Patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study

Introduction

Despite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise.

Methods

Twenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method.

Results

The sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.

Discussion

These findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

Circulating serum miR-362-3p and miR-6721-5p as potential biomarkers for classification patients with adult-type diffuse glioma

According to the fifth edition of the WHO Classification of Tumours of the Central Nervous System (CNS) published in 2021, grade 4 gliomas classification includes IDH-mutant astrocytomas and wild-type IDH glioblastomas. Unfortunately, despite precision oncology development, the prognosis for patients with grade 4 glioma remains poor, indicating an urgent need for better diagnostic and therapeutic strategies. Circulating miRNAs besides being important regulators of cancer development could serve as promising diagnostic biomarkers for patients with grade 4 glioma. Here, we propose a two-miRNA miR-362-3p and miR-6721-5p screening signature for serum for non-invasive classification of identified glioma cases into the highest-grade 4 and lower-grade gliomas. A total of 102 samples were included in this study, comprising 78 grade 4 glioma cases and 24 grade 2-3 glioma subjects. Using the NanoString platform, seven miRNAs were identified as differentially expressed (DE), which was subsequently confirmed via RT-qPCR analysis. Next, numerous combinations of DE miRNAs were employed to develop classification models. The dual panel of miR-362-3p and miR-6721-5p displayed the highest diagnostic value to differentiate grade 4 patients and lower grade cases with an AUC of 0.867. Additionally, this signature also had a high AUC = 0.854 in the verification cohorts by RT-qPCR and an AUC = 0.842 using external data from the GEO public database. The functional annotation analyses of predicted DE miRNA target genes showed their primary involvement in the STAT3 and HIF-1 signalling pathways and the signalling pathway of pluripotency of stem cells and glioblastoma-related pathways. For additional exploration of miRNA expression patterns correlated with glioma, we performed the Weighted Gene-Co Expression Network Analysis (WGCNA). We showed that the modules most associated with glioma grade contained as many as six DE miRNAs. In conclusion, this study presents the first evidence of serum miRNA expression profiling in adult-type diffuse glioma using a classification based on the WHO 2021 guidelines. We expect that the discovered dual miR-362-3p and miR-6721-5p signatures have the potential to be utilised for grading gliomas in clinical applications.

Identification of serum miR-1246 and miR-150-5p as novel diagnostic biomarkers for high-grade serous ovarian cancer

Epithelial ovarian cancer (EOC) is one of the leading cancers in women, with high-grade serous ovarian cancer (HGSOC) being the most common and lethal subtype of this disease. A vast majority of HGSOC are diagnosed at the late stage of the disease when the treatment and total recovery chances are low. Thus, there is an urgent need for novel, more sensitive and specific methods for early and routine HGSOC clinical diagnosis. In this study, we performed miRNA expression profiling using the NanoString miRNA assay in 34 serum samples from patients with HGSOC and 36 healthy women. We identified 13 miRNAs that were differentially expressed (DE). For additional exploration of expression patterns correlated with HGSOC, we performed weighted gene co-expression network analysis (WGCNA). As a result, we showed that the module most correlated with tumour size, nodule and metastasis contained 8 DE miRNAs. The panel including miR-1246 and miR-150-5p was identified as a signature that could discriminate HGSOC patients with AUCs of 0.98 and 1 for the training and test sets, respectively. Furthermore, the above two-miRNA panel had an AUC = 0.946 in the verification cohorts of RT-qPCR data and an AUC = 0.895 using external data from the GEO public database. Thus, the model we developed has the potential to markedly improve the diagnosis of ovarian cancer.

3-O sulfation of syndecan-1 mediated by the sulfotransferase HS3ST3a1 enhances myeloma aggressiveness

Multiple myeloma is a hematological neoplasm derived from plasma cells invariably developing in the bone marrow (BM). The persisting clinical challenge in MM resides in its high ability to resist drugs as shown by the frequent relapses observed in patients regardless of the treatment applied. In a mouse model of MM, we identified a subpopulation of cells harboring increased resistance to current MM drugs. These cells bound a proliferation inducing ligand (APRIL), a key MM promoting/survival factor. APRIL binding involved the heparan sulfate (HS) chain present on syndecan-1 (SDC-1), and correlated with reactivity to the anti-HS antibody 10e4. 10e4+cells had a high proliferation activity, and were able to form colonies in 3-D cultures. 10e4+ cells were the only cells able to develop in BM after intravenous injection. They also resisted drugs in vivo, since their number increased after treatment in BM. Notably, 10e4+ cells differentiated into 10e4- cells upon in vitro and in vivo expansion. Expression of one sulfotransferase, HS3ST3a1, allowed modification of syndecan-1 to confer reactivity to 10e4 and binding to APRIL. HS3ST3a1 deletion inhibited tumorigenesis in BM. Notably, the two populations coexisted at a variable frequency in the BM of MM patients at diagnosis. In total, our results indicate that 3-O-sulfation on SDC-1 carried out by HS3ST3a1 defines aggressive MM cells, and that targeting of this enzyme could possibly be used to better control drug resistance.

