Frequency of stress dosing and adrenal crisis in paediatric and adult patients with congenital adrenal hyperplasia: a prospective study

OBJECTIVE

Patients with congenital adrenal hyperplasia (CAH) require life-long glucocorticoid replacement, including stress dosing (SD). This study prospectively assessed adrenal crisis (AC) incidence, frequency, and details of SD and disease knowledge in adult and paediatric patients and their parents.

DESIGN

Prospective, observational study.

METHODS

Data on AC and SD were collected via a patient diary. In case of AC, medical records were reviewed and patient interviews conducted. Adherence to sick day rules of the German Society of Endocrinology (DGE) and disease knowledge using the German version of the CAH knowledge assessment questionnaire (CAHKAQ) were assessed.

RESULTS

In 187 adult patients, the AC incidence was 8.4 per 100 patient years (py) and 5.1 in 100 py in 38 children. In adults, 195.4 SD episodes per 100 py were recorded, in children 169.7 per 100 py. In children 72.3% and in adults 34.8%, SD was performed according to the recommendations. Children scored higher on the CAHKAQ than adults (18.0 [1.0] vs 16.0 [4.0]; P = .001). In adults, there was a positive correlation of the frequency of SD and the incidence of AC (r = .235, P = .011) and CAHKAQ score (r = .233, P = .014), and between the incidence of AC and CAHKAQ (r = .193, P = .026).

CONCLUSION

The AC incidence and frequency of SD in children and adults with CAH are high. In contrast to the paediatric cohort, the majority of SD in adults was not in accordance with the DGE recommendations, underlining the need for structured and repeated education of patients with particular focus on transition.

Major immunophenotypic abnormalities in patients with primary adrenal insufficiency of different etiology

Introduction

Patients with primary adrenal insufficiency (PAI) suffer from increased risk of infection, adrenal crises and have a higher mortality rate. Such dismal outcomes have been inferred to immune cell dysregulation because of unphysiological cortisol replacement. As the immune landscape of patients with different types of PAI has not been systematically explored, we set out to immunophenotype PAI patients with different causes of glucocorticoid (GC) deficiency.

Methods

This cross-sectional single center study includes 28 patients with congenital adrenal hyperplasia (CAH), 27 after bilateral adrenalectomy due to Cushing's syndrome (BADx), 21 with Addison's disease (AD) and 52 healthy controls. All patients with PAI were on a stable GC replacement regimen with a median dose of 25 mg hydrocortisone per day. Peripheral blood mononuclear cells were isolated from heparinized blood samples. Immune cell subsets were analyzed using multicolor flow cytometry after four-hour stimulation with phorbol myristate acetate and ionomycin. Natural killer (NK-) cell cytotoxicity and clock gene expression were investigated.

Results

The percentage of T helper cell subsets was downregulated in AD patients (Th1 p = 0.0024, Th2 p = 0.0157, Th17 p < 0.0001) compared to controls. Cytotoxic T cell subsets were reduced in AD (Tc1 p = 0.0075, Tc2 p = 0.0154) and CAH patients (Tc1 p = 0.0055, Tc2 p = 0.0012) compared to controls. NKCC was reduced in all subsets of PAI patients, with smallest changes in CAH. Degranulation marker CD107a expression was upregulated in BADx and AD, not in CAH patients compared to controls (BADx p < 0.0001; AD p = 0.0002). In contrast to NK cell activating receptors, NK cell inhibiting receptor CD94 was upregulated in BADx and AD, but not in CAH patients (p < 0.0001). Although modulation in clock gene expression could be confirmed in our patient subgroups, major interindividual-intergroup dissimilarities were not detected.

Discussion

In patients with different etiologies of PAI, distinct differences in T and NK cell-phenotypes became apparent despite the use of same GC preparation and dose. Our results highlight unsuspected differences in immune cell composition and function in PAI patients of different causes and suggest disease-specific alterations that might necessitate disease-specific treatment.

Synthetic glucocorticoids instead of hydrocortisone do not increase mineralocorticoid needs in adult patients with salt wasting congenital adrenal hyperplasia

It has been postulated that in patients with congenital adrenal hyperplasia (CAH) with salt wasting (SW), fludrocortisone needs might be higher in those on synthetic glucocorticoid replacement therapy in comparison to conventional hydrocortisone due to the lower mineralocorticoid activity. Here we report the results of a cross-sectional single center study comparing mineralocorticoid needs between patients taking synthetic glucocorticoids (S-GC) (N = 24) and those on conventional hydrocortisone (HC) (N = 16). We could show that while both groups took comparable HC-equivalent dosages, there was no significant difference in FC dosage (GC: 0.075 mg; IQR 0.05-0.1; HC: 0.1 mg; IQR 0.05-0.1; p = 0.713). Although there was a trend for higher renin levels in the S-GC group (67.1 µU/ml; IQR 40.5-113.9 vs. 40.4 IQR 14.2-73.1; p = 0.066), this failed to reach significance. With regard to blood pressure, those taking S-GC had even significantly elevated mean systolic (125.0 mmHg, IQR 117.5-130.0 vs 116.5 mmHg IQR 111.8-124.8; p = 0.036) and diastolic (78.0 mmHg, IQR 74.3-83.8 vs 74.5mmHG, IQR 69.3-76.0; p = 0.044) during the day. Systolic dipping was however more pronounced in those on GC in comparison to those taking HC (11.3%; IQR 8.7-14.6 vs. 6.4 IQR 3.4-12.7; p = 0.031). In conclusion, we could show in this small, albeit well-balanced cohort that mineralocorticoid dosage does not significantly differ between patients receiving synthetic glucocorticoids or conventional hydrocortisone. Higher blood pressure values despite the tendency for higher renin levels in those on S-GC support the notion that the assessment of MR adequacy should be guided by the clinical picture and blood pressure on a regular basis.

