Israel's first national remote cardiac rehabilitation program - patient response and potential factors affecting successful completion

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Sheba Medical Center

Introduction

Cardiac rehabilitation is an essential program for the reduction of future cardiac events and improve quality of life. However, many vulnerable individuals do not achieve this desired outcome due to the restrictive nature of institution-based rehabilitation. With this in mind was developed the Remote Cardiac Rehabilitation Program (RCRP). Our aim was to create the optimal conditions so that our patients are guided and stimulated in order to successfully complete the program.

Material and method

This study involved 306 patients with established CHD who underwent a six-month RCRP, three months of which were subsidized by health insurance. RCRP involves regular exercise, monitored by a smart sports watch and transferred to both the medical operations center as well as the mobile application on the patient’s smartphone. We built models to get predictors for the best patient performance in the last (third) month. Predictions were made based on their performance in the first month and some demographical data. Age and gender were taken as base features to all the models.

Results and discussion

The study involved patients, 81.5% men, aged 57.59 (±10.62), who were admitted to the RCRP mainly after myocardial infarction or coronary interventions (49%). The median minutes per week that patients performed aerobic exercise was 164, a median of 92 minutes at target HR (established by exercise physiologist), and the median percent of heart rate reserve was 76 % across exercise training. The median number aerobic sessions per week was 4, while the median daily steps was 8,370. Values had no significant differences across the 24 weeks. Following the 24-weeks of intervention, there was a significant improvement in exercise capacity, assessed by estimated METS using pre and post exercise stress tests from 9.95±2.57 to 11.71±3.43 (p<0.001). The most significant predictors of program adherence were older age and the number of weekly aerobic minutes and sessions in the first weeks of training (p<0.005). There is a direct relationship between the patient's age and the program compliance - the older the patient, the higher the compliance.

Conclusion

Adherence and the performance achieved by patients in the RCRP is well within guideline recommendations, leading to a significant improvement in exercise capacity. Older age, as well as early program adherence were significant factors which led to better program completion.

The first national program of remote cardiac rehabilitation - goal achievements, adherence, and responsiveness in elderly patients

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Sheba medical center

Background

Remote cardiac rehabilitation (RCR) after myocardial infarction is an innovative program in the field of telemedicine. RCR is included in the health basket. Many believe that telemedicine programs better fit younger patients, whose technological literacy is higher than older patients. Older patients are also thought to have difficulty consuming technology-based programs and meeting program goals. The objectives of this study were as follows: 1) To study patterns of physical activity, goal achievement, and improvement in functional level among RCR participants over 65 compared with younger patients. 2) To study the variables that can predict better patient adherence and compliance with the rehabilitation program.

Methods

A retrospective study of post-myocardial infarction patients enrolled in six-month RCR program. The activity of the patients was monitored using a smart watch. The data were collected and analyzed by a special telemedicine system. RCR program goals were: (i)150 minutes of aerobic activity per week; (ii) 120 minutes of the activity within the target heart rate; (iii) 8000 steps per day. Predictive models were created to evaluate variables predicting adherence and compliance with the program.

Results

306 participants, 80 of them were elderly (average age 70 ± 3.38). At the end of the program, there was a significant improvement (p <0.001) in the functional capacity of all participants. The elderly improved from 8.11 ± 2.8 to 11.25 ± 12.6 METs, while the final METs results in the elderly group were similar to other participants. During all program months, the elderly showed better achievement of program goals compared to younger ones (p <0.01). We found that age of patients is a clear predictor (p <0.01) of early dropout from the program and goals achievements – the higher the age, the fewer dropouts and better achievement.

Conclusions

Elderly can successfully participate in telemedicine rehabilitation programs, and such programs are beneficial for them. Age is not a limitation, but a predictor for better achievement of goals and compliance with the RCR program.

Rehabilitation of the unmotivated: remote cardiac rehabilitation among patients of all risk levels who reported unwillingness to participate in hospital-based rehabilitation

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Cardiac Prevention and Rehabilitation Institute, Leviev Heart Center, Sheba medical center

Introduction

Remote cardiac rehabilitation (RCR) is recognized as a viable alternative to conventional, center-based rehabilitation. However, to achieve meaningful functional improvement, a high level of adherence and motivation to collaborate with the healthcare team, is necessary. The feasibility of RCR among patients who actively avoid hospital rehabilitation has not been adequately investigated by randomized studies.

