Full-length-transcriptomic analysis in mice and human heart using Single-Molecule Real-time Sequencing (SMRT) identified 15 novel isoforms and a novel promoter region of PGC1-alpha

Background

Alternative splicing is a process by which exons within a pre-mRNA are joined or skipped, resulting in isoforms being encoded by a single gene. Alternative Splicing affecting transcription factors may have substantial impact on cellular dynamics. The PPARG Coactivator 1 Alpha (PGC1-α), is a major modulator in energy metabolism. Data from murine skeletal muscle revealed distinctive isoform patterns giving rise to different phenotypes, i.e. mitogenesis and hypertrophy. Here, we aimed to establish a complete dataset of isoforms in murine and human heart applying single-molecule real-time (SMRT)-sequencing as novel approach to identify transcripts without need for assembly, resulting in true full-length sequences. Moreover, we aimed to unravel functional relevance of the various isoforms during experimental ischemia reperfusion (I/R).

Methods

RNA-Isolation was performed in murine (C57Bl/6J) or human heart tissue (obtained during LVAD-surgery), followed by library preparation and SMRT-Sequencing. Bioinformatic analysis was done using a modified IsoSeq3-Pipeline and OS-tools. Identification of PGC1-α isoforms was fulfilled by similarity search against exonic sequences within the full-length, non-concatemere (FLNC) reads. Isoforms with Open-Reading-Frame (ORF) were manually curated and validated by PCR and Sanger-Sequencing. I/R was induced by ligature of the LAD for 45 min in mice on standard chow as well as on high-fat-high-sucrose diet. Area At Risk (AAR) and remote tissue were collected three and 16 days after I/R or sham-surgery (n=4 per time point). Promotor patterns were analyzed by qPCR.

Results

Deciphering the full-length transcriptome of murine and human heart resulted in ∼60000 Isoforms with 99% accuracy on mRNA-sequence. Focusing on murine PGC1-α-isoforms we discovered and verified 15 novel transcripts generated by hitherto unknown splicing events. Additionally, we identified a novel Exon 1 originating between the known promoters followed by a valid ORF, suggesting the discovery of a novel promoter. Remarkably, we found a homologous novel Exon1 in human heart, suggesting conservation of the postulated promoter.

In I/R the AAR exhibited a significant lower expression of established and novel promoters compared to remote under standard chow 3d post I/R. 16d post I/R, the difference between AAR & Remote equalized in standard chow while remaining under High-Fat-Diet.

Conclusion

Applying SMRT-technique, we generated the first time a complete full-length-transcriptome of the murine and human heart, identifying 15 novel potentially coding transcripts of PGC1-α and a novel exon 1. These transcripts are differentially regulated in experimental I/R in AAR and remote myocardium, suggesting transcriptional regulation and alternative splicing modulating PGC1-α function in heart. Differences between standard chow and high fat diet suggest impact of impaired glucose metabolism on regulatory processes after myocardial infarction.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Collaborative Research Centre 1116 (German Research Foundation)

[Burdens at Admission, Short-term Effects and Predictors of Health Status at Discharge among 1 803 Patients with Fibromyalgia Syndrome]

Objective: Taking Fibromyalgia syndrome (FMS) as an example, the article illustrates a problem that to our knowledge has not been addressed in rehabilitation research so far: According to our large dataset, a sizeable proportion of patients had to be sent home with extremely severe burdens (<2^nd percentile in the normal population) at discharge - in spite of good improvements during their stay. Data and methods: Since 2009, patients in the RehaKlinikum Bad Säckingen, an in-patient rehab center for orthopedic-rheumatic diseases, answer the questionnaire "Indicators of Rehabilitation Status" (IRES) at the beginning and the end of their stay. We analysed IRES-data of 1 803 patients with FMS (94% women). In addition to analyses of change, we determined the degrees of severity at admission and discharge on the basis of a comparison with the normative sample of the IRES. In order to predict membership of the high-risk group of patients with still "extremely severe" values at discharge, we performed binary logistic regression analyses. Results: At admission, about 90% of the patients showed either "extreme" (65%<2^nd percentile) or "severe" (27% 2^nd-10^th percentile) values on the IRES summary score as well as on the scores for "psychic status", "pain", "symptoms of orthopedic and cardiovascular diseases", and "functioning in everyday life". In sum, then, FMS-patients have come to rehabilitation with multiple burdens of a severe to extreme degree. At discharge, the mean summary score had improved with a "strong" effect size of SRM=1.07. In spite of these good overall improvements, however, 37.4% of the patients went home with "extreme" burdens remaining, even though almost 60% of them had experienced "strong" (28%) or "relevant" (31%) improvements. The most important predictor of affiliation to this "high-risk group" was - as expected - the IRES summary score at admission. But unexpectedly influential were also some characteristics of social status such as lower household income and lower degrees of education. Conclusion: In rehabilitation research, analyses of change between pre- and post-measurement values should be accompanied by assessments of severity of rehabilitation status at discharge because even good improvements do not necessarily mean that a patient has been rehabilitated successfully.

