obwohl präoperative Physiotherapie positiven Einfluss auf die Komplikationsrate nehmen kann, wird sie in Deutschland nicht regelhaft umgesetzt.

Ziel Untersuchung der Machbarkeit einer digitalen Umsetzung präoperativer Physiotherapie aus der Perspektive von Ärzt*innen, Physiotherapierenden und Patient*innen. Dazu werden Bedarfe an eine digitale Intervention sowie inhaltliche und technische Anforderungen erfragt.

Methode In einer qualitativen Studie wurden 2 Ärzt*innen, 5 Physiotherapierende und 2 Patienten interviewt. Die Daten wurden transkribiert und mittels qualitativer Inhaltsanalyse nach Schreier 35 ausgewertet.

Ergebnisse Die Ergebnisse bestätigten die hohe Relevanz der präoperativen Versorgung. Digitale Interventionen können die in diesem Zusammenhang existierende Versorgungslücke schließen. Die formulierten Anforderungen an eine Individualisierung und einen motivierenden Charakter können insbesondere durch Apps realisiert werden.

Diskussion Die zu entwickelnde App soll darauf abzielen 1.) eine Verhaltensänderung anzubahnen, 2.) Wissen zu vermitteln und 3.) Übungen anzuleiten. Vor dem Hintergrund der Zielsetzungen und dem Kontext, in dem die App Anwendung finden soll, ist von einer hohen Komplexität bei der Entwicklung und besonders der Implementierung auszugehen. Gleichzeitig ermöglicht die vorgelegte Analyse eine direkte Bearbeitung der identifizierten Herausforderungen.

Schlussfolgerung Die Entwicklung einer App als Teil der präoperativen Vorbereitung hat das Potenzial, eine aktuelle Versorgungslücke zu schließen und die möglichen negativen Folgen einer Operation zu adressieren. Die vorgelegte Studie gibt Hinweise für die nächsten Entwicklungsschritte.

Eine theoriegeleitete Implementierung von Messinstrumenten in der physiotherapeutischen Versorgung einer Stroke Unit

Hintergrund Der Einsatz von Messinstrumenten objektiviert und unterstützt die klinische Entscheidungsfindung von Physiotherapierenden bei Planung, Durchführung und Evaluation einer Therapie. Die dadurch erhaltenen Informationen ermöglichen eine patientenzentrierte Versorgung und haben das Potential, die interprofessionelle Kommunikation zu verbessern. Trotz der genannten Vorteile findet die Nutzung von Messinstrumenten im klinischen Alltag bislang keine ausreichende Anwendung.

Ziel Systematische Implementierung von Messinstrumenten in die physiotherapeutische Versorgung der Stroke Unit des Universitätsklinikums Münster mithilfe des „Implementation of Change Model“. Zudem wird evaluiert, ob durch eine Anwendung des Modells eine gesteigerte Nutzung der Messinstrumente festgestellt werden kann.

Methode Zur Implementierung von Messinstrumenten wurde das Implementation of Change Model schrittweise mit diversen Methoden umgesetzt. Zur Ergebnisevaluation wurden quantitative (Fragebogenerhebung) und qualitative Forschungsmethoden (Fokusgruppendiskussion) angewandt.

Ergebnisse Nach Abschluss der Erprobungsphase, Auswertung der Dokumentation, der Befragungen sowie einer Diskussion zeigte sich, dass durch Anwendung des Implementation of Change Models die Nutzung von Messinstrumenten bei Patient*innen mit Schlaganfall gesteigert werden konnte. Aus Sicht der Befragten nahm die Überzeugung über den klinischen Nutzen von Messinstrumenten zu. Es konnte auch eine subjektive Verbesserung der Qualität der Behandlung festgestellt werden.