Method

This year-long prospective study enrolled 60 cardiac patients at various risk levels, including those with heart transplants and heart failure, who refused to participate in conventional rehabilitation. Accordingly, 40 participants were randomized to a 6-month RCR program, while the remaining 20 received usual care in the community. Both groups were monitored for activity and self-reported outcomes. RCR is based on behavioral theories, includes multidisciplinary support, motivational and educational content, regular exercise, controlled by a smart sports watch, and transmitted to both the medical operations center and the patients mobile phone application. The main outcome was the change in Peak VO2, measured by the Cardiopulmonary Exercise Testing, after 4 months of intervention compared to baseline.

Results

The study included 60 patients, 82% men, aged 55 (±12), who were admitted to the 6-month RCR program mainly after myocardial infarction or coronary interventions (44%), heart failure (29%), cardiomyopathy (13.5%) and heart transplantation (10.5%). After RCR, there was a significant increase in Peak VO2 in the intervention group (+2.46±7.1 mL/(kg·min) compared to the control group (-0.72±7.9 mL/(kg·min) (p<0.001). High-density lipoprotein (HDL) levels also improved significantly.

The average minutes per week of aerobic exercise was 221 (±124.74), which was 147% of the goal. The average minutes at the recommended target heart rate was 117.38 (±78.36), and the percentage of intensity of training was 69.39% (±15.11) of the maximum capacity. The average aerobic sessions per week was 5 (±3), while the resistance sessions was 0.8 (±0.74). The average daily step count in the intervention group was 9145 (±3860) versus 4445 (±3005; p<0.001). The surveys showed a significant improvement in patients’ mental and physical perception of health in the intervention vs. control group.

Conclusion

The adherence and results achieved by patients in RCR who avoided conventional rehabilitation were well within guideline recommendations, resulting in a significant improvement in physical capacity. Risk level, age, and lack of motivation at the beginning of the program were not barriers to achieving goals and cooperation.

Adherence to remote cardiac rehabilitation during the coronavirus pandemic

Funding Acknowledgements

Type of funding sources: None.

Introduction

The global crisis of COVID-19 has highlighted how the health care system needs to adapt. With the announcement of a partial lockdown, cardiac rehabilitation centers in Israel were closed and patients were left without regular training and risk factor management. However, the Remote Cardiac Rehabilitation Programs (RCRP), which had been previously developed, continued to function. The purpose of this study was to evaluate the performance of RCRP during the pandemic.

Methods

We compared retrospective cohort data on the performance of RCRP patients and care teams over two time periods: (P1) nine weeks before lockdown; and (P2) seven weeks during the lockdown. Included in the analysis were parameters of exercise adherence, objective training efficacy, and satisfaction.

Results

The analysis included 38 patients, 92% male, age 58 ± 11 enrolled in the RCRP predominantly following myocardial infarction or coronary interventions (57%). Patient activity during the lockdown period increased with higher average exercise minutes per week as well as higher exercise minutes performed at the designated target heart rate (all P for trend < 0.05). In a mid-study survey, over 86% of patients responded that they felt safe and satisfied with the RCRP. 

Conclusions

The RCRP has proven to be reliable and effective in maintaining the mental and physical health of patients in the face of a national crisis, even with a substantial reduction in staff. Automation by flexible rules, incorporated in the system, resolved numerous time-consuming tasks, thus allowing for more time to be dedicated to human interaction.