Altered red blood cell distribution width in overweight adolescents and its association with markers of inflammation

BACKGROUND

Obesity and the metabolic syndrome are dramatically increasing problems. Red blood cell distribution width (RDW), the variability in size of circulating red blood cells, has been demonstrated to be altered in different clinical settings. This analysis aimed to investigate the relationship between RDW and obesity in adolescents and in an animal model of diet-induced obesity (DIO).

METHODS

Seventy-nine male adolescents (aged 13-17 years) were studied. Thirty-seven of them were overweight (body mass index ≥ 90th percentile). RDW, markers of inflammation and stem cell factor (SCF) were determined. In an animal study, mice were fed with different diets for 15 weeks. RDW was determined using an animal blood count machine.

RESULTS

RDW differed significantly between normal-weight adolescents (13.07 ± 0.09) and overweight adolescents (13.39 ± 0.10, P = 0.015), whereas erythrocyte counts and haematocrit did not differ. RDW correlated to markers of inflammation and inversely to SCF. In the mice animal model, nutritional changes increased RDW, whereas overweight per se did not change RDW.

CONCLUSIONS

RDW is elevated in overweight and reflects the inflammatory state. RDW potentially represents an additional and cost-effective tool to indicate inflammation. Future studies are needed to understand the differential influences of nutrition and overweight on RDW.

[Use of trajectories for measuring change in medical rehabilitation: a contribution toward comparison of different methods of outcome measurement]

OBJECTIVE

The question of which methods should be used to assess the effects of medical rehabilitation has a long and controversial history. With regard to this background the project "Outcome measurement in medical rehabilitation" aimed at developing a better understanding of the process of change and its assessment. We also looked into possible causes for discrepancies between the results of direct and indirect measures of change. Aims of our study were: (1) to picture trajectories of change in a simple and descriptive way, (2) to compare the resulting solutions, (3) to highlight relations with direct measurement of change and/or global estimation of effects, (4) to compare the predictive value of different measurements of change.

METHODS

We used available data from rehabilitation research which covered direct and indirect measurement of change as well as global measurement of effects and which therefore enabled us to compare different methods of outcome measurements. The well documented record includes data from n=466 patients with chronic back pain. Different trajectories (3 and 5 groups) were defined using their pre/post data.

RESULTS

Depending on limits chosen for positive or negative courses and chosen outcome 20% to almost 40% of the patients showed improvements over the follow-up period. About the same percentages changed for the worse. However, two-thirds of the patients improved at least in one outcome. Compared with those, who did not experience improvements in any outcome, this group indicated better global rehabilitation effects. The different types of trajectories (3 and 5 groups) substantially contribute to the explained variance of catamnestic status at 12 months beyond other predictors as well as beyond initial status. The same applies to the prediction of disability days.

CONCLUSION

The description of trajectories of change yields useful results. In contrast to complex statistical methods we were able to identify groups of patients that can easily be described.

["Scores of Independence for Neurologic and Geriatric Rehabilitation (SINGER)" - development and validation of a new assessment instrument]

In the context of developing and testing a procedure for "Outcome-oriented payment for rehabilitation after stroke", we found that the instruments commonly used to measure the outcomes of rehabilitation after stroke (e. g., Barthel-Index or FIM) were not meeting the special requirements of the new payment system. Therefore the "Scores of Independence for Neurologic and Geriatric Rehabilitation" (SINGER) was developed as a new assessment instrument. This instrument is based on the ICF and measures 20 aspects of "independence in activities of daily living". The characteristic feature of the SINGER is, above all, the way all items are graded in 6 steps: the gradation does not refer to the degree of disability but to the kind and amount of help required for the respective activity, i. e.: 0 = totally dependent on professional help; 1 = professional contact help needed; 2 = contact help by (instructed) lay persons sufficient; 3 = preparation or supervision by lay persons still needed; 4 = independent with assistive device or still slow; 5 = independent without assistive device. For experienced personnel in neurologic rehabilitation, these gradations are "intuitively plausible". A manual moreover describes each grade in detail for each item so that the instrument can be used in rehabilitation facilities without extensive training. The SINGER has been tested and validated in a pilot study (n = 100) and in 2 subsequent studies with large case numbers in neurologic rehabilitation (n = 1058 and n = 700 patients after stroke in all categories of severity). Factor analyses showed that the instrument contains 2 dimensions which can be interpreted as "physical activities" and "activities of communication and cognition". Each of these 2 dimensions can be split into 2 sub-dimensions that can be assigned to the tasks of therapeutical professions in care/Occupational Therapy, physiotherapy, logopedics, and neuro- psychology. The test criteria of reliability, sensitivity, convergent validity, floor and ceiling effects as well as sensitivity to change show good to very good results. Particular emphasis can be given to the high degree of interrater reliability and the wide range of possible applications in clinical practice as well as in research. A limitation of the instrument to be taken into account is the fact that the SINGER has not yet been tested and validated in geriatric rehabilitation facilities.