11-Oxygenated androgens are not secreted by the human ovary: in-vivo data from four different cases of hyperandrogenism

OBJECTIVE

Differentiation of an adrenal from an ovarian source of hyperandrogenemia can be challenging. Recent studies have highlighted the importance of 11-oxygenated C19 steroids to the androgen pool in humans. The aim of this study was to confirm the origin of 11-oxygenated androgens in females and to explore their potential use in the diagnostics of hyperandrogenic disorders.

METHODS

We measured testosterone and its precursors (dehydroepiandrosterone-sulfate and androstenedione) and 11-oxygenated androgens (11β-hydroxyandrostenedione (11-OHA4) and 11-ketotestosterone (11-KT)) in the periphery, adrenal and ovarian veins in four different cases of hyperandrogenism in females (polycystic ovary syndrome (PCOS), primary bilateral macronodular adrenal hyperplasia, Sertoli-Leydig cell tumor and ovarian steroid cell tumor).

RESULTS

Two patients demonstrate excessive testosterone secretion in neoplastic ovarian tumors which was not paralleled by a significant secretion of 11-oxygenated androgens as determined by adrenal and ovarian vein sampling. In androgen-secreting bilateral adrenal macronodular hyperplasia, steroid profiles were characterized by elevated 11-KT and 11-OHA4 concentrations in adrenal veins and the periphery. In the patient with PCOS, peripheral 11-KT concentrations were slightly elevated in comparison to the other patients, but the 11-KT and 11-OHA4 concentrations were comparable in ovarian veins and in the periphery.

CONCLUSION

This study confirms that 11-OHA4 and 11-KT are not biosynthesized by the ovary. We propose that the testosterone/11-KT ratio as well as 11-OHA4 could help identify predominant adrenal androgen excess and distinguish neoplastic and non-neoplastic ovarian androgen source.

SIGNIFICANCE STATEMENT

This study confirms that 11β-hydroxyandrostenedione (11-OHA4) and 11-ketotestosterone (11-KT) are not biosynthesized by the human ovary. We propose that the testosterone/11-KT ratio as well as 11-OHA4 could help to identify predominant adrenal androgen excess and distinguish neoplastic and non-neoplastic ovarian androgen source.

11-Oxygenated C19 steroids are the predominant androgens responsible for hyperandrogenemia in Cushing's disease

BACKGROUND

Symptoms of hyperandrogenism are common in patients with Cushing's disease (CD), yet they are not sufficiently explained by androgen concentrations. In this study, we analyzed the contribution of 11-oxygenated C19 steroids (11oxC19) to hyperandrogenemia in female patients with CD.

METHODS

We assessed saliva day profiles in females with CD pre (n = 23) and post (n = 13) successful transsphenoidal surgery, 26 female controls, 5 females with CD treated with metyrapone and 5 treated with osilodrostat for cortisol, cortisone, androstenedione (A4), 11-hydroxyandrostenedione (11OHA4), testosterone (TS), 11-ketotestosterone (11KT), as well as metabolites of classic and 11-oxygenated androgens in 24-h urine. In addition, morning baseline levels of gonadotropins and estradiol, sex hormone-binding globulin, cortisol and dehydroepiandrosterone sulfate (DHEAS) in serum and adrenocorticotrophic hormone in plasma in patients and controls were investigated.

RESULTS

Treatment-naïve females with CD showed a significantly elevated area under the curve of 11OHA4 and 11KT in saliva throughout the day compared to controls (11OHA4 mean rank difference (mrd) 18.13, P = 0.0002; 11KT mrd 17.42; P = 0.0005), whereas A4, TS and DHEAS were comparable to controls. Gonadotropin concentrations were normal in all patients with CD. After transsphenoidal surgery, 11oxC19 and their metabolites dropped significantly in saliva (11OHA4 P < 0.0001; 11KT P = 0.0010) and urine (11-oxo-androsterone P = 0.0011; 11-hydroxy-androsterone P < 0.0001), treatment with osilodrostat and metyrapone efficaciously blocked 11oxC19 synthesis.

CONCLUSION

Hyperandrogenemia in CD is predominantly caused by excess of 11oxC19 steroids.

OR27-1 11-Oxygenated C19 Steroids Are the Predominant Androgens Responsible for Hyperandrogenemia in Cushing's Disease

Background

Symptoms of hyperandrogenism are common in patients with Cushing's disease (CD), but they cannot be sufficiently explained by measured concentrations of circulating androgens. In this study we analyzed the contribution of 11-oxygenated (11oxC19) androgens to hyperandrogenemia in female patients with CD as well as the influence of treatment with steroidogenesis inhibitors osilodrostat and metyrapone on 11oxC19 and classic androgens.

Methods

In this single-center study, we assessed saliva day profiles of 23 females with treatment naïve CD, 26 female controls, 5 females with CD treated with metyrapone and 5 treated with osilodrostat for cortisol, cortisone, androstenedione (A4), 11-hydroxyandrostenedione (11OHA4), testosterone (T), 11-ketotestosterone (11KT) by by liquid chromatography tandem mass spectrometry as well as morning baseline levels of gonadotropins and estradiol, sex hormone-binding globulin, cortisol anddehydroepiandrosterone sulfate (DHEAS) in serum and adrenocorticotropic hormone in plasma.