Development of an extensive workflow for comprehensive clinical pharmacogenomic profiling: lessons from a pilot study on 100 whole exome sequencing data

This pilot study is aimed at implementing an approach for comprehensive clinical pharmacogenomics (PGx) profiling. Fifty patients with cardiovascular diseases and 50 healthy individuals underwent whole-exome sequencing. Data on 1800 PGx genes were extracted and analyzed through deep filtration separately. Theoretical drug induced phenoconversion was assessed for the patients, using sequence2script. In total, 4539 rare variants (including 115 damaging non-synonymous) were identified. Four publicly available PGx bioinformatics algorithms to assign PGx haplotypes were applied to nine selected very important pharmacogenes (VIP) and revealed a 45-70% concordance rate. To ensure availability of the results at point-of-care, actionable variants were stored in a web-hosted database and PGx-cards were developed for quick access and handed to the study subjects. While a comprehensive clinical PGx profile could be successfully extracted from WES data, available tools to interpret these data demonstrated inconsistencies that complicate clinical application.

Analysis of historical negative control group data from the rat in vivo micronucleus assay

A database of micronuclei counts for historical negative control data from rat in vivo micronuclei tests performed in 10 different laboratories was established. Data were available from over 4000 negative control rats from 10 laboratories. The mean frequency of micronucleated cells (MN)/1000 cells ranged from 0.44 to 2.22, a 5-fold range. Overall there were no major sex or strain differences in frequency, although there were some small but statistically significant differences within laboratories. There was appreciable variability between experiments compared with variability within experiments in some laboratories. No specific factor was identified which could explain this variability although it was noted that many different vehicles were used in the experiments. It is hoped that these data will help laboratories beginning studies with the rat micronucleus assay and those involved in the assessment of micronucleus assay results.

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature

BACKGROUND

Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce.

AIMS

To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research.

DESIGN

Systematic, narrative review.

DATA SOURCES

Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion.

REVIEW METHODS

The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated.

RESULTS

Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression.

CONCLUSION

Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

[Prevalence and symptoms of vitamin D deficiency in general practices]

In 776 primary care patients serum vitamin D level was measured in month of september showing deficiency (<50 nmol/l) in 45,1%, severe deficiency (<30 nmol/l) in 9,8% and serum levels below the recommended target level of 75 nmol/l in 88,9% of cases. Three possible symptoms of vitamin D deficiency were assessed by a visual analogue scale (0-10): fatigue, muscle weakness, and muscle and joint pain. A significant correlation between muscle weakness and degree of vitamin D deficiency was shown (p=0,04), whereas there was no correlation in the two other symptoms. However, patients with vitamin D deficiency more frequently reported fatigue (p=0,02) and muscle weakness (p=0,009) than patients without deficiency did, and no difference was seen concerning muscle and joint pain.

[Characteristics of consultations by general practitioners in Switzerland - time, topics and verbal behaviour]

To conduct consultations is the main task of general practitioners. This study concerns itself with consultations, what they are about, how they are structured and how their achievements can be described. In total, 127 recorded consultations were analysed. The 12 recorded general practitioners were themselves involved in the data analysis. The analysis confirms that in comparison to the European average, the Swiss consultation is rather long with a consultation length of 12.5 minutes. 80% of the consultation time is taken up by mere conversation. Per average, three medical topics are discussed within that time. Thus, about three minutes are at disposal per topic. In every consultation we can also find one non-medical topic. The structure of a consultation is complex and changes continually depending on the performed tasks.