Schlussfolgerung Das Implementation of Change Model eignet sich zur systematischen Anwendung durch eine Gruppe von Physiotherapierenden in der Akutversorgung, wodurch sich die Nutzung von Messinstrumenten bei Patient*innen mit Schlaganfall steigerte. Es wird empfohlen, weitere Erkenntnisse mit einer größeren Gruppe von Therapierenden und in anderen Versorgungsbereichen durchzuführen.

Der physiotherapeutische Takt

Hintergrund Die Interaktion zwischen Patienten und Therapeuten gilt als unspezifischer Wirkfaktor in der physiotherapeutischen Behandlung. Neben praktischen, interpersonalen und kommunikativen Fähigkeiten beeinflussen organisatorische Rahmenbedingungen die Interaktion.

Ziel In dieser Arbeit erfolgte eine handlungsfeldspezifische Analyse der Interaktion zwischen Patienten und Therapeuten in ambulanten Physiotherapiepraxen. Dabei wurde der Frage nachgegangen, welche Merkmale die Interaktion in der ambulanten Praxis charakterisieren und welche Bedeutung die Rahmenbedingungen der ambulanten Praxis in diesem Zusammenhang haben.

Methode Die Studie wurde gemäß der Grounded Theory nach Corbin und Strauss konzipiert 1 2. Das Datenmaterial umfasste Videoaufzeichnungen von Behandlungen, Protokolle des lauten Denkens der aufgezeichneten Behandlungen, Feldprotokolle von Beobachtungen und Transkriptionen von Interviews. Nach dem Prinzip des Contrast Samplings wurden nach Rahmenbedingungen und Therapeutenmerkmalen differenzierte Situationen aufgenommen. Das Datenmaterial wurde transkribiert und interpretativ-kodierend ausgewertet. In die Studie waren insgesamt 9 in ambulanten Praxen arbeitende Therapeuten eingeschlossen.

Ergebnisse Der Takt der ambulanten Physiotherapiepraxis wurde ausgehend von der zentralen Anforderung „immer im Takt bleiben“ definiert. Organisatorisch-strukturelle, therapeutisch-inhaltsbezogene und beziehungsbezogene Aufgaben sind Dimensionen dieses Takts. Sie verdeutlichen, dass pauschale Zeitvorgaben einem situationsspezifischen und patientenzentriertem Vorgehen entgegenstehen.

Schlussfolgerung Der Takt der ambulanten Physiotherapiepraxis eröffnet eine Perspektive auf Anforderungen in der ambulanten Praxis. Dieser stellt ein heuristisches Modell dar, welches den gelungenen Umgang mit den Widersprüchlichkeiten beschreibt und insbesondere die situations- und beziehungsbezogenen Aspekte berücksichtigt.

Case of the month: January 1999--Fetus with echogenic mass in third ventricle

A 29-week gestational age newborn male infant was found to have an echogenic mass in the 3rd ventricle by prenatal ultrasound 2 weeks prior to delivery. At delivery he was poorly responsive and had hydrocephalus and ascites. A CT scan after birth showed cerebral infarction, amorphous tissue in the left hemisphere and numerous calcifications. Despite supportive treatment he died 4 days after birth. Postmortem examination of the brain revealed marked distortion of the architecture and a supratentorial undifferentiated neoplasm consistent with a PNET. The tumor showed extensive areas of hemorrhage and necrosis and involvement of lateral and third ventricles, brain parenchyma, and meninges.

Transcriptional regulation of the BCL-X gene by NF-kappaB is an element of hypoxic responses in the rat brain