Results

Treatment naïve females with CD showed significantly elevated area under the curve (AUC) of 11OHA4 and 11KT throughout the day compared to controls (11OHA4 mean rank difference (mrd) 18.13, p = 0.0002; 11KT mrd 17.42; p = 0.0005) whereas A4, T and DHEAS were comparable to controls. Patients with more symptoms of hyperandrogenism displayed higher concentrations of 11oxC19 androgens and had significantly lower SHBG concentrations. Gonadotropin levels were normal in all patients with CD (LH 7.18 U/l (SD 14.28 U/l); FSH 7.68 U/l (SD 12.0 U/l)) and did not correlate with any other parameters. Treatment with osilodrostat and metyrapone efficaciously blocked 11oxC19 synthesis. In metyrapone but not in osilodrostat treatment a trend towards increased concentrations of T and significantly increased A4-concentrations were observed (A4 mrd 23.07, p = 0.0119).

Conclusion

Hyperandrogenemia in CD is predominantly caused by excess of 11oxC19 androgens. Due to lower compensatory increase of A4 and T, osilodrostat seems to be more suitable for treatment of females with CD and hyperandrogenism than metyrapone.

Presentation: Tuesday, June 14, 2022 9:45 a.m. - 10:00 a.m.

Preoperative Imaging with [18F]-Fluorocholine PET/CT in Primary Hyperparathyroidism

Primary hyperparathyroidism (pHPT) is a common endocrine disorder due to hyperfunctioning parathyroid glands. To date, the only curing therapy is surgical removal of the dysfunctional gland, making correct detection and localization crucial in order to perform a minimally invasive parathyroidectomy. ¹⁸F-Fluorocholine positron emission tomography/computed tomography (¹⁸F-FCH PET/CT) has shown promising results for the detection of pHPT, suggesting superiority over conventional imaging with ultrasounds or scintigraphy. A total of 33 patients with pHPT who had negative or equivocal findings in conventional imaging received ¹⁸F-FCH PET/CT preoperatively and were retrospectively included. A pathological hyperfunctional parathyroid gland was diagnosed in 24 cases (positive PET, 72.7%), 4 cases showed equivocal choline uptake (equivocal PET, 12.1%), and in 5 cases, no enhanced choline uptake was evident (negative PET, 15.2%). Twelve of the twenty-four detected adenoma patients underwent surgery, and in all cases, a pathological parathyroid adenoma was resected at the site detected by PET/CT. Two of the six patients without pathological choline uptake who received a parathyroidectomy revealed no evidence of parathyroid adenoma tissue in the histopathological evaluation. This retrospective study analyzes ¹⁸F-FCH PET/CT in a challenging patient cohort with pHPT and negative or equivocal conventional imaging results and supports the use of ¹⁸F-FCH for the diagnosis of hyperfunctional parathyroid tissue, especially in this patient setting, with a 100% true positive and true negative detection rate. Our study further demonstrates the importance of ¹⁸F-FCH PET/CT for successful surgical guidance.

Personalized drug testing in human pheochromocytoma/paraganglioma primary cultures

Aggressive pheochromocytomas and paragangliomas (PPGLs) are difficult to treat, and molecular targeting is being increasingly considered, but with variable results. This study investigates established and novel molecular-targeted drugs and chemotherapeutic agents for the treatment of PPGLs in human primary cultures and murine cell line spheroids. In PPGLs from 33 patients, including 7 metastatic PPGLs, we identified germline or somatic driver mutations in 79% of cases, allowing us to assess potential differences in drug responsivity between pseudohypoxia-associated cluster 1-related (n = 10) and kinase signaling-associated cluster 2-related (n = 14) PPGL primary cultures. Single anti-cancer drugs were either more effective in cluster 1 (cabozantinib, selpercatinib, and 5-FU) or similarly effective in both clusters (everolimus, sunitinib, alpelisib, trametinib, niraparib, entinostat, gemcitabine, AR-A014418, and high-dose zoledronic acid). High-dose estrogen and low-dose zoledronic acid were the only single substances more effective in cluster 2. Neither cluster 1- nor cluster 2-related patient primary cultures responded to HIF-2a inhibitors, temozolomide, dabrafenib, or octreotide. We showed particular efficacy of targeted combination treatments (cabozantinib/everolimus, alpelisib/everolimus, alpelisib/trametinib) in both clusters, with higher efficacy of some targeted combinations in cluster 2 and overall synergistic effects (cabozantinib/everolimus, alpelisib/trametinib) or synergistic effects in cluster 2 (alpelisib/everolimus). Cabozantinib/everolimus combination therapy, gemcitabine, and high-dose zoledronic acid appear to be promising treatment options with particularly high efficacy in SDHB-mutant and metastatic tumors. In conclusion, only minor differences regarding drug responsivity were found between cluster 1 and cluster 2: some single anti-cancer drugs were more effective in cluster 1 and some targeted combination treatments were more effective in cluster 2.

Salivary Profiles of 11-oxygenated Androgens Follow a Diurnal Rhythm in Patients With Congenital Adrenal Hyperplasia

CONTEXT

Several studies have highlighted the importance of the 11-oxygenated 19-carbon (11oxC19) adrenal-derived steroids as potential biomarkers for monitoring patients with 21-hydroxylase deficiency (21OHD).