Assessed parameter	Entire study duration	Period 1	Period 2	P value
Aerobic minutes per week, average	221.1	205.5	241.7	0.01
Number of Aerobic sessions per week, median	3.8	3.6	4	NA
Average number of Minutes at Target HR per session, per week (% of session time at target HR)	116.2 (52.5%)	107.7 (52.4%)	127.2 (52.6%)	< 0.001
The average %HRR during aerobic session, per week	75.7	75.4	76.1	0.47
Steps per day, average	8,830	9,000	8,600	0.06
Mobile application entries per week, average	4.43	4.3	4.6	0.50

Patients activity before (P1) and during (P2) the lockdown

Antibodies against neo-epitope of microbial and human transglutaminase complexes as biomarkers of childhood celiac disease

Tissue transglutaminase (tTG) and microbial transglutaminase (mTG) cross-link gliadins to form complexes that expose immunogenic neo-epitopes to produce tTG and mTG-neo-epitope antibodies. The aim of this study was to test the diagnostic performance of antibodies against non-complexed and complexed forms of transglutaminases, to correlate their activities to the intestinal damage and to explore age group dependency in celiac disease (CD). A total of 296 children with untreated CD and 215 non-celiac disease controls were checked by in-house enzyme-linked immunosorbent assays detecting immunoglobulin (Ig)A, IgG or combined detection of IgA and IgG (check) against tTG, AESKULISA® tTG New Generation (tTG-neo) and mTG-neo (RUO), IgA and IgG antibodies against deamidated gliadin peptide (DGP) and human IgA anti-endomysium antibodies (EMA) using AESKUSLIDES® EMA. Intestinal pathology was graded according the revised Marsh criteria, and age dependencies of the antibody activities were analysed. Using cut-offs estimated from receiver operating characteristic (ROC) curves, the highest area under curve (AUC) of the TG assays was 0·963 for tTG-neo check, followed by tTG check (0·962) when the diagnosis was based on enteric mucosal histology. tTG-neo check was the most effective to reflect the intestinal abnormalities in CD (r = 0·795, P < 0·0001). High levels of anti-mTG-neo IgG and anti-tTG-neo IgG appeared in the earlier age groups, as compared to anti-tTG IgG (P < 0·001). Considering antibody diagnostic performance based on AUC, enteric damage reflection and predictability at an early age, the anti-neo tTG check was the most effective diagnostic biomarker for pediatric CD. The mTG neo check might represent a new marker for CD screening, diagnosis and predictability.

Sensorimotor training and whole-body vibration training have the potential to reduce motor and sensory symptoms of chemotherapy-induced peripheral neuropathy-a randomized controlled pilot trial

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent and clinically relevant side effect of chemotherapy. The symptoms diminish patients' quality of life and represent a decisive limiting factor for medical therapy. To date, effective treatment options are lacking. Specific exercise interventions have proven promising to target relevant symptoms. We conducted a prospective, four-armed, randomized, controlled trial, to evaluate the effects of sensorimotor training (SMT) and whole-body vibration training (WBV) on patients with CIPN. Participants (N = 40) were randomized to either one of two intervention groups (SMT N = 10 or WBV N = 10) or oncological control group (N = 10) and matched by gender and age with a healthy control (N = 10). The intervention groups exercised twice a week for 6 weeks. Primary endpoint was the reduction of CIPN-related symptoms (improve peripheral deep sensitivity, Achilles tendon reflex (ASR) and patellar tendon reflex (PSR), light-touch perception, sense of position, and lower leg strength). Secondary endpoints were nerve conduction velocity and amplitude, balance control, quality of life, and CIPN-related pain. Patients exercising improved sensory and associated motor symptoms. Significant intergroup differences were found for the tendon reflexes (ASR P = .017 and PSR P = .020), peripheral deep sensitivity (P = .010), and pain (P = .043). Furthermore, tendencies were found regarding the subjective improvement of symptoms (P = .075) and two subscales of the EORTC-QLQ-C30 questionnaire: pain (P = .054) and dyspnea (P = .054). The results for the SMT group were superior regarding the tendon reflexes, and a tendency regarding the subjective report of symptoms, while WBV was superior regarding pain. SMT and WBV behold a large potential to reduce CIPN-related symptoms and can be considered feasible and safe for patients with CIPN (compliance 97.5%, no adverse events).Registration: DRKS00013027.

Das Verhalten des Blutgerinnungsfaktors X (Stuart-Prower) aus Plasma und Serum bei der Gelfiltration an Sephadex G 200

Menschliches und bovines Plasma und Serum wurde an Sephadex G 200 aufsteigend chromatographiert und in den Fraktionen die Faktor-X-Aktivität bestimmt. Faktor X aus Plasma wurde in allen Fällen schneller aus der Säule eluiert als der gleiche Faktor aus Serum. Aus diesem Befund kann auf eine während der Blutgerinnung aufgetretene Molekülverkleinerung des Proteins geschlossen werden, welches die Faktor-X-Aktivität trägt. Unsere Ergebnisse werden im Rahmen der zu dem Thema vorliegenden Literatur diskutiert.