[Computer Aided Support for Deciding on Applications for Rehabilitation ("CEBRA")]

The CEBRA project aimed at developing a computer aided procedure by which applications for rehabilitation can be assessed according to uniform and transparent criteria so that the applications together with a recommendation for decision-making can be transferred to the sociomedical services for final decision. For this, we first analyzed the existing manuals and guidelines for assessing applications for rehabilitation with the aim of identifying the main criteria, and then to translate them into measurable parameters. We then developed questionnaires for physicians treating the applicants as well as for the applicants themselves. Finally, algorithms were defined which compress the various combinations of these parameters into a recommendation for decision-making. Between October 2004 and March 2005, a pilot study was performed which ran parallel to the normal processes of decision-making by the insurance administration. In the pilot study, 436 applications were included for which questionnaires were available both from a physician and an applicant. The recommendations given by the CEBRA programme were finally compared with the decisions that had in fact been made by the administration in these cases. The results of the pilot study showed that the algorithms employed are capable of distinguishing very clearly and in a meaningful way between applicants with only minor medical problems and disabilities, on the one hand, and with medium or severe problems on the other. The comparison with the administrative decisions in these cases showed a similar rate of approval (80%) in both procedures. This means that the CEBRA programme does not change the general rate of approval. With respect to the individual cases, however, the comparisons revealed no statistically significant concordance between the two procedures. Reasons for this finding may result from the fact that--even though the same persons were compared--the information underlying the CEBRA recommendations or the administrative decisions, respectively, were not the same and may in fact have been quite different. In sum, we conclude that the CEBRA programme can very well improve the basis of information as well as the objectivity of making decisions on applications for rehabilitation.

[Further development and validation of a clinical auditing procedure for rehabilitation facilities]

Visitations (audits) are considered an instrument of external quality assurance by which the structural and organizational set-up of health facilities can be assessed on site by external experts. The Deutsche Rentenversicherung Bund (including the former Bundesversicherungsanstalt für Angestellte, BfA, the statutory pension insurance agency for white collar employees) is the largest body responsible for rehabilitation in Germany, and it regularly carries out visitations in the approximately 650 rehab centres it sends its patients to. The project presented in this article aimed at developing a manual with detailed descriptions of the procedures and criteria of the assessment, as well as at checking the inter-rater-reliability of the assessment. The manual was developed in cooperation with experts of the Deutsche Rentenversicherung Bund. It contains a description of the areas to be assessed during a visitation as well as leading questions and criteria for the evaluation of single features. The manual was examined in "test visitations" in 10 centres, each of which was visited by three visitation teams (1 medical and 1 administrative expert) simultaneously. When the resulting 30 assessments were compared, the criterion "overall quality of the centre" (which was assessed on a 10-point scale) showed precise agreement in 47 %, and a deviation by 1 point in 33 % of the cases. Single features assessed on a three-point scale (no improvement needed/improvement recommended/immediate improvement obligatory) resulted in precise agreement in between 80 % ("medical and therapeutic processes") and 86 % ("structural features") of the cases. Two-point scales (condition fulfilled or not fulfilled) showed an agreement between 89 % ("internal quality management") and 97 % ("single structural features"). In order to maintain and further develop this good inter-rater-reliability, the visitors of Deutsche Rentenversicherung Bund are continually trained in applying the visitation manual. In addition to transferring knowledge, these internal training courses are aimed at exchanging views and experience in order to enhance consensus among the visitors. This approach of Deutsche Rentenversicherung Bund could be regarded as "internal quality assurance" of its visitation procedure.