[Smoking behaviour and willingness to stop smoking in patients admitted in an internal medicine ward]

Smoking is one of the leading preventable risk factors for the development of lung-, cardio-vascular diseases and cancer. We report results of a prospective survey regarding smoking behaviour and willingness to stop smoking in patients of an internal medicine clinic. Twenty percent of participants admitted smoking cigarettes in the previous 7 days. Smokers were more often males and were younger than non- or ex-smokers. Every second smoker reported being told to stop smoking by a physician before but only about a third was offered active support in doing so. About half of the smoking participants were interested to quit smoking and to participate in a hospital-based smoking cessation program. In patients admitted to the hospital, smoking behaviour and willingness to quit smoking should be recorded and help in quitting smoking should be offered actively. Beside recording smoking behaviour and willingness to quit, patients who are admitted in the hospital should be offered help to quit smoking or to join a proactive structured smoking cessation program.

[Fatigue and anemia]

We herein report on an 80-year old male patient with a history of muscle weakness, fatigue and weight loss since several months. Because of a pathologic synacthen test in combination with decreased levels of ACTH, we diagnosed a secondary chronic adrenal insufficiency. Because of a normochromic, normocytic, and hypo-proliferative anemia, bone marrow puncture was performed, showing an anemia of chronic disease. We initiated hydrocortisone and anemia and patients' symptoms were fully reconstituted.

Design, construction, and first commissioning results of superconducting source for ions at NSCL/MSU

A new electron cyclotron resonance ion source (ECRIS) was constructed at the NSCL/MSU to replace the existing SC-ECRIS. This ECRIS operates at 18+14.5 GHz microwave frequencies with a planned upgrade to 24-28 GHz in the second phase of commissioning. A superconducting hexapole coil system produce the radial magnetic field; the axial trapping is produced with six superconducting solenoid coils enclosed in an iron yoke to allow the optimization of the distance between the plasma electrode and the resonant zone in the plasma. We report the details of the design, construction, and initial commissioning results of this new ECRIS.

Cortical glutamatergic neurons mediate the motor sedative action of diazepam

The neuronal circuits mediating the sedative action of diazepam are unknown. Although the motor-depressant action of diazepam is suppressed in alpha1(H101R) homozygous knockin mice expressing diazepam-insensitive alpha1-GABA(A) receptors, global alpha1-knockout mice show greater motor sedation with diazepam. To clarify this paradox, attributed to compensatory up-regulation of the alpha2 and alpha3 subunits, and to further identify the neuronal circuits supporting diazepam-induced sedation, we generated Emx1-cre-recombinase-mediated conditional mutant mice, selectively lacking the alpha1 subunit (forebrain-specific alpha1(-/-)) or expressing either a single wild-type (H) or a single point-mutated (R) alpha1 allele (forebrain-specific alpha1(-/H) and alpha1(-/R) mice, respectively) in forebrain glutamatergic neurons. In the rest of the brain, alpha1(-/R) mutants are heterozygous alpha1(H101R) mice. Forebrain-specific alpha1(-/-) mice showed enhanced diazepam-induced motor depression and increased expression of the alpha2 and alpha3 subunits in the neocortex and hippocampus, in comparison with their pseudo-wild-type littermates. Forebrain-specific alpha1(-/R) mice were less sensitive than alpha1(-/H) mice to the motor-depressing action of diazepam, but each of these conditional mutants had a similar behavioral response as their corresponding control littermates. Unexpectedly, expression of the alpha1 subunit was reduced in forebrain, notably in alpha1(-/R) mice, and the alpha3 subunit was up-regulated in neocortex, indicating that proper alpha1 subunit expression requires both alleles. In conclusion, conditional manipulation of GABA(A) receptor alpha1 subunit expression can induce compensatory changes in the affected areas. Specifically, alterations in GABA(A) receptor expression restricted to forebrain glutamatergic neurons reproduce the behavioral effects seen after a global alteration, thereby implicating these neurons in the motor-sedative effect of diazepam.

[Therapy-refractory arterial hypertension in a young patient]

We report on a 41-year-old patient admitted for refractory arterial hypertension that had developed after a curative chemotherapy regimen due to seminoma stadium IIb four years ago. After exclusion of secondary forms of arterial hypertension (actually unsuccessfully treated with 5 different antihypertensive drugs) we performed a controlled medication intake-trial in our outpatient clinic. 90 minutes after taking the pills the patient complained of dizziness and perspiration while hypotension and bradycardia were measured simultaneously. Due to the difficult psychosocial situation (conflicts with the insurance and in the family, financial problems) and the suspected narcisstic personality disorder the issue of the proven malcompliance was not openly discussed in order to preserve the patient-doctor alliance. The antihypertensive regimen was then reduced to a double regimen. In the second part of the article the most common reasons for refractory arterial hypertension, especially the problem of treatment malcompliance, are summarized.