Signal transduction pathways that mediate neuronal commitment to apoptosis involve the nuclear factor kappa B (NF-kappaB) transcription factor. The bcl-x gene is a member of the bcl-2 family of genes that regulate apoptosis, and gives rise to two proteins, Bcl-XL and Bcl-XS, via alternative mRNA splicing. BCl-XL protein, like Bcl-2, is a dominant inhibitor of apoptotic cell death, whereas Bcl-XS promotes apoptosis. While there is high expression of Bcl-XL in the developing and adult brain, few transcriptional control elements have been identified in the bcl-x promoter. There are two functional nuclear factor-kappa B (NF-kappaB) DNA binding sites clustered upstream of the brain-specific transcription start site in the upstream promoter region of murine bcl-x. Recombinant NF-kappaB proteins bind to these sites. Also NF-kappaB overexpression, coupled with bcl-x promoter/reporter assays using a series of murine bcl-x promoter and deletion mutants, has identified the downstream 1.1kb of the bcl-x promoter as necessary for basal promoter activity and induction by NF-kappaB in support of the hypothesis that NF-kappaB can act to enhance BCl-XL expression via highly selective interactions with the bcl-x promoter, where NF-kappaB binding and promoter activation are dependent on specific DNA binding site sequences and NF-kappaB protein dimer composition. Hypoxia induces apoptosis in the hippocampus where the NF-kappaB dimers c-Rel/p50 and p50/pS0 bind to the bcl-x promoter NF-kappaB site.

Chronic ethanol exposure during late gestation produces behavioral anomalies in neonatal lambs

A total of 45 pregnant ewes were assigned to one of three treatment groups: 1 g ethanol/kg maternal body weight (n = 18); pair-fed control (n = 15); and ad lib control (n = 12). Dosing started at gestational day (GD) 106, and was administered every other day until GD 134. Parturition occurred between GD 144 and 147. Analysis of the placentas indicated that ethanol exposure decreased cotyledon diameter and cotyledon weight compared to the control groups (p < 0. 05). At birth, lambs were given a Vigor Score and then behavior was assessed using a videotape monitoring system for 24 h. Offspring in the ethanol treatment group were significantly less vigorous at birth (p < 0.05). This finding reversed during the subsequent 24 h such that the ethanol-exposed lambs were significantly more active (p = 0.001) than the control lambs. Morphometric and histologic examination of the cerebral cortex and hippocampus revealed no differences amongst the three treatment groups. Collectively, the data demonstrate that moderate ethanol exposure during the third-trimester equivalent of gestation can produce placental dysmorphology and postnatal behavioral anomalies in neonatal lambs in the absence of gross neurologic injury.

Pharmacology and toxicology of chronically infused epidural clonidine.HCl in dogs

To evaluate the physiological effects and toxicity of epidural clonidine.HCl, male Beagle dogs were prepared with chronic lumbar epidural catheters and administered constant infusions of either saline (N = 10), or 80 micrograms/hr (N = 6), 200 micrograms/hr (N = 6), or 320 micrograms/hr (N = 12) clonidine.HCl at a rate of 4 ml/24 hr for 28 days. Saline infusion had no effect upon any behavioral measure. Epidural clonidine produced a dose-dependent increase in thermal skin-twitch response latency (antinociception), lowering of respiration rate, heart rate, and blood pressure, and increased sedation. The effects were maximum from approximately Day 1 to Day 3 when, with the exception of respiration which remained depressed, a progressive adaptation was observed over the course of the study. There were no negative effects on body weight, body temperature, motor function, bowel or bladder function, or clinical pathology values. After 28 days of continuous infusion, the dogs were deeply anesthetized and terminated. Cisternal cerebrospinal fluid taken at termination displayed no clinically significant differences in protein or glucose concentration. All groups, including control, had dogs which had a chronic inflammatory response in the epidural space, as represented by fibrosis, foreign body giant cells, and lymphocytes, but no spinal cord pathology. Both the steady-state plasma and CSF concentrations of clonidine were proportional to the dose; the ratio of CSF to plasma concentration was approximately 0.5. The failure to see any change in CSF composition, significant spinal cord pathology, or signs of tissue or organ toxicity emphasizes the safety of epidurally administered clonidine at infusion rates up to 320 micrograms/hr and at infusate concentrations up to 2 mg/ml.