Renal Sympathetic Denervation by CT-Guided Ethanol Injection: A Phase II Pilot Trial of a Novel Technique

OBJECTIVES

CT-guided ethanol-mediated renal sympathetic denervation in treatment of therapy-resistant hypertension was performed to assess patient safety and collect preliminary data on treatment efficacy.

MATERIALS AND METHODS

Eleven patients with therapy-resistant hypertension (blood pressure of >160 mmHg despite three different antihypertensive drugs including a diuretic) and following screening for secondary causes were enrolled in a phase II single arm open label pilot trial of CT-guided neurolysis of sympathetic renal innervation. Primary endpoint was safety, and secondary endpoint was a decrease of the mean office as well as 24-h systolic blood pressure in follow-up. Follow-up visits at 4 weeks, 3, and 6 months included 24-h blood pressure assessments, office blood pressure, laboratory values, as well as full clinical and quality of life assessments.

RESULTS

No toxicities ≥3° occurred. Three patients exhibited worsened kidney function in follow-up analyses. When accounting all patients, office systolic blood pressure decreased significantly at all follow-up visits (maximal mean decrease -41.2 mmHg at 3 months). The mean 24-h systolic blood pressure values decreased significantly at 3 months, but not at 6 months (mean: -9.7 and -6.3 mmHg, respectively). Exclusion of five patients who had failed catheter-based endovascular denervation and/or were incompliant for antihypertensive drug intake revealed a more pronounced decrease of 24-h systolic blood pressure (mean: -18.3 and -15.2 mmHg at 3 and 6 months, p = 0.03 and 0.06).

CONCLUSION

CT-guided sympathetic denervation proved to be safe and applicable under various anatomical conditions with more renal arteries and such of small diameter.

Measurement of the Direct CP Asymmetry in B¯→X(s+dγ) Decays with a Lepton Tag

We report the measurement of the direct CP asymmetry in the radiative B¯→X(s+dγ) decay using a data sample of (772 ± 11)×10(6) BB[over ¯] pairs collected at the ϒ(4S) resonance with the Belle detector at the KEKB asymmetric-energy e(+)e(-) collider. The CP asymmetry is measured as a function of the photon energy threshold. For Eγ*≥2.1  GeV, where Eγ* is the photon energy in the center-of-mass frame, we obtain A(CP)(B¯→X(s+dγ))=(2.2±3.9±0.9)%, consistent with the standard model prediction.

Serum levels for midkine, a heparin-binding growth factor, inversely correlate with angiotensin and endothelin receptor autoantibody titers in patients with macroangiopathy

AIM

Peripheral artery disease results in impaired blood flow to the extremities, most often as a consequence of atherosclerotic disease. The hallmark of atherosclerosis is chronic inflammation in the vessel wall. The renin-angiotensin and endothelin systems are considered important pathophysiological effectors. Midkine, a multifunctional cytokine, fulfils different roles in inflammation and promotion of neoangiogenesis. The aim of this study was to assess whether circulating midkine serum levels in patients with peripheral artery disease correlate with established atherosclerosis risk factors, as well as titers of functional autoantibodies directed against receptors of the renin-angiotensin and endothelin system.

METHODS

Clinical data, laboratory values and serum samples from 118 patients operated on for severe peripheral artery disease, and from 100 healthy blood donors were collected. Serum samples were analysed for midkine concentrations as well as autoantibody titers against angiotensin II type 1 and endothelin-1 type A receptors.

RESULTS

Midkine values were significantly higher in the study population than in healthy controls (P<0.001). Circulating midkine levels did not correlate with neither of the traditional risk factors age, sex, obesity, smoking, hypertension, high cholesterol levels, or diabetes mellitus. An unexpected inverse correlation was found with the autoantibodies against angiotensin II type 1 receptor (P<0.05) and endothelin-1 type A receptor (P<0.01).