OBJECTIVE

To analyze circadian rhythmicity of 11oxC19 steroids in saliva profiles and evaluate their relevance as potential monitoring parameters in 21OHD.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional single-center study including 59 patients with classic 21OHD (men = 30; women = 29) and 49 body mass index- and age-matched controls (men = 19; women = 30).

OUTCOME MEASURES

Salivary concentrations of the following steroids were analyzed by liquid chromatography-tandem mass spectrometry: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11β-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT).

RESULTS

Similar to the previously described rhythmicity of 17OHP, 11OHA4 and 11KT concentrations followed a distinct diurnal rhythm in both patients and controls with highest concentrations in the early morning and declining throughout the day (11-OHA4: mean reduction of hormone concentrations between timepoint 1 and 5 (Δ mean) in male patients = 66%; male controls Δ mean = 83%; female patients Δ mean = 47%; female controls Δ mean = 86%; 11KT: male patients Δ mean = 57%; male controls Δ mean = 63%; female patients Δ mean = 50%; female controls Δ mean = 76%). Significant correlations between the area under the curve for 17OHP and 11KT (rpmale = 0.773<0.0001; rpfemale = 0.737<0.0001), and 11OHA4 (rpmale = 0.6330.0002; rpfemale = 0.5640.0014) were observed in patients but not present or reduced in controls.

CONCLUSIONS

Adrenal 11oxC19 androgens are secreted following a diurnal pattern. This should be considered when evaluating their utility for monitoring treatment control.

Hyperechogenic intimal lesions and wall thickness of the temporal and facial arteries in elderly patients with arterial occlusions of the eye

OBJECTIVE

To determine the association of arteriosclerosis, characterised by hyperechogenic intimal lesions (HIL), with wall thickness of the temporal and facial arteries in elderly patients with ocular arterial occlusions.

METHODS

Patients suffering from non-arteritic ocular perfusion disorders were included. High-resolution compression sonography (18 MHz) images of the temporal arteries (frontal and parietal branch at the upper margin of the auricle) and facial arteries (at the crossing point of the artery over the mandible) were analysed for the presence of HIL (grade 0: absent; grade 1: moderate; grade 2: severe). Characteristics of patients with and without evidence of HIL >grade 1 were compared.

RESULTS

In total, 330 cranial artery segments of 55 patients were analysed. HIL ≥grade 1 was present in 13.0% of all artery segments and in 38.1% of all patients. Patients with HIL ≥grade 1 in at least one arterial segment displayed significantly increased maximum wall thickness of the temporal arteries (0.62±0.23 mm vs 0.50±0.13 mm; p<0.01) and facial arteries (0.71±0.20 mm vs 0.54±0.19 mm; p=0.01). Patients with at least one temporal or facial artery segment with HIL were older, more often male and more frequently suffered from diabetes mellitus.

CONCLUSION

The presence of HIL goes along with a significantly increased wall thickness of the temporal and facial arteries. These findings should be considered when interpreting the results of sonography of the cranial arteries in the diagnostic workup of suspected giant cell arteritis.

11-oxygenated androgens and their relation to hypothalamus-pituitary-gonadal-axis disturbances in adults with congenital adrenal hyperplasia

CONTEXT

Hypothalamus-pituitary-gonadal (HPG)-axis disturbances are a common phenomenon in patients with classic congenital adrenal hyperplasia (CAH). 11-oxygenated androgens have been suggested to play a role in this context.

DESIGN

Cross-sectional single center study including 89 patients (N = 42 men, N = 55 women) with classic CAH.

MAIN OUTCOME MEASURES

Differences in steroid markers in men with hypogonadism and women with secondary amenorrhea with a special focus on 11-ketotestosterone (11KT) and 11β-hydroxyandrostenedione (11OHA4).

RESULTS

Hypogonadotropic hypogonadism was present in 23 % of men and 61 % of those women currently not on contraceptives suffered from irregular menstrual cycles or amenorrhea. Testicular adrenal rest tumor (TART) was documented in 28 % of men. 11KT (3.5x) and 11OHA4 (5.7x) among other adrenal steroids were significantly elevated in men with hypogonadism and in women with amenorrhea in comparison to those with a regular cycle (11KT: 5.2x; 11OHA4: 3.7x). 11-oxygenated androgens were not higher in men with TART than in those without. There was a negative association of 11KT and 11OHA4 with FSH but not with LH in men. As expected, all steroids were strongly correlated with each other and cases of disproportionally elevated 11-oxygenated androgens that could explain for HPG-disturbances or TART in otherwise controlled patients were rare and also found in eugonadal individuals.

CONCLUSIONS

In CAH, 11-oxygenated androgens are elevated in women with menstrual disturbances and in men with hypogonadotropic hypogonadism. Due to the close correlation of 11-oxygenated androgens with other adrenal steroids it remains to be shown if their measurement is superior to conventional markers of androgen control.

Temporal artery compression sonography for the diagnosis of giant cell arteritis in elderly patients with acute ocular arterial occlusions

OBJECTIVES

To validate cut-off values of quantitative high-resolution temporal artery compression sonography (TCS) for the diagnosis of cranial GCA (cGCA) in patients with acute arterial ocular occlusions and in an independent control group.