[Development and psychometric testing of a patient questionnaire for medical rehabilitation (IRES-3)]

BACKGROUND

Re-analyses of extensive datasets as well as theoretical considerations have led to the conclusion that the patient questionnaire "Indicators of Rehabilitation Status" (IRES) should be revised in several respects. The new version IRES-3 was developed on the basis of a theoretical model of rehabilitation following the ICF (International Classification of Functioning, Disability and Health) as well as of elements of the earlier version IRES-2. In addition, we included the results of expert panels on the definition of treatment goals in medical rehabilitation.

METHODS

The IRES-3 was tested in 453 patients in rehabilitation clinics of seven diagnostic areas. To compare the IRES-3 with other generic instruments, the SF-36 and the HADS were employed at the same time. For purposes of cross-validation, an external sample could be used. The dimensional structure was tested in confirmatory factor analyses.

RESULTS

With rare exceptions, the tests showed good values for item difficulties, ceiling and floor effects, internal consistencies and test-retest-reliability. Convergent validity could be established for the IRES-3 when compared to relevant scales of the SF-36 and the HADS. Indices of sensitivity to change were comparable, if not somewhat superior to the effects on comparable scales of the SF-36. The assessment of the construct validity and the dimensional structure of the questionnaire led to the definition of eight dimensions which can be interpreted as somatic, emotional, functional, occupational, social, pain, coping, as well as health information and behaviour. The dimensional structure of the IRES-3 can be regarded as theoretically meaningful as well as empirically proven. STANDARDIZATION: For purposes of standardization, data were collected on a sample representative of the population aged 30-75 years in Germany. These data allow a norm-oriented interpretation of scales and dimensions of the IRES-3 for patients in rehabilitation.

APPLICATION

The questionnaire is ready for application, including a computer programme for data entry and analysis.

[Significance of the chronic fatigue syndrome in rehabilitation medicine--status and perspectives]

It appears that from a clinical point of view chronic exhaustion or fatigue is an important factor in rehabilitation. This is, however, first of all a phenomenon that can be described as a function in accordance with the International Classification of Functioning, Disability and Health (JCF), caused by chronic illnesses or chronic excessive stress. The clinical and sociomedical ranking of chronic fatigue or exhaustion in respect of rehabilitation was discussed in the framework of a Workshop at the 12th Rehabilitation Science Colloquium, 2003 from the viewpoints of psychiatric rehabilitation, methodology, sociology and practical rehabilitation, and conclusions for future research were drawn. The definition of chronic fatigue is first of all mainly based on the feeling of chronic tiredness but also on phenomena of disturbed concentration, physical discomfort, headache and disorders of "drive" and mood. A psychiatric diagnosis linked with symptoms of chronic fatigue is neurasthenia, which is arrived at according to precisely defined criteria. Depressive disorder is one of the most important differential diagnoses in this sphere. Examinations by general practitioners revealed that about 90 % of the patients who had been diagnosed as suffering from psychovegetative disorders completely agreed with the diagnosis of neurasthenia. Neurasthenia resulted more often in work disability periods than disorders of somatisation and other psychosomatic diagnoses. Basing on the "IRES" scale "vital exhaustion", singular of even serious changes become evident in about 50 % to 90 % of the patients undergoing rehabilitation, depending on their individual range of indications. As was to be expected, the majority of pathologic findings concerns patients undergoing psychosomatic rehabilitation, since in such cases there is an overlapping with symptoms of psychosomatic diseases. It is, however, remarkable that also in somatically oriented orthopaedic rehabilitation symptoms of fatigue are seen in up to 50 % of the patients. Preliminary studies have shown that these symptoms can be definitely ameliorated within the rehabilitation framework, although pathological signs are still abundantly apparent in follow-up examinations. Markedly severe degrees of "vital exhaustion" and "vocational exhaustion" are also seen in rheumatology patients undergoing somatic rehabilitation. This agrees with case history details related by many female and male patients. Hence, it appears necessary to adapt rehabilitative intervention to both the psychovegetative and the medical behavioural aspects of this symptom. Scientific classification of the entire sphere of chronic fatigue in respect of rehabilitation requires classification of the relevant functions within the ICF framework. To this end it would be necessary to conduct patient inquiries within cross-sectional studies on the one hand and, on the other, a systematic consensus process among experts would have to be used for allocation to the relevant functions. This is the basis for development of suitable assessment tools for use in prospective studies in order to systematically evaluate the impact on functions and especially their effects on activities and participation.

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'

PURPOSE

An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres.

METHOD

In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N=200 patients per centre.

RESULTS

Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres.

CONCLUSIONS

The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.