CONCLUSION

The high levels of midkine in severe peripheral artery disease patients introduce this cytokine as a possible novel effector in the advanced atherosclerotic process. These results also suggest a functional link between vascular receptor autoantibody formation and down-regulated midkine serum levels, that may be relevant in the pathogenesis of clinically relevant peripheral artery occlusive disease.

Immunogenicity of SEREX-identified antigens and disease outcome in pancreatic cancer

Despite spontaneous or vaccination-induced immune responses, pancreatic cancer remains one of the most deadly immunotherapy-resistant malignancies. We sought to comprehend the spectrum of pancreatic tumor-associated antigens (pTAAs) and to assess the clinical relevance of their immunogenicity. An autologous SEREX-based screening of a cDNA library constructed from a pancreatic T3N0M0/GIII specimen belonging to a long-term survivor (36 months) revealed 18 immunogenic pTAA. RT-PCR analysis displayed broad distribution of the identified antigens among normal human tissues. PNLIPRP2 and MIA demonstrated the most distinct pancreatic cancer-specific patterns. ELISA-based screening of sera for corresponding autoantibodies revealed that although significantly increased, the immunogenicity of these molecules was not a common feature in pancreatic cancer. QRT-PCR and immunohistochemistry characterized PNLIPRP2 as a robust acinar cell-specific marker whose decreased expression mirrored the disappearance of parenchyma in the diseased organ, but was not related to the presence of PNLIPRP2 autoantibodies. Analyses of MIA-known to be preferentially expressed in malignant cells-surprisingly revealed an inverse correlation between intratumoral gene expression and the emergence of autoantibodies. MIA(high) patients were autoantibody-negative and had shorter median survival when compared with autoantibody-positive MIA(low) patients (12 vs. 34 months). The observed pTAA spectrum comprised molecules associated with acinar, stromal and malignant structures, thus presenting novel targets for tumor cell-specific therapies as well as for approaches based on the bystander effects. Applying the concept of cancer immunoediting to interpret relationships between gene expression, antitumor immune responses, and clinical outcome might better discriminate between past and ongoing immune responses, consequently enabling prognostic stratification of patients and individual adjustment of immunotherapy.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Multicolor fluorescence in situ hybridization (FISH) applied to FISH-banding

During the last decade not only multicolor fluorescence in situ hybridization (FISH) using whole chromosome paints as probes, but also numerous chromosome banding techniques based on FISH have been developed for the human and for the murine genome. This review focuses on such FISH-banding techniques, which were recently defined as 'any kind of FISH technique, which provide the possibility to characterize simultaneously several chromosomal subregions smaller than a chromosome arm. FISH-banding methods fitting that definition may have quite different characteristics, but share the ability to produce a DNA-specific chromosomal banding'. While the standard chromosome banding techniques like GTG lead to a protein-related black and white banding pattern, FISH-banding techniques are DNA-specific, more colorful and, thus, more informative. For some, even high-resolution FISH-banding techniques the development is complete and they can be used for whole genome hybridizations in one step. Other FISH-banding methods are only available for selected chromosomes and/or are still under development. FISH-banding methods have successfully been applied in research in evolution- and radiation-biology, as well as in studies on the nuclear architecture. Moreover, their suitability for diagnostic purposes has been proven in prenatal, postnatal and tumor cytogenetics, indicating that they are an important tool with the potential to partly replace the conventional banding techniques in the future.

Continuous non-invasive blood pressure monitoring using concentrically interlocking control loops

A new method and apparatus for non-disruptive blood pressure (BP) recording in the finger based on the vascular unloading technique is introduced. The instrument, in contrast to intermittent set point readjustments of the conventional vascular unloading technique, delivers BP without interruptions, thus refining the Penáz' principle. The method is based on concentrically interlocking control loops for correct long-term tracing of finger BP, including automatic set point adaptation, light control and separate inlet and outlet valves for electro-pneumatic control. Examples of long-term BP recordings at rest and during autonomic function tests illustrate the potential of the new instrument.