METHODS

Consecutive patients who underwent TCS as part of the diagnostic workup of acute arterial ocular occlusions and controls not suffering from ocular ischaemia/systemic vasculitis were included. The diagnostic accuracy of the established TCS cut-off value of maximum temporal artery wall thickness (≥0.7 mm) and a novel numeric TCS score incorporating the degree of wall thickening in the four temporal artery segments assessed (0-3 points per segment) was tested by receiver operating characteristics analysis. Subgroup analyses were performed for female and male patients and patients older and younger than age of 70 years.

RESULTS

Of 114 patients with acute ocular arterial occlusions, 30 patients received a final clinical diagnosis of cGCA. The sensitivity and specificity of the ≥0.7 mm TCS cut-off for the diagnosis of cGCA were 100 and 84.5% in the overall cohort. The TCS score did not improve the diagnostic yield (cut-off ≥5; sensitivity 100%, specificity 85.7%). In male patients >70 years of age, the specificity of TCS was limited, secondary to age- and sex-related differences in temporal artery wall thickness, which we confirmed in the independent control group.

CONCLUSION

TCS yields high diagnostic accuracy in the diagnosis of cGCA in patients with acute ocular arterial occlusions. Age- and sex-related differences in temporal artery wall thickness influence the diagnostic accuracy of TCS.

Simulated ward round training in the medical curriculum Munich

Conducting a ward round in a structured and goal-oriented manner is one of the central competencies of a physician's work. Despite its relevance, ward round competence was only addressed in an unstructured way in the Medical Curriculum Munich (MeCuM) prior to 2011. Therefore, the project's aim was to implement an evidence-based course on medical ward round competence. This project report provides a guideline for developing such a training course. Project planning and development was guided by the steps of the "Kern cycle", beginning with needs assessment, learning objectives definition, and selection of appropriate teaching methods, and ending with implementation and evaluation.

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study

BACKGROUND

 This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients.

METHODS

 Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System).

RESULTS

 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site.

CONCLUSION

 This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

A Diagnostic Algorithm Based on a Simple Clinical Prediction Rule for the Diagnosis of Cranial Giant Cell Arteritis

Background: Risk stratification based on pre-test probability may improve the diagnostic accuracy of temporal artery high-resolution compression sonography (hrTCS) in the diagnostic workup of cranial giant cell arteritis (cGCA). Methods: A logistic regression model with candidate items was derived from a cohort of patients with suspected cGCA (n = 87). The diagnostic accuracy of the model was tested in the derivation cohort and in an independent validation cohort (n = 114) by receiver operator characteristics (ROC) analysis. The clinical items were composed of a clinical prediction rule, integrated into a stepwise diagnostic algorithm together with C-reactive protein (CRP) values and hrTCS values. Results: The model consisted of four clinical variables (age > 70, headache, jaw claudication, and anterior ischemic optic neuropathy). The diagnostic accuracy of the model for discrimination of patients with and without a final clinical diagnosis of cGCA was excellent in both cohorts (area under the curve (AUC) 0.96 and AUC 0.92, respectively). The diagnostic algorithm improved the positive predictive value of hrCTS substantially. Within the algorithm, 32.8% of patients (derivation cohort) and 49.1% (validation cohort) would not have been tested by hrTCS. None of these patients had a final diagnosis of cGCA. Conclusion: A diagnostic algorithm based on a clinical prediction rule improves the diagnostic accuracy of hrTCS.

Atherosclerotic Burden and Arterial Stiffness are Not Increased in Patients with Milder Forms of Primary Aldosteronism Compared to Patients with Essential Hypertension

Patients with primary aldosteronism (PA) are at increased cardiovascular risk, compared to patients with essential hypertension (EH). Cardiovascular damage could depend on PA phenotype, potentially being lower in milder forms of PA. Our aim was to assess atherosclerotic burden and arterial stiffness in 88 prospectively recruited patients, including 44 patients with mild PA and EH respectively. All patients underwent a structured study program, including measurements of ankle-brachial index, oscillometric measurement of central pulse wave velocity (cPWV) and vascular ultrasound examination of the supraaortic arteries, the abdominal aorta, and the femoropopliteal arteries. A plaque score was calculated to estimate atherosclerotic burden for each patient. This is a prospective case-control study set at a tertiary care hospital. Patients with PA and EH matched well for age, gender, blood pressure, BMI, and cardiovascular risk factors such as diabetes mellitus and smoking status. Common carotid intima-media thickness (0.77 vs. 0.75 mm; p=0.997) and cPWV (7.2 vs. 7.1 m/s; p=0.372) were comparable between patients with PA and EH. The atherosclerotic burden, as expressed by the plaque score, did not differ between the two groups (p=0.159). However, after initiation of treatment cPWV was significantly decreased in patients with PA (p=0.017). This study shows that subclinical atherosclerotic burden and arterial stiffness in patients with milder forms of PA is comparable to patients with EH. Nevertheless, specific treatment for PA significantly improved cPWV, which argues for a more liberal use of mineralocorticoid receptor antagonists in patients with arterial hypertension.

Retrobulbar Spot Sign in Metachronous Bilateral Central Retinal Artery Occlusion of Cardioembolic Origin

ABSTRACT

A 78-year-old man suffered sudden visual loss of his right eye. Five years earlier, he had experienced vision loss of his left eye due to central retinal artery occlusion (CRAO); back then, the etiology for the CRAO was not established. Current ocular ultrasound depicted a hyperechoic spot within the optic nerve in both eyes. Echocardiography identified a calcified mass adherent to the mitral valve as the embolic source of the CRAO. This case shows the value of ocular B-mode ultrasound in demonstration and proof of the etiology for CRAO.