[Initial status of patients and effects of rehabilitation after stroke--analysis of a patients' and a physicians' questionnaire in three neurological rehabilitation centres with a follow-up after 6 months]

Rehabilitation after stroke has to face specific problems when treating patients with more or less severe disabilities in cognition and communication. Correspondingly, stroke rehabilitation takes a special position within the larger field of rehabilitation, and relatively little is known outside the neurological scientific community about the status of patients at admission, the case mix in the centres and the short- and medium-term effects of rehabilitation. The present study describes in some detail the initial status in unselected samples of consecutive patients (n = 768) from three neurological rehabilitation centres. The description shows a very inconsistent picture in all centres, ranging from patients with no neurological deficits to patients needing intensive care. Across the centres, we found remarkable differences in case mix. In order to measure the effects of rehabilitation after stroke, an instrument was developed that combines a physicians' questionnaire aiming at an assessment of the severely disabled cases with a patients' questionnaire for the less severe cases for which the physicians' questionnaire would show "ceiling effects" so that improvements could no longer be depicted. The application of the instrument showed that about 50 % of the sample were not capable of answering the patients' questionnaire. For the patients with neurological deficits, the functional parameters of the physicians' questionnaire showed significant improvements at discharge that can be interpreted as "strong" effects (effect sizes 1.0-1.3). For the patients with less severe deficits (and usually in later stages of the rehabilitation process), the patients' questionnaire showed "strong" improvements on the somatic and psychosocial scales both at discharge and 6 months later. On the functional scales, however, only small improvements were found. Finally, predictors could be identified that explain a large amount of the variance for length of stay (R(2) =.42) as well as for the effects of rehabilitation (R(2) =.74). When comparing effects across rehabilitation units with differences of case mix, these predictors should be statistically controlled in order to assure fair comparisons.

[Knowledge management in rehabilitation--proposal for a systematic development of clinical practice guidelines]

In the past ten years, the German pension scheme has launched several initiatives that can be regarded as milestones on the way to a scientifically founded rehabilitation system. These initiatives were: the Rehab Commission (1989 - 1991), the Quality Assurance Programme (since 1994), and the German Research Funding Programme "Rehabilitation Sciences" (in cooperation with the Federal Ministry for Education and Research, since 1996). As a next step on this way, we propose an initiative aiming at a systematic development and implementation of clinical practice guidelines for the main diagnostic groups in rehabilitation. Guidelines for diagnostic and therapeutic decisions are an instrument to sift through the abundance of fast changing knowledge in medicine, to assess the existing knowledge according to its scientific evidence, and to transform it into recommendations for clinical practice. In rehabilitation, guidelines seem to be particularly needed because specialized knowledge is mostly disseminated through an informal "training on the job". Our proposal intends to establish a reference centre for each of the main indications (cardiology, musculoskeletal diseases, etc.). These centres should cooperate with experts from clinical practice and research, as well as with representatives of the cost-carrying agencies and patient organisations, and should systematically analyse the processes of rehabilitation in the most important diagnostic groups. Guided by a "process matrix of rehabilitation", these analyses should identify the points at which far-reaching decisions are called for during the processes of rehabilitation. At these points, the knowledge base available for rational decisions should be examined. When there is no sufficient scientific knowledge, consensus conferences should be organized in order to collect and assess the available expertise of practitioners and to establish guidelines for clinical practice. Since compliance with such guidelines could be easily checked in the routine quality assurance programme, this proposal seems to be a promising way of improving the knowledge base in rehabilitation in a rather short time.

[Reconditioning in groups: an effective programme for the rehabilitation of patients with low back pain?]

The article reports on a study in which elements of a group-oriented reconditioning programme for patients with low back pain were incorporated into the routine of an in-patient orthopaedic rehabilitation clinic. The specific elements of the new programme consisted of stable group structures during the whole stay of 3 to 4 weeks, and of 3 to 7 hrs. walks in hilly ground three times a week. The effects of this programme were tested against a standard programme with a mix of passive and active elements using a controlled study design. 92 persons participated in an experimental group and 81 persons in a control group with no significant differences found between the two groups at admission. Effects were measured by means of a physicians' questionnaire and a multidimensional patients' questionnaire (IRES) answered at admission, at discharge, and at six- and twelve-month follow-up. The results of a two-factorial analysis of variance with repeated measures showed that the interaction between group and time on the summary score of the IRES was not significant, although the experimental group showed somewhat better effects at all times of measurement. The discussion focuses on the reasons for this result, among which the unexpectedly good effects in the control group are named, as well as certain difficulties with the implementation of a strongly activity-oriented programme into the course of a "normal" rehabilitation clinic.