[Orthostatic hypotension and hypertension lying down: a clinical dilemma. 56-year-old patient with multiple system atrophy]

A 56-year-old patient with multisystem atrophy of Parkinson type presents himself with severe, symptomatic and orthostatic hypotension and concomitant arterial hypertension while in a recumbent position. Etiology and pathophysiology of orthostatic hypotension and concomitant hypertension in recumbent position is discussed as it relates to this specific patient. Specific indications for antihypertensive therapies and other potential therapeutic options are also discussed.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

[Foot drop paralysis after intoxicated state]

Bei einem 20-jährigen Mann kommt es nach einem Rauschzustand zu einer peripheren Peronaeusparese, ausgelöst durch langes Verharren in einer Hockstellung. Das typische klinische Bild der Peronaeusparese ist der Steppergang. Druckparesen sind die häufigsten Ursachen der peripheren N. peronaeus-Läsionen. Die Therapie ist konservativ. Eine Anpassung eines Heidelberger-Winkels (Kunststoffschiene) wird empfohlen. Generell scheint die Prognose bei druckbedingten Läsionen gut zu sein. Die Peronaeusparese sollte vom Tibialis anterior-Syndrom differenziert werden.

Salz, Hypertonie und kardiovaskuläres Risiko

Eine große Zahl von Studien fand eine signifikante direkte Beziehung zwischen täglichem Kochsalzkonsum und Blutdruck. Der blutdrucksenkende Effekt einer Kochsalzrestriktion von 100 mmol pro Tag wird auf 3–5 mmHg systolisch und 1–2 mmHg diastolisch geschätzt. Das Ausmaß der Blutdruckreduktion hängt stark von der Salzsensitivität ab. Die momentane Datenlage unterstützt die Empfehlung, den täglichen Kochsalzkonsum auf Mengen unter 100 mmol zu senken (= 2.3 g Natrium oder 5.8 g Natriumchlorid). In westlichen Ländern liegt der tägliche Kochsalzkonsum bei etwa 150 mmol. Die Reduktion des Kochsalzkonsums dürfte sich vor allem positiv bei Diabetikern, Schwarzen, älteren und adipösen Personen auswirken. Hingegen ist es fraglich, ob eine generelle Einschränkung des Kochsalzkonsums bei Personen ohne arterielle Hypertonie sinnvoll ist, da der Effekt auf den Blutdruck in dieser Population bescheiden ist. Ob eine generelle Einschränkung des Kochsalzkonsums schlussendlich die kardiovaskuläre Morbidität und Mortalität in der Bevölkerung beeinflusst, ist unklar.

[A small virus among the large]

Eine Parvovirus B19-Infektion kann sich im Erwachsenenalter mit arthritischen Beschwerdem, Arthralgien mit oder ohne grippale Symptome manifestieren. Die Beschwerden heilen meistens innerhalb von zwei bis drei Wochen spontan aus. Eine symptomatische Behandlung mit nichtsteroidalen Antirheumatika wirkt beschwerdelindernd. Ob eine akute oder chronische Parvovirus B19-Infektion prädisponierend auf die Entwicklung einer Kollagenose oder einer Rheumatoide Arthritis wirkt, ist in der Literatur bisher nicht bewiesen worden.

[Angiotensin II receptor blockers--evidence along the cardiovascular continuum]

The introduction of Angiotensin II receptor blockers (ARB) in 1995 was another milestone in the pharmacological management of hypertension. Due to the manifold effects on several target organs Angiotensin II is one of the most important mediator in the pathogenesis of hypertension. The blockade of the Angiotensin II receptor type 1 is a crucial cornerstone in interrupting the pathophysiological pathways in hypertension. Furthermore ARB have an excellent tolerability comparable with placebo. In the last decade large placebo-controlled trials could prove the efficiency of ARB in terms of morbidity and mortality. Patients after acute myocardial infarction and patients with chronic heart failure benefit from treatment with ARB equally compared to treatment with ACE inhibitors. Combining ARB and ACE inhibitors in patient after myocardial infarction increases the rate of adverse events without improving survival. Increase of microalbuminuria and worsening of diabetic nephropathy is reduced by ARB in patients with diabetes type 2, but an advantage over ACE inhibitors could not be documented. Hypertensive patients with electrocardiographically left ventricular hypertrophy treated with ARB seem to have an additional benefit in terms of morbidity and mortality compared to treatment with beta-blockers. In the early treatment of stroke patients treated with ARB have a lower 12-mounth mortality than patients receiving placebo. In conclusion, Angiotensin II receptor blockers are due to their well proved efficiency, the cardio- and renoprotective qualities and the excellent tolerability profile a useful therapeutic option in the management of patients with hypertension.