Implementation of self-directed learning within clinical clerkships

Background: The main aim of medical curricula is to prepare students for the first day at the work place. While teaching clinical competence is pivotal, clinical clerkships are often the last chance to close knowledge gaps with the help of clinical teachers. Self-directed learning is a dynamic field for research within medical education, though its curricular implementation is rare. This study focuses on the needs assessment of clinical clerkships using the concept of self-directed learning. Methods: The study comprised an educational experience at the Ludwig-Maximilians Universität (LMU) Munich. Medical students (n=1446, 59% female) in their second clinical year were instructed to specify learning objectives (LOs) by Doran`s SMART criteria and to gauge the probability of their fulfilment prior to the mandatory clerkship. In a second questionnaire one week later, the students rated the actual subjective fulfilment of the LOs. Data was coded with regards to the German National Catalogue of Competence-Based Learning Objectives for Undergraduate Medical Education (NKLM) and investigated qualitatively. Factors that determine goal achievement were collected and coded binary (barrier vs. enabler). Univariate analysis was used when appropriate. Results: The acquisition of "clinically practical abilities" (29%), "diagnostic methods" (21%) and "professional communication" (13%) were the LOs mentioned most. Throughout the week, subjective fulfilment diminished. Rich (vs. poor) availability to "practical exercise" (31%), "engagement of the physicians and other medical staff" (27%) and "personal initiative" (23%) resulted in higher subjective fulfilment. Conclusions: The self-chosen LOs reflect the needs of students for which the clinical teacher should be prepared. Considering these findings, it seems possible to close practical training gaps. We support the consideration of establishing curricular anchored self-directed learning in clinical clerkships. Further empirical studies would be beneficial in revealing its positive effects on the learning progress.

Transocular sonography in acute arterial occlusions of the eye in elderly patients: Diagnostic value of the spot sign

PURPOSE

To characterize the diagnostic yield of the spot sign in the diagnostic workup of acute arterial occlusions of the eye in elderly patients.

METHODS

Clinical characteristics of consecutive patients aged ≥ 50 years with acute central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or anterior ischemic optic neuropathy (AION) were recorded. Videos of transocular sonography were assessed for the presence of the spot sign by two blinded readers. Group comparisons were made between CRAO-patients with and without the spot sign. Two experienced cardiovascular physicians allocated CRAO-cases to a presumed aetiology, without and with knowledge on the presence/absence of the spot sign.

RESULTS

One-hundred-twenty-three patients were included, 46 of whom suffered from CRAO. A spot sign was seen in 32 of 46 of patients with CRAO and in 7 of 23 patients with BRAO. Interobserver agreement was excellent (Cohen`s kappa 0.98). CRAO-patients with the spot sign significantly more frequently had a medical history of cardiovascular disease (62.8 vs. 21.4%, p = 0.03) and left heart valve pathologies (51.9 vs. 10%, p = 0.03). The spot sign was not found in any of the three patients with CRAO secondary to cranial giant cell arteritis. The assumed CRAO aetiology differed in 37% of cases between two cardiovascular physicians, regardless whether transocular sonography findings were known or not.

CONCLUSION

The spot sign is a simple sonographic finding with excellent interobserver agreement, which proofs the embolic nature of CRAO, but does not allow exact attribution of the underlying aetiology.

[Diagnostic work-up in central retinal artery occlusion and ischemic optic neuropathy - what is important?]

Ischemia of the retina in central retinal artery occlusion (CRAO) and of the optic nerve in ischemic optic neuropathy (ION) are common causes of irreversible vision loss in elderly patients and require a thorough diagnostic work-up. First and foremost, giant cell arteritis should be confirmed or ruled out. The further work-up of non-arteritic CRAO and non-arteritic ION (nAION) aims to determine the cardiovascular risk profile. Patients with nAION should be screened for sleep apnoea. In non-arteritic CRAO, the search for embolic sources is the most important diagnostic task. A "white spot sign" seen on transorbital ultrasound confirms the diagnosis of embolic CRAO and rules out an arteritic etiology of CRAO.

MON-177 CAH-X Syndrome in a German Cohort of Patients with Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is encoded by the CYP21A2 gene. The CYP21A2 gene is flanked and partially overlapped by the TNXB gene encoding an extracellular matrix protein called Tenascin-X. Deficiency of Tenascin X can cause the Ehlers-Danlos Syndrome (EDS). Deletions of CYP21A2 extending into TNXB rarely cause CAH combined with EDS. Heterozygosity of TNXB mutations causing haploinsufficiency of TNX, however, have been described in about 5-7% in a patient cohort from the US and has been named CAH-X syndrome, CAH associated with mild hypermobility form of EDS.

We genetically investigated a cohort of 81 adult patients (31 males, mean age 37,8 years +/- 9,8) with classic CAH for CAH-X. Patients genetically positive for CAH-X and unaffected CAH control patients matched for sex, age and BMI underwent a thorough clinical investigation including joint examination by Beighton 9-point scale, skin and neurological examination, by a standardised protocol of thransthoracic echocardiography and muscle ultrasound. In addition serum tenascin-X has been measured.