Occurrence of prosaposin as a neuronal surface membrane component

Prosaposin is a precursor of four saposins that are required for the lysosomal hydrolysis of sphingolipids by specific hydrolases. Besides its precursor role, prosaposin also exists as a secreted protein. The present investigation reveals that prosaposin also exists as an integral component of the surface membranes of neuronal cells. Subcellular fractionation studies demonstrate that the membrane-bound prosaposin occurs specifically in plasma membranes of NS20Y rat neuroblastoma cells. An immunohistochemical study of the neuroblastoma cells using rat prosaposin-specific antibodies also showed that a portion of prosaposin is located on the surface of neurites as well as on cell bodies. Similar histochemical studies with antibodies that specifically recognized human prosaposin revealed the presence of prosaposin in dendrites, axons, and cell bodies of subcortical and spinal cord neurons in both human adult brain and in fetal brain (24-wk gestation). These findings suggest an important role of prosaposin in neuronal development.

Caudal regression versus sirenomelia: sonographic clues

Seven cases with the pathologic/autopsy diagnosis of caudal regression or sirenomelia in which antenatal sonography had been performed were reviewed. The three patients with caudal regression had similar findings on antenatal sonogram, including normal or increased amniotic fluid, mild dilation or normal urinary systems, nonfused extremities, and sacral agenesis. In the four patients with sirenomelia, common sonographic findings included marked oligohydramnios, suspected renal agenesis, and sacral agenesis. A history of maternal diabetes was elicited in all patients with caudal regression and in none of the patients with sirenomelia. Findings confirm recent articles in pediatric pathology suggesting that caudal regression is a separate entity, distinct from sirenomelia.

Umbilical cord haemangioma associated with an eruptive cutaneous haemangioma in a female infant

We report a female infant noted prenatally to have an umbilical cord mass. At birth, a labial strawberry haemangioma was noted. She subsequently developed an abdominal mass which was discovered to be a proliferating haemangioma, continuous with both the labial and the umbilical stump lesions.

In vivo myeloarchitectonic analysis of human striate and extrastriate cortex using magnetic resonance imaging

A primary goal of investigations into the organization of human cerebral cortex is to determine the functional specificity of architectonic regions. This includes the correlation of neurobehavioral deficits with neuropathological data for clinical diagnosis and treatment, and the identification of active brain regions using functional neural imaging techniques, such as positron emission tomography, electroencephalographic and magnetoencephalographic (EEG and MEG) source localization algorithms, and direct cortical stimulation. Currently, the architectonic classification of a cortical region identified by these methods is inferred from the comparison of its cerebral topographic position to cytoarchitectonic brain atlases. However, substantial intersubject variability in the position of cytoarchitectonic regions with respect to cerebral topographic landmarks may lead to errors in this procedure. An alternative method is presented here, which uses magnetic resonance (MR) imaging to identify myeloarchitectonic regions of isocortex directly by estimating the relative concentration of myelin within cortical laminae. This high-resolution MR protocol is used to identify striate cortex (Brodmann's area 17) and extrastriate cortex in vivo. Correspondence of MR signal intensity with myeloarchitectonic data from a postmortem brain confirms this identification. As MR imaging technology improves, this noninvasive method has the potential to identify and discriminate among at least 50 cortical regions in the living human brain.

Neocortical damage during HIV infection

Clinical and pathological evidence of subcortical central nervous system (CNS) damage is observed commonly in patients with human immunodeficiency virus (HIV) encephalitis. Whether other CNS regions are also affected has not been well studied. We report neocortical damage in patients with HIV encephalitis. Using quantitative techniques, we demonstrate statistically significant thinning of the neocortex, with a loss of large cortical neurons. Qualitative and quantitative assessments of neocortical neuropil reveal a loss of synaptic density and vacuolation of dendritic processes. Failure to demonstrate an association of these changes with the presence of HIV antigens suggests that neocortical damage may be an indirect effect of HIV infection of the CNS.