Phase II pharmacodynamic trial of erlotinib in advanced non-small cell lung cancer (NSCLC) patients previously treated with platinum-based chemotherapy: FISH results

7160

Background: The HER1/EGFR inhibitor erlotinib significantly prolongs survival of patients with previously-treated advanced NSCLC. Methods for selecting patients most likely to derive clinical benefit from erlotinib are not established. Increased HER1/EGFR gene copy number has been suggested as a potential predictive biomarker of clinical benefit, and was investigated in this phase II study. Methods: Advanced NSCLC patients who failed first line chemotherapy were treated with erlotinib monotherapy, 150 mg/d p.o. Each patient underwent tumor biopsy before start of treatment. Tumor HER1/EGFR gene amplification status was assessed using FISH, and classified as positive (amplification, polysomy, high polysomy) or negative (disomy, trisomy). Results: 83 patients were included: median age 56 (range 35–78); sex: male 72%, female 28%; histology: adenocarcinoma 43%, large cell 31%, squamous cell 19%, others 7%; smoking status: 44 current smokers, 28 former smokers, 11 never smokers. Of 73 evaluable patients, 7 (10%) achieved partial response (PR), 28 (38%) had stable disease (SD) and 38 (52%) had disease progression. PRs were observed in 4 males / 3 females; in 5 adenocarcinomas / 1 large cell/ 1 squamous cell; in 2 current / 3 former / 2 never smokers. Erlotinib was well tolerated and no unexpected toxicities were seen. HER1/EGFR gene copy number was evaluated in 53 patients. 15 patients were FISH +, 10 of whom achieved clinical benefit (PR, or SD for ≥12 weeks). Only 5 of 38 FISH - patients had clinical benefit. FISH + patients achieved a longer median time to progression (137 vs 43 days; p = 0.00011; HR 0.35) as well as overall survival (226 vs 115 days; p = 0.3221, HR 0.722). Conclusion: In this study, increased HER1/EGFR gene copy number was associated with a better outcome on erlotinib therapy.

[Table: see text]

[Table: see text]

Non-invasive beat-to-beat cardiac output monitoring by an improved method of transthoracic bioimpedance measurement

The report describes a method of impedance cardiography using an improved estimate of thoracic volume. The formulas and their implementation in hardware and software are explained and new shortband electrodes are described which generate a good homogeneous thoracic field. Examples of stroke volume and cardiac output curves underline the capabilities of the monitoring system "Task Force Monitor". In several experiments, results are compared to thermodilution as well as to BioZ measurements: the new method excels in comparison with thermodilution and is comparable to the BioZ device. Compared to traditional electrodes, the new shortband electrodes are shown to provide better reproducibility.

[Dynamic decision making in emergency medicine. Example of paraplegia after a traffic accident]

Dynamic decision making is one of the key skills in crew resource management training in aviation. In emergency medicine it is important to practice this skill as a prerequisite for effective treatment of patients. We report a case of paraplegia after a road traffic accident and cervical spine injury. During the prehospital treatment the patient's state was re-evaluated at different times. Although the patient was initially unconscious the physician at the scene decided not to intubate the trachea as the level of consciousness improved during resuscitation. In the emergency room a C5 fracture and a prolapsed intervertebral disc were diagnosed and immediate decompression and stabilisation of the cervical spine were performed. Dynamic decision-making has been in practise for a long time in aviation, similarities to decisions in medicine and the psychological background are described on the basis of the case report.

The hierarchically organized splitting of chromosome bands into sub-bands analyzed by multicolor banding (MCB)

To clarify the nature of chromosome sub-bands in more detail, the multicolor banding (MCB) probe-set for chromosome 5 was hybridized to normal metaphase spreads of GTG band levels at approximately 850, approximately 550, approximately 400 and approximately 300. It could be observed that as the chromosomes became shorter, more of the initial 39 MCB pseudo-colors disappeared, ending with 18 MCB pseudo-colored bands at the approximately 300-band level. The hierarchically organized splitting of bands into sub-bands was analyzed by comparing the disappearance or appearance of pseudo-color bands of the four different band levels. The regions to split first are telomere-near, centromere-near and in 5q23-->q31, followed by 5p15, 5p14, and all GTG dark bands in 5q apart from 5q12 and 5q32 and finalized by sub-band building in 5p15.2, 5q21.2-->q21.3, 5q23.1 and 5q34. The direction of band splitting towards the centromere or the telomere could be assigned to each band separately. Pseudo-colors assigned to GTG-light bands were resistant to band splitting. These observations are in concordance with the recently proposed concept of chromosome region-specific protein swelling.