3,3'-Dimethyl-1,1'-methylenediimidazolium tetrachlorocobaltate(II)

The title compound, (C9H14N4)[CoCl4], a methylene-bridged bis-imidazolium salt containing a tetrachlorocobaltate anion, is one of the first examples where an alkyl-bridged bis-imidazolium compound could be structurally characterized. Short C-H...Cl contacts between the imidazolium C-H bonds and the Cl atoms of the counter-anion build up a three-dimensional network and indicate that the C-H bonds are strongly polarized.

Diagnostic significance of transferrinuria and albumin-specific dipstick testing in primary care patients with elevated office blood pressure

This study assesses the diagnostic accuracy of transferrinuria and an albumin-specific dipstick assay for detection of renal target organ damage (microalbuminuria) in hypertensive patients in a general practice setting. A spot urine sample of 130 nondiabetic patients with elevated office blood pressure readings (>140 and/or 90 mmHg) was investigated by measuring albumin to creatinine ratio (ACR) and transferrin to creatinine ratio (TCR) and by using an albumin-specific dipstick test (Micral). ACR was considered as comparative gold standard. TCR was elevated (>0.19 mg/mmol) in 26 urine samples (20.0% of the test samples). ACR was raised in 29 samples (22.3% of the test samples). Elevated TCR had a sensitivity of 97% and specificity of 91% for detection of microalbuminuria. Positive predicting value for microalbuminuria was 65%; negative predicting value was 99%. Correlation between ACR and TCR was strong (r=0.96). Dipstick testing for albumin was positive in 23 urine samples (17.7% of the test samples), 27 (20.8%) tests were false positive and six (4.6%) false negative. When dipstick was positive, the sensitivity of detecting microalbuminuria was 79%, and specificity 73%. In conclusion, detection of urinary transferrin in nondiabetic patients with hypertension is strongly associated with urinary albumin excretion. However, assessment of TCR does not identify additional patients with microalbuminuria compared to measurement of ACR alone. The semiquantitative Micral test offers a simple and valuable method to screen hypertensive patients for microalbuminuria in a primary care setting.

[Father of a family with pruritic papules below the belt line]

Die Herbstmilbe befällt häuptsächlich im August/September den Menschen als Fehlwirt. Bevorzugt werden Körperstellen mit eng anliegenden Kleidern (z.B. Gummizug, Gürtel) befallen. Die Milben lösen mit ihrem Speichel das Gewebe punktuell auf und lösen so eine ausgeprägte Immunreaktion aus. Es entsteht eine Papel und starker Juckreiz. Die Milben werden meistens durch Kratzen zerstört, lindernd wirken lokale Kortikosteroide. Die Hautreaktion besteht für etwa zehn Tage. Als Prophylaxe wird empfohlen, Füsse und Beine gut bedeckt zu halten, Mückenschutzpräparate zu verwenden und nachmittags keine Gartenarbeiten durchzuführen.

[Idiopathic gingival hyperplasia]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei Gingivahyperplasie besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Sarkoidose im Allgemeinen und speziell bei Beteiligung der Gingiva eingegangen.

[A 63-old patient with right-sided hypogastric pain at 6 months after appendectomy]

Anhand einer Fallbeschreibung werden die Differentialdiagnosen bei rechtsseitigem Unterbauchschmerz mit den entsprechenden weiterführenden Abklärungen besprochen. Schwerpunktmässig wird im Kommentar anhand des beschriebenen Falles auf die Bildgebung von Dünndarmprozessen und im speziellen auf das diffuse, grosszellige B-Zell-Lymphom (Schwerpunkt Therapie, Prognose) eingegangen.

Drug Hypersensitivity Syndrome to Carbamazepine and Human Herpes Virus 6 Infection: Case Report and Literature Review

We describe a patient with a drug-induced hypersensitivity syndrome to carbamazepine and a concomitant active infection with human herpes virus 6 (HHV-6). The potential role of HHV-6 regarding the drug-induced hypersensitivity syndrome is discussed and the main clinical features of this potentially fatal adverse drug reaction are highlighted.