Interstitial deletion of chromosome 2q associated with ovarian dysgenesis

In the present report we describe a girl with mental retardation, Dandy-Walker malformation, craniofacial anomalies, cardiac defect, and ovarian dysgenesis associated with an interstitial deletion of chromosome 2. The interstitial deletion in the proband was associated with an apparently balanced translocation involving chromosomes 2 and 7 in the father.

The cerebellum: 3. Anatomic-MR correlation in the coronal plane

Thin (5-mm) coronal high-field (1.5-T) MR images of four human brain specimens and 14 normal volunteers were correlated with myelin-stained microtomic sections of the specimen cerebella. The primary white-matter tracts innervating several hemispheric (posterior quadrangular, superior, and inferior semilunar, gracile, biventer, tonsil) and vermian (declive, folium, tuber) lobules are oriented perpendicularly to the coronal plane of section and are shown well on proton-density-weighted (long TR/short TE) and T2-weighted (long TR/long TE) spin-echo images, which provide excellent contrast between gray and white matter. Several of the surface sulci and fissures of the cerebellar hemispheres (including the superior posterior, horizontal, secondary, and posterolateral fissures) also course perpendicular to the coronal plane and are depicted well on T1-weighted (short TR/short TE) and T2-weighted images, which maximize contrast between CSF and parenchyma. The opportunity for side-to-side comparison of the hemispheres is a distinct advantage of the coronal view. Nevertheless, more obliquely oriented surfaces (preculminate, primary, inferior posterior, inferior anterior, and intrabiventral fissures) and deep hemispheric structures (primary white-matter tracts to central, anterior quadrangular, and floccular lobules) may be obscured by volume-averaging in the coronal plane; moreover, much of the finer anatomy of the vermis is depicted poorly. The constant surface and deep anatomy of the cerebellum revealed on coronal images in normal volunteers encourages detailed mapping. MR imaging in the coronal plane should be especially useful in identifying, localizing, and quantifying normal and abnormal morphologic differences between the cerebellar hemispheres.

The cerebellum: 3. Anatomic-MR correlation in the coronal plane

Thin (5-mm) coronal high-field (1.5-T) MR images of four human brain specimens and 14 normal volunteers were correlated with myelin-stained microtomic sections of the specimen cerebella. The primary white-matter tracts innervating several hemispheric (posterior quadrangular, superior, and inferior semilunar, gracile, biventer, tonsil) and vermian (declive, folium, tuber) lobules are oriented perpendicularly to the coronal plane of section and are shown well on proton-density-weighted (long TR/short TE) and T2-weighted (long TR/long TE) spin-echo images, which provide excellent contrast between gray and white matter. Several of the surface sulci and fissures of the cerebellar hemispheres (including the superior posterior, horizontal, secondary, and posterolateral fissures) also course perpendicular to the coronal plane and are depicted well on T1-weighted (short TR/short TE) and T2-weighted images, which maximize contrast between CSF and parenchyma. The opportunity for side-to-side comparison of the hemispheres is a distinct advantage of the coronal view. Nevertheless, more obliquely oriented surfaces (preculminate, primary, inferior posterior, inferior anterior, and intrabiventral fissures) and deep hemispheric structures (primary white-matter tracts to central, anterior quadrangular, and floccular lobules) may be obscured by volume-averaging in the coronal plane; moreover, much of the finer anatomy of the vermis is depicted poorly. The constant surface and deep anatomy of the cerebellum revealed on coronal images in normal volunteers encourages detailed mapping. MR imaging in the coronal plane should be especially useful in identifying, localizing, and quantifying normal and abnormal morphologic differences between the cerebellar hemispheres.