Expression of neutrophil collagenase (matrix metalloproteinase-8) in human atheroma: a novel collagenolytic pathway suggested by transcriptional profiling

BACKGROUND

Loss of interstitial collagen, particularly type I collagen, the major load-bearing molecule of atherosclerotic plaques, renders atheroma prone to rupture. Initiation of collagen breakdown requires interstitial collagenases, a matrix metalloproteinase (MMP) subfamily consisting of MMP-1, MMP-8, and MMP-13. Previous work demonstrated the overexpression of MMP-1 and MMP-13 in human atheroma. However, no study has yet evaluated the expression of MMP-8, known as "neutrophil collagenase," the enzyme that preferentially degrades type I collagen, because granulocytes do not localize in plaques.

METHODS AND RESULTS

Transcriptional profiling and reverse transcription-polymerase chain reaction analysis revealed inducible expression of MMP-8 transcripts in CD40 ligand-stimulated mononuclear phagocytes. Western blot analysis demonstrated that 3 atheroma-associated cell types, namely, endothelial cells, smooth muscle cells, and mononuclear phagocytes, expressed MMP-8 in vitro upon stimulation with proinflammatory cytokines such as interleukin-1beta, tumor necrosis factor-alpha, or CD40 ligand. MMP-8 protein elaborated from these atheroma-associated cell types migrated as 2 immunoreactive bands, corresponding to the molecular weights of the zymogen and the active molecule. Extracts from atherosclerotic, but not nondiseased arterial tissue, contained similar immunoreactive bands. Moreover, all 3 cell types expressed MMP-8 mRNA and protein in human atheroma in situ. Notably, MMP-8 colocalized with cleaved but not intact type I collagen within the shoulder region of the plaque, a frequent site of rupture.

CONCLUSIONS

These data point to MMP-8 as a previously unsuspected participant in collagen breakdown, an important determinant of the vulnerability of human atheroma.

[Effects of treatment in mother-child rehabilitation centres]

Effects of Treatment in Mother-Child Rehabilitation Centres. The study aims at an external evaluation of mother-child rehabilitation centres in Germany. The centres taking part in the project will get detailed information about their present state of quality in the dimensions of structure, process and outcome as well as patient satisfaction and job satisfaction of the employees. This article focuses on quality of outcome. Two main questions are addressed: How do women treated in mother-child rehabilitation centres assess their health problems at admission, and what are the effects after three weeks of inpatient treatment? The results show that in comparison with a German norm population, 55 % to 75 % of the women in the present study reported intense distress in all dimensions of health (somatic, functional and psychosocial). The analysis of effects after treatment confirms a distinct improvement of health status reported by patients as well as by doctors and therapists. Data of a follow-up after 6 months will show whether these positive effects can be maintained.

Azithromycin versus pivampicillin in the treatment of acute exacerbations of chronic bronchitis: a single-blind, double-dummy, multicentre study

This single-blind, double-dummy, multicentre study compared oral azithromycin, administered as tablets, 500 mg once daily for 3 days, versus oral pivampicillin, 700 mg twice daily for 10 days, in adults with acute exacerbations of chronic bronchitis (not needing parenteral antibiotic therapy, hospitalization or oxygen support). Clinical success (cure + improvement) rates were similar for both groups at the end of treatment (day 10; azithromycin, 124 of 133 [93%]; pivampicillin, 79 of 92 [86%]) and at follow-up (day 52; 98 of 126 [78%] versus 66 of 81 [81%]). The treatments produced similar levels of pathogen eradication at the end of treatment (49 of 54 [91%] versus 32 of 37 [86%]). Azithromycin-treated patients had significantly reduced chest discomfort at the end of treatment, and a trend towards improved lung function. The two groups were similar with respect to improvements in other clinical symptoms and patient well-being, and to the incidences of adverse events and treatment discontinuations. This oral azithromycin regime is an effective treatment for acute exacerbations of chronic bronchitis, similar in efficacy to the longer pivampicillin regime and may offer superior patient compliance.

[Freiburg/Bad Säckingen Scientific Rehabilitation Research Group]

The Freiburg/Bad Säckingen Rehabilitation Research Network aims on problem solutions in rehabilitation in Germany. The core concept of the Research Group is "goal orientation in diagnosis, therapy and evaluation". This concept refers to both individual goals of patients and structural measures. The 13 projects of the Research Group deal with topics such as "specific communication problems in rehabilitation", "differential indication", "health economics", "methods", and "intervention and evaluation". To establish a long-term internal network in the Research Group and to facilitate intensive communication and co-operation between the various university-based and non-university-based institutions of rehabilitation in the Research Group area, Project Management and Methodological Support Offices were created.

