Quality measurement of out-patient neuropsychological therapy after stroke in Germany: definition of indicators and retrospective pilot study

BACKGROUND

In contrast to the hospital setting, today little work has been directed to the definition, measurement, and improvement of the quality of out-patient medical and therapeutic care. We developed a set of indicators to measure the quality of out-patient neuropsychological therapy after stroke.

METHODS

The indicators cover core and interdisciplinary aspects of out-patient neuropsychological work such as mediation of patients into social care in case of need. Selection of the quality-indicators was done together with a consensus group of out-patient therapists and supported by evidence, validity, reliability as well as estimated relevance and variability with the quality of care. The set of indicators was further tested in a retrospective cohort study. Anonymous data of 104 patients were collected from out-patient clinical records of five clinics between November 2017 and April 2018. Associations between process and outcome quality were estimated exploitatively.

RESULTS

Results allowed for the identification of areas with greater variability in the quality of process care and indicated that attention training as recommended by current guidelines had the lowest overall rate for meeting the quality-aim (met in 44% of the cases). This was followed by time < 1 month until the start of therapy (63% met) and mediation into social care in case of need (65% met). We further observed that overall quality and involving relatives in the therapy was associated with higher rates of professional reintegration (p-value = 0.03). However, the need for mediation into social care was associated with a reduced chance for successful professional reintegration (p-value = 0.009).

CONCLUSION

In conclusion, we describe a first set of quality indicators which cover different aspects of out-patient neuropsychological therapy and sufficient variability with care. First data further suggests that meeting the specified quality aims may indeed have relevant effects on outcomes.

[Herpes simplex virus infection of the hand]

HISTORY AND CLINICAL FINDINGS

An 18-month-old infant was admitted for a suspected bacterial hand infection that had developed within 2 days. Examination demonstrated multiple vesicles with erythema involving the dorso-ulnar aspect of the thumb. The infant was in a good condition, had no constitutional symptoms and a history of gingivo-stomatitis 6 months ago.

EXAMINATIONS

The diagnosis of herpes simplex infection was based on the history and the clinical findings.

TREATMENT AND COURSE

Treatment consisted of dry dressings, and over the next 3 weeks, the lesion healed without scarring.

CONCLUSION

Herpes simplex virus infection of the hand is uncommon, often misdiagnosed and therefore overtreated or inadequately treated. Usually the diagnosis can be made from history and clinical findings. In general, the infection is managed conservatively. Treatment by incision and drainage is contraindicated.

[Pseudoxanthoma elasticum. Clinically typical but frequently overlooked]

A 52-year-old man had small yellowish, striated or reticular papules since the age of 5 years. These appeared first on the large flexures, and later on the neck, abdomen, penis and the mucosa of the lips. He developed angina at the age of 47 years. A bypass operation, however, did not lead to complete regression of cardiac symptoms. Four years later, the vision in his right eye deteriorated because of arterial occlusion, and the patient was treated with laser coagulation; he was started on long-term treatment with acetylsalicylic acid (250 mg/d) and calcium dobesilate (1,500 mg/d). Despite this, the vision in his left eye also deteriorated progressively. Fundoscopy revealed bilateral pigmentary changes in the macular region, variations in the retinal arterial diameters and "angioid streaks". Pulses were absent in the right radial artery, the left posterior tibial artery and both dorsalis pedis arteries, but there were no trophic changes or symptoms. The serum total cholesterol (246 mg/dl), triglycerides (177 mg/dl) and LDL-cholesterol (193 mg/dl) were only slightly elevated. The diagnosis of pseudoxanthoma elasticum with typical changes in the elastic fibres was confirmed by elastin staining in a biopsy from one of the lesions.

Humoral response of cynomolgus macaques to human soluble CD4: antibody reactivity restricted to xeno-human determinants

The CD4 cell surface glycoprotein which is expressed primarily by a subset of T lymphocytes plays a key role in normal immune responses. In the immunopathogenesis of AIDS, it serves as the high-affinity receptor for HIV, facilitating viral attachment and entry into CD4+ cells. As such, the truncated soluble form of this molecule (sT4) has been proposed as a therapeutic drug for the treatment of AIDS whereby it would act as decoy for viral entry into cells or facilitate elimination of soluble viral envelope glycoprotein. In a study designed to look at the effect of sT4 on immune function, sT4 was administrated to experimentally naive primates. In this report, we show that administration of sT4 to cynomolgus macaque monkeys over a period of up to 3 weeks results in antibody responses with specificities for human CD4 molecules. Antisera thus generated bound sT4 and cell surface CD4 expressed on human T lymphocytes but failed to bind to cynomolgus lymphocytes. These antibodies caused no apparent adverse effects on normal immune functions of the cynomolgus macaques. We conclude from these data that the antibody response to soluble CD4 in cynomolgus monkeys is directed at determinants present on human CD4 but absent on monkey CD4. The restricted xenogeneic specificity of the antibody response indicates that soluble CD4 may not be highly immunogenic in syngeneic hosts. The present study also shows that these antibodies can block HIV-induced syncytium formation indicating that the antibodies bind to regions on the CD4 molecule close to the HIV-env gp120 binding site. The gp120 binding site, which resides within the N-terminal V1 domain of CD4, encompasses a region which corresponds to the complementarity determining regions (CDRs) of immunoglobulins. The CDR-like regions of CD4-V1 manifest the greatest species divergence, are tolerant to experimental in vitro mutagenesis, and generate the predominant antibody response in mice immunized with human CD4 indicating that differences in the V1 sequence between human and other non-human primates may localize to this regions.