In our cohort we identified one patient with CAH and EDS and 4 patients with CAH-X syndrome. All CAH-X patients had serum concentrations of tenascin-X below the normal range, however, not different from 35 unaffected CAH patients with regard to serum concentration. All 4 patients with CAH-X syndrome showed some associated clinical symptoms. Two had joint hypermobility detected by Beighton 9-point score. Two of four CAH-X patients showed cardiac abnormalities (mild mitral regurgitation in one patient and a surgically corrected common arterial trunk type I A in the other patient). The patient with CAH and EDS showed cardiac abnormalities in addition to typical EDS symptomatology. All 5 affected patients complained about back pain and showed foot malposition. Profound changes in muscle ultrasound were found in 60 % of patients with CAH-X syndrome (3/5) and in none of the controls (0/5).

In conclusion, our data confirm the previously described prevalence of CAH-X. Beighton-score seems to be a quick and cheap screening instrument for CAH-X and should be performed in all patients with classic CAH, since protein level in serum cannot be used for screening for CAH-X-Syndrome. A stronger focus needs to be made on back pain and foot malposition as symptoms of CAH-X and echocardiography should be performed in all CAH-X patients. Therapy should depend on clinical symptoms in patients.

A horse and a zebra: an atypical clinical picture including Guillain-Barré syndrome, recurrent fever and mesenteric lymphadenopathy caused by two concomitant infections

Background

While Campylobacter jejuni represents the most common cause of bacterial gastroenteritis, Yersinia pseudotuberculosis infections are very rarely diagnosed in adults.

Case

We report on a previously healthy patient who presented several times at our hospital with fever, Guillain-Barré syndrome, recurrent abdominal symptoms and distinct mesenteric lymphadenopathy, respectively. This complicated and diagnostically challenging course of disease was caused by a C. jejuni and Y. pseudotuberculosis coinfection. Antibiotic treatment with doxycycline was effective.

Conclusion

Broad serology testing was crucial to discover that two concomitant infections were causing the symptoms. This case demonstrates that when a clinical picture is not fully explained by one known infection, another infection with the same underlying risk factor has to be considered, hence “a horse and a zebra”.

Electronic supplementary material

The online version of this article (10.1007/s15010-020-01397-5) contains supplementary material, which is available to authorized users.

Scaffolding clinical reasoning of medical students with virtual patients: effects on diagnostic accuracy, efficiency, and errors

Background Understanding clinical reasoning is a major challenge in medical education research. Little is known about the influence of scaffolding and feedback on the clinical reasoning of medical students. The aim of this study was to measure the effects of problem representation (cognitive representation of a clinical case) and structured scaffolding for reflection with or without feedback on the diagnostic efficiency and characterization of diagnostic errors of medical students. Methods One hundred and forty-eight advanced medical students were randomly assigned to one of five groups (2 × 2 design with a control group). They worked on 15 virtual clinical cases (five learning cases, five initial assessment cases, and five delayed assessment cases) in an electronic learning environment. After each case, they stated their presumed diagnosis and explained their diagnostic conclusion. Diagnostic accuracy, efficiency, and error distribution were analyzed. Results The diagnostic accuracy (number of correctly solved cases) and efficiency (solved cases/total time) did not differ significantly between any of the groups in the two different assessment phases [mean = 2.2-3.3 (standard deviation [SD] = 0.79-1.31), p = 0.08/0.27 and mean = 0.07-0.12 (SD = 0.04-0.08), p = 0.16/0.32, respectively]. The most important causes for diagnostic errors were a lack of diagnostic skills (20%), a lack of knowledge (18%), and premature closure (17%). Conclusions Neither structured reflections nor representation scaffolding improved diagnostic accuracy or efficiency of medical students compared to a control group when working with virtual patients.

Guessing right - whether and how medical students give incorrect reasons for their correct diagnoses

Background: Clinical reasoning is one of the central competencies in everyday clinical practice. Diagnostic competence is often measured based on diagnostic accuracy. It is implicitly assumed that a correct diagnosis is based on a proper diagnostic process, although this has never been empirically tested. The frequency and nature of errors in students' diagnostic processes in correctly solved cases was analyzed in this study. Method: 148 medical students processed 15 virtual patient cases in internal medicine. After each case, they were asked to state their final diagnosis and justify it. These explanations were qualitatively analyzed and assigned to one of the following three categories: correct explanation, incorrect explanation and diagnosis guessed right. Results: The correct diagnosis was made 1,135 times out of 2,080 diagnostic processes. The analysis of the associated diagnostic explanations showed that 92% (1,042) reasoning processes were correct, 7% (80) were incorrect, and 1% (13) of the diagnoses were guessed right. Causes of incorrect diagnostic processes were primarily a lack of pathophysiological knowledge (50%) and a lack of diagnostic skills (30%). Conclusion: Generally, if the diagnosis is correct, the diagnostic process is also correct. The rate of guessed diagnoses is quite low at 1%. Nevertheless, about every 14th correct diagnosis is based on a false diagnostic explanation and thus, a wrong diagnostic process. To assess the diagnostic competence, both the diagnosis result and the diagnostic process should be recorded.

Assessment of Disease Activity in Takayasu Arteritis: Potential Role of Contrast-Enhanced Ultrasound

PURPOSE

 To assess the diagnostic value of intima media thickness measurements and contrast-enhanced ultrasound (CEUS) of the supraaortic arteries in the assessment of disease activity in Takayasu arteritis (TA).