[Quality management in medical rehabilitation]

In the context of the quality assurance program of the German pension insurance institutions, instruments and procedures have been developed in the past few years in order to assess the quality of structure, process, and results of inpatient rehabilitation, as well as patient satisfaction. The routine implementation of these procedures aims at providing rehabilitation hospitals with fast information on shortcomings in their current practice, so that concepts of treatment and--in the long run--effects of rehabilitation can be systematically improved. When the "quality profiles" of rehabilitation hospitals are compared ("benchmarking"), paying institutions of rehabilitation could gain information on the cost-quality-ratio of particular hospitals as well as important leads for improving the steering processes of patients and hospitals. In the present article, results of a first "field-run" of the procedures for measuring patient satisfaction and quality of rehabilitation processes are reported. A comparative analysis of patient satisfaction in four orthopaedic/rheumatologic rehabilitation hospitals showed high degrees of overall satisfaction in all hospitals. In several subdimensions of patient satisfaction, however, significant differences between hospitals were found. Quality of rehabilitation processes--as assessed by a standardized peer-review--varied substantially between 36 hospitals. Problems of quality were found especially in some dimensions that must be considered as crucial for rehabilitation, e.g., in the history and diagnosis of disabilities, in the consideration of psycho-social problems, or in the assessment of occupational capacities.

[Therapy goals in medical rehabilitation]

The definition of appropriate and measurable goals for treatment is a fundamental quality feature of medical practice. In co-operation with experts, we developed a catalogue of therapy goals for medical rehabilitation. In a two-stage procedure we first analyzed the target definitions that are currently used in medical rehabilitation. In a second step we used these targets as input for expert panels. Based on a modified model of the WHO classification ICIDH, the goals were defined on four dimensions: somatic, functional, psychosocial and educative. The established goals are relevant and measurable. Nevertheless, there is still a lack of adequate and sound measurement procedures for many goals. Therefore, there is an urgent need for further research in this field.

[Agreement and differences between reviewers in a peer review procedure]

In Germany the statutory pension insurance institutions have started a quality assurance programme. Our institute developed a peer review procedure for screening the process quality of rehabilitation care. The peer review was tested in a pilot study. Our article refers to the examination of interrater reliability, intrarater reliability and reviewer bias. First of all, experienced doctors were trained in reviewing reports routinely written by rehabilitation doctors at discharge of their patients. The peers had to judge on 56 process criteria belonging to six categories (e.g. case history). The reliability coefficients were calculated for the overall judgement of each category and the overall judgement of the process quality of rehabilitation care. The coefficients of interrater reliability and the coefficients of average intrarater reliability range from sufficient to good. Only few reviewers showed a general tendency to harsh or lenient rating. The objectivity of the tested peer review procedure seems definitely higher than in American studies of peer review of hospital charts.

[Peer review: a method for the analysis of the quality of processing in-patient rehabilitation methods]

In order to evaluate the process quality of inpatient rehabilitation we established a peer-review system. In our approach, measurement of process quality is based on the report written by rehabilitation doctors at discharge of their patients. First of all, a list of 52 criteria relevant to process quality was defined by experienced clinicians using the Delphi technique. These criteria may be divided into six dimensions: anamnesis, diagnostic interventions, goals of therapy and therapy, judgement on vocational abilities, recommendations for further treatment and epicrisis. Thereafter, the experts in a manual defined specific requirements for each of the 52 criteria. In a pilot study, we were able to demonstrate reliability and practicability of the peer review system. Using this approach shortcomings in present rehabilitation practice may be detected. Nearly 400 reports from 20 rehabilitation hospitals were reviewed by thoroughly trained peers. Most frequently shortcomings were found in the description of patient's disabilities and in the definition of specific rehabilitation goals. Furthermore, this procedure enables comparison of process quality in different rehabilitation hospitals. In our pilot study we found marked differences in the process quality of the 20 rehabilitation hospitals.

[References for evaluation instruments for quality assurance in rehabilitation--2. The IRES questionnaire for clinical aspects and research]

The article presents the comprehensive Indicators of Reha Status (IRES) patient questionnaire that can be used for assessment and outcome measurement in rehabilitation. We explain why the ¿preventive-rehabilitative¿ orientation characteristic of the system of rehabilitation in Germany asks for particularly sensitive instruments as well as for inclusion of certain psychosocial variables. The results of validation studies are presented in some detail. In discussing possible applications of the questionnaire, we concentrate on its use for clinical practice (functional and psychosocial diagnostics, quality assessment). Finally, information is given on how to obtain questionnaires and the special computer programme for data entry and analysis.