[Placebo: an unappreciated factor in medicine]

Placebo is a provoking factor in medicine that is discussed controversially and not fully understood so far. From the scientific point of view and according to evidence-based medicine a proved indication to prescribe a placebo does not exist. Therapy of pain may be an exclusion. In our daily work we consciously use the placebo-effect, but on the other hand we are committed to the placebo-phenomenon. This article gives an overview of various aspects of placebo. The currently supported theory about the placebo response, conditioning and expectancy, are discussed. Further, the side effects (nocebo-phenomenon) and the utility of placebo in randomised clinical trials is highlighted.

[Patient questions on Barrett esophagus]

Anhand eines Fallbeispieles wird die Prognose, die Therapieoptionen und ein mögliches endoskopisches Nachkontroll-Schema bei Barrett-Ösophagus besprochen. Grundlage für die Diskussion bilden Fragen, welche von einem betroffenen Patienten anlässlich einer Erstkonsultation gestellt wurden.

[Scleral icterus in a 22-year-old housewife]

Anhand einer Fallbeschreibung wird die Differentialdiagnose der isolierten Hyperbilirubinämie besprochen. Im Kommentar wird schwerpunktmässig die klinische Beudeutung der chronischen, unkonjugierten Hyperbilirubinämie (Gilbert's Syndrom) diskutiert.

[Hypertensive emergency]

Hypertensive emergencies are acute, life-threatening events, characterised by high blood pressure and concomitant acute hypertensive target organ damage. These patients need immediate lowering of blood pressure mostly with parenteral drugs in the range of the autoregulative capacity of organ circulation and in-hospital monitoring of the vital functions. Hypertensive urgencies are not necessarily life-threatening, but persistence of high blood pressure may lead to acute target organ damage. Blood pressure should be lowered within 24 to 48 hours. Oral therapy is normally sufficient and hospitalisation is rarely necessary, but maintenance of antihypertensive therapy outside the hospital has to be ascertained.

[The Basel Medical University Polyclinic on the brink of the 21st century: retrospective and prospective view]

At the occasion of its 125th anniversary the outpatient department of internal medicine is being analysed with regard to its history, development and future. Originally it was founded to improve practical patient-oriented teaching of students and to serve the poor population of Basel. While today the Swiss Health Insurance system warrants proper care for every citizen and thus renders the latter purpose unnecessary, new marginal patient groups have evolved that need proper attention such as HIV patients, asylum-seekers, geriatric patients and others. Teaching obligations have even increased, especially with regard to primary care and family medicine. Thus the reasons for running a medical outpatient department have changed considerably, but still include teaching, research and provision of care to special patient groups. Outpatient departments have to be flexible and to adapt to modern trends in health care.

Prevalence and clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening

BACKGROUND AND METHODS

There are few data on the prevalence and clinical outcome of hepatitis C infection in children. We studied 458 children who underwent cardiac surgery in Munich, Germany, before 1991, when blood-donor screening for hepatitis C was introduced in Germany. Their mean age at first operation was 2.8 years; none of the children had received blood transfusions before or 'after cardiac surgery, and none of their mothers had antibodies to the hepatitis C virus (anti-HCV). We compared these patients with 458 control subjects matched for age and sex.

RESULTS

Sixty-seven (14.6 percent) of the 458 patients who had undergone cardiac surgery had anti-HCV, as compared with 3 (0.7 percent) of the control subjects (P<0.001). At a mean interval of 19.8 years after the first operation, 37 (55 percent) of the 67 patients who were positive for anti-HCV had detectable HCV RNA in their blood. The infection had cleared in the other 30 patients, as evidenced by negative results on three polymerase-chain-reaction analyses performed at six-month intervals. Only 1 of the 37 patients who were positive for HCV RNA had elevated levels of liver enzymes; that patient had severe right-sided congestive heart failure. Of the 17 patients who underwent liver biopsies, only 3 had histologic signs of progressive liver damage. These three patients had additional risk factors: two had congestive heart failure, and the third had also been infected with hepatitis B virus.

CONCLUSIONS

Children who had undergone cardiac surgery in Germany before the implementation of blood-donor screening for hepatitis C had a substantial risk of acquiring the infection. However, after about 20 years, the virus had spontaneously cleared in many patients. The clinical course in those still infected seems more benign than would be expected in people infected as adults.