The cerebellum in sagittal plane--anatomic-MR correlation: 2. The cerebellar hemispheres

Thin (5-mm) sagittal high-field (1.5-T) MR images of the cerebellar hemispheres display (1) the superior, middle, and inferior cerebellar peduncles; (2) the primary white-matter branches to the hemispheric lobules including the central, anterior, and posterior quadrangular, superior and inferior semilunar, gracile, biventer, tonsil, and flocculus; and (3) several finer secondary white-matter branches to individual folia within the lobules. Surface features of the hemispheres including the deeper fissures (e.g., horizontal, posterolateral, inferior posterior, and inferior anterior) and shallower sulci are best delineated on T1-weighted (short TR/short TE) and T2-weighted (long TR/long TE) sequences, which provide greatest contrast between CSF and parenchyma. Correlations of MR studies of three brain specimens and 11 normal volunteers with microtone sections of the anatomic specimens provides criteria for identifying confidently these structures on routine clinical MR. MR should be useful in identifying, localizing, and quantifying cerebellar disease in patients with clinical deficits.

The cerebellum in sagittal plane--anatomic-MR correlation: 1. The vermis

Correlation of thin (5-mm) sagittal high-field (1.5-T) MR images of three brain specimens and 11 normal volunteers with microtome sections of the human cerebellar vermis and hemispheres demonstrates that proton-density-weighted (long TR/short TE) and T2-weighted (long TR/long TE) spin-echo pulse sequences provide the greatest contrast between gray and white matter. These images also can display (1) the corpus medullare and primary white-matter branches to the vermian lobules, including the lingula, centralis, culmen, declive, folium, tuber, pyramis, uvula, and nodulus; and (2) several finer secondary branches to individual folia within the lobules. Surface features of the vermis including the deeper fissures (e.g., preculminate, primary, horizontal, and prepyramidal) and shallower sulci are best delineated by T1-weighted (short TR/short TE) and T2-weighted images, which provide greatest contrast between CSF and parenchyma. Given that the width of the normal vermis varied from 6 to 12 mm in our volunteers, the acquisition of thin slices (less than or equal to 5 mm) was required to minimize volume averaging of the cerebellar hemispheres with the vermis on a midline sagittal MR section. Knowledge of the detailed normal anatomy of the cerebellar vermis on sagittal MR images can assist in the identification of various pathologic alterations.

Infantile Gaucher's disease: a case with neuronal storage

The brain of a 17-month-old boy with infantile Gaucher's disease and oculomotor apraxia was studied by light and electron microscopy. Light microscopic examination showed large perivascular accumulations of Gaucher's cells in frontal lobe white matter, severe neuronal loss in the calcarine cortex and dentate nucleus of the cerebellum, and neuronophagia and microglial nodules in the brainstem. Electron microscopy demonstrated intraneuronal cytoplasmic inclusions containing twisted tubules characteristic of Gaucher's disease in both the oculomotor nucleus and a random sample of cortex.

Human immunodeficiency virus (HIV) and JC virus in acquired immune deficiency syndrome (AIDS) patients with progressive multifocal leukoencephalopathy

Of the 93 acquired immune deficiency syndrome (AIDS) patients autopsied between 1983 and 1986, 27 had evidence of viral encephalitis of which 3 had progressive multifocal leukoencephalopathy (PML), confirmed by electron microscopy. Using in situ hybridization with biotinylated JC virus probes, paraffin sections from the brains of these 27 patients were examined. JC virus was found only in those patients with histologically proven PML, while no evidence of JC virus was detected in the brains of the other 24 AIDS patients despite the presence of white matter pathology. Brain biopsies of the PML patients demonstrated human immunodeficiency virus (HIV)-infected macrophages infiltrating regions of demyelination. When the patients died (2 to 6 months after diagnosis of PML), many more macrophages contained HIV antigens and some had fused to form multinucleated giant cells. These findings suggest that in AIDS patients, papovaviruses not only cause damage by directly infecting oligodendroglia but causes additional damage by eliciting the ingress of macrophages latently infected with HIV. As was seen with other infections (e.g., cytomegalovirus) of the CNS this might be a general mechanism of HIV entry into the brain.