[Epidemiology of rheumatic complaints in Germany. Data on the prevalence and physical and psychosocial disability]

Because of their considerable socioeconomic costs rheumatic symptoms are a major concern in industrialized nations. Our study provides data on the prevalence of rheumatic symptoms in the general population and on their physical and psychosocial impact. We performed a survey of 1814 randomly selected non institutionalized persons, aged 40 to 69 years, living in the Federal Republic of Germany. The selected subjects were asked whether they had pain in one or more of the following sites: neck/back, joints of upper extremities, joints of lower extremities. Physical and psychosocial disability was assessed using a multidimensional questionnaire that included a German version of the Arthritis Impact Measurement Scales (AIMS) and validated instruments concerning psychosocial dimensions of health status. The prevalence of rheumatic symptoms increases between 40 and 59 years and decreases thereafter. Rheumatic symptoms are more frequent in women than in men. The predominant pain localization is the back. Individuals reporting pain in one region (back, upper and lower extremities) often feel pain in other areas as well and often suffer from additional symptoms such as weakness and sleep disturbance. We found significant disabilities in physical (mobility, activities of daily living, physical activities) and psychosocial (depression, anxiety, exhaustion, family problems) dimensions of health status in subjects reporting rheumatic symptoms.

["Indicators of Reha-Status (IRES)"--a patient questionnaire for assessing need and success of rehabilitation]

A basic instrument is presented which enables essential parameters of rehabilitation patients' somatic, functional and psychosocial status to be brought out and data collected at a "middle level of detail" in a standardized manner, i.e. a patient questionnaire which can be used to complement medical assessment or, for example in follow-up, as a stand-alone tool. Development and testing of the instrument has been supported over the past three years by the LVA Württemberg pension insurance fund, both financially and conceptually. In the present article, questionnaire contents and structure are described, and validation findings reported, standardization on a representative sample of the resident population (n = 1848) is set out. The validation studies performed showed the instrument to be reliable, valid and sensitive, and meeting with good acceptance on the part of patients. Finally, a specifically designed computer programme is set out which facilitates questionnaire data input and basic analyses. Potential applications for the IRES questionnaire are for example seen in describing rehabilitation course and outcome, in documenting the effectiveness of rehabilitation measures (quality control), or in the framework of rehabilitation diagnosis, in particular relative to functional and psychosocial dimensions.

[Predictors of early retirement and focused assignment to medical rehabilitation]

Previous work and results from the project "Identification of a high-risk profile for early retirement" were presented. The project is being supported by the LVA-Württemberg (pension insurance for blue collar workers). In this project, a two-step screening process to determine prospective early retirees and provide specific assignment for medical rehabilitation is being developed and tested, with the goal of adhering better to the basic principle of "rehabilitation before retirement". The foundations for the solution proposed in the two-step screening are predictors of early retirement, with which prospective retirees can be detected early on. On the basis of a cohort study on environmental effects and frequency of illness during the period 1974-85, we have identified predictors for early retirement and premature death. Early retirees complained of health problems even years before retirement. In particular, they complained of shortness of breath and respiratory tract ailments, general impairment of physical performance, and ailments of the skeletal and motor apparatus. Data for persons who died prematurely after 1974 were largely consistent with those for early retirees. Most prominent in this case were complaints indicating coronary risk or angina pectoris, chronic bronchitis, and peripheral circulation problems. We evaluated the significantly increased health problems in the risk groups from the 1974 inquiries as indicators or predictors for early retirement. We utilized them for a questionnaire which was designed to determine the predictive risk profile for early retirement, and may be therefore suitable as a screening instrument for identifying prospective early retirees among currently employed insured persons (screening stage 1).

[Assessment of the effectiveness of inpatient rehabilitation measures in patients with chronic low back pain: a prospective, randomized, controlled study]

Chronic low-back pain is a frequent symptom causing considerable socioeconomic costs in many countries. Outpatient treatment of low-back pain often remains unsatisfactory. In our prospective study, one hundred patients on the five months waiting list were allocated randomly to attending the hospital either four months or six months later, the latter serving as a control group for those undergoing treatment. Health status was assessed using a multidimensional questionnaire, which had proven a reliable, valid and sensitive instrument in former studies. After four to six weeks of multidisciplinary inpatient treatment, a significant decrease in pain, anxiety and depression was found, whereas no improvement was observed in the control group. Multidisciplinary inpatient treatment therefore at least has short-term positive effects on patients' health status.