[Palliative culture in the stationary care for the elderly]

Nursing homes are challenged by a significant change in the patient-structure. To care for dying elderly people means to enable them to live in dignity till the end. Helpful therefore is to implement Palliative Care into existing structures. This requires personal and organizational learning and development. The first step is to make central differences and contradictions visible und communicable. We describe three organizational types which leads into different core-processes. Organizational measures supporting the development of a palliative culture and indicators of successful implementation are presented.

Multitude multicolor chromosome banding (mMCB) – a comprehensive one-step multicolor FISH banding method

Multicolor chromosome banding (MCB) using one single chromosome-specific MCB probe set per experiment was previously reported as powerful tool in molecular cytogenetics for the characterization of all kinds of human marker chromosomes. However, a quick analysis of karyotypes with highly complex chromosomal changes was hampered by the problem that up to 24 MCB experiments were necessary for a comprehensive karyotype description. To overcome that limitation the 138 available region-specific microdissection-derived libraries for all human chromosomes were combined to one single probe set, called multitude MCB (mMCB). A typical fluorescence banding pattern along the human karyotype is produced, which can be evaluated either by transforming these profiles into chromosome region-specific pseudo-colors or more reliably by studying the fluorescence profiles. The mMCB probe set has been applied on chromosomes of normal male and female probands, two primary myelodysplastic syndromes and two solid tumor cell lines. Additionally, a cell line of Gorilla gorilla (GGO) studied previously by single chromosome-specific MCB was reevaluated by the mMCB method. All results were in concordance with those obtained in parallel or by other cytogenetic and molecular cytogenetic approaches indicating that mMCB is a powerful multicolor FISH banding tool for fast characterization of complex karyotypes.

Evidence for a new microdeletion syndrome in 15q21

We report on the fourth known case with an interstitial deletion in 15q21. In the present case the breakpoints have been determined by GTG-banding, microdissection and the recently developed multicolor banding (MCB) technique as 15q21.1-q21.3. Common features in all four cases are mental retardation, growth retardation, a beak-like nose with hypoplastic alae nasi and a thin upper lip. Additional frequent features are small hands and feet, hypotonia, low hair implantation, low set ears, clinodactyly and obesity. The possibility that a critical region for a new microdeletion-syndrome is situated in 15q21 is discussed.

Multicolor chromosome banding (MCB) with YAC/BAC-based probes and region-specific microdissection DNA libraries

Multicolor chromosome banding (MCB) allows the delineation of chromosomal regions with a resolution of a few megabasepairs, i.e., slightly below the size of most visible chromosome bands. Based on the hybridization of overlapping region-specific probe libraries, chromosomal subregions are hybridized with probes that fluoresce in distinct wavelength intervals, so they can be assigned predefined pseudo-colors during the digital imaging and visualization process. The present study demonstrates how MCB patterns can be produced by region-specific microdissection derived (mcd) libraries as well as collections of yeast or bacterial artificial chromosomes (YACs and BACs, respectively). We compared the efficiency of an mcd library based approach with the hybridization of collections of locus-specific probes (LSP) for fluorescent banding of three rather differently sized human chromosomes, i.e., chromosomes 2, 13, and 22. The LSP sets were comprised of 107 probes specific for chromosome 2, 82 probes for chromosome 13, and 31 probes for chromosome 22. The results demonstrated a more homogeneous coverage of chromosomes and thus, more desirable banding patterns using the microdissection library-based MCB. This may be related to the observation that chromosomes are difficult to cover completely with YAC and/or BAC clones as single-color fluorescence in situ hybridization (FISH) experiments showed. Mcd libraries, on the other hand, provide high complexity probes that work well as region-specific paints, but do not readily allow positioning of breakpoints on genetic or physical maps as required for the positional cloning of genes. Thus, combinations of mcd libraries and locus-specific large insert DNA probes appear to be the most efficient tools for high-resolution cytogenetic analyses.