MATERIALS AND METHODS

 Patients with TA and involvement of the carotid and/or subclavian/axillary arteries underwent CEUS imaging in addition to B-mode and color duplex ultrasound. The maximum IMT (mIMT) was measured and high-resolution CEUS of the most prominently thickened vessel segment was performed. Two blinded readers reviewed the CEUS movies, with semiquantitative assessment of microbubble enhancement of the arterial wall (grade 0: no or minimal; grade 1: moderate; grade 2: pronounced). Clinical symptoms, acute phase reactants, and established indices of clinical disease activity (NIH criteria, ITAS score) were recorded.

RESULTS

 40 examinations in 17 patients were analyzed. According to clinical judgement, 27 and 13 cases were classified as clinically inactive and active, respectively. An mIMT-cutoff of > 2.7 mm identified active disease with a sensitivity and specificity of 69.2 % and 88.9 %, respectively (area under the curve 0.83). The interobserver agreement of CEUS analysis was substantial (Cohen's kappa 0.76). By consensus reading, 17, 15, and 8 cases were classified as uptake grade 0, grade 1 and grade 2, respectively. Grade 0 uptake was exclusively present in 17 clinically inactive patients. Grade 1 uptake was seen in 10 patients with clinically inactive disease and 5 patients with clinically active disease. Grade 2 uptake was exclusively present in 8 patients with active disease.

CONCLUSION

 Both sonographic IMT measurements and high-resolution CEUS are promising in the ad-hoc assessment of disease activity in patients with TA.

Ward round competences in surgery and psychiatry - a comparative multidisciplinary interview study

BACKGROUND

The ward round is a key element in everyday hospital inpatient care irrespective of the medical speciality. The underperformance in conducting ward rounds of junior clinicians has already been described. Therefore, necessary skills and competences of clinicians need to be defined, taught and delivered for curricular instruction. In addition to published data on ward round competences in internal medicine this study aims to determine the common competences for surgical and psychiatric ward rounds in order to find differences depending on the speciality.

METHODS

Semi-structured interviews with surgical (N = 30) and psychiatric ward staff (N = 30) of a university hospital and five community hospitals were conducted. Competences necessary for performing ward rounds as well as structural aspects were identified by systematic content analysis and frequency analysis, supported by adequate statistics.

RESULTS

Relevant competences for both fields are: collaborative clinical reasoning, communication with the patient and the team, organization, teamwork, management of difficult situations, self-management, error-management, teaching, empathy, nonverbal communication, patient-management and professionalism. Clinical skills were mentioned more often in surgical interviews, while nonverbal communication was described more often in psychiatric interviews. Empathy and communication with the team were more frequently attributed to psychiatric residents.

CONCLUSION

The competences which were identified as necessary for conducting a ward round in surgery and psychiatry are similar and correspond to previously reported competences in internal medicine. Clinical skills are of greater importance in surgery than in psychiatry. Concerning empathy and nonverbal communication, further research is needed to determine whether they are of minor importance in surgery or whether there is a lack of awareness of these competences.

Ocular ischaemic complications in giant cell arteritis: CHADS2-score predicts risk of permanent visual impairment

OBJECTIVES

To identify independent risk factors for permanent visual loss (PVL) in patients with giant cell arteritis (GCA), with a special focus on sonographic findings of the temporal, carotid and subclavian/axillary arteries, and on established scoring systems of ischaemia risk assessment.

METHODS

Consecutive patients with a diagnosis of GCA between 2002 and 2013 were retrospectively identified from a prospectively maintained database. Data on clinical characteristics including ophthalmological findings, laboratory values, and sonographic findings of the temporal, carotid an axillary arteries were extracted. CHADS2- and CHA2DS2-VASc-score were calculated. Clinical, laboratory and sonographic characteristics of patients with and without PVL were compared. Multiple logistic regression models were calculated to identify variables independently associated with PVL.

RESULTS

One-hundred-fifty-two patients were included in the analysis. PVL occurred in 30.2% of patients, with anterior ischaemic optic neuropathy as predominant underlying cause (91.3%). The frequency of PVL was strongly dependent on the age at diagnosis, with a significant increase after the age of 70 years. In multivariate analysis, axillary artery vasculitis with an odds ratio (OR) of 0.3 and constitutional symptoms with an OR of 0.1 were negatively associated with PVL. A CHADS2-score of 1 (OR 10.7) or ≥2 (OR 25) was associated with a significantly increased risk of PVL.

CONCLUSIONS

The risk of PVL secondary to GCA increases with age but is lower in patients presenting with constitutional symptoms and/or exhibiting axillary artery involvement. The CHADS2-score may help to discriminate patients with low vs. high risk of PVL.

Ward rounds in internal medicine: Validation of an Entrustable Professional Activity (EPA) observation checklist

Objectives: Ward rounds serve a crucial daily activity in hospitals. Building on the Entrustable Professional Activity "Conducting internal medicine ward rounds" consisting of ten competencies and 25 corresponding activities, this study aims at assessing content and external validity of an observation checklist for this EPA. Methods: A focus group aimed at content validation of the checklist. Five participants therefore evaluated it with respect to comprehensiveness and comprehensibility. To investigate external validity, 14 authentic ward rounds were video-taped and rated by two raters with the adapted observation checklist in terms of the appearance of certain activities in the videos. Results: After some adaptions, participants of the focus group agreed on a checklist consisting of nine competencies, 25 activities and 110 examples of observable behaviours supporting content validity. External validity was studied by using the observation checklist for ratings of ward round videos. The checklist was regarded as a valuable tool to structure observation. Along with the high frequencies of observed behaviour and interrater-reliability, external validity can be assumed. Conclusion: The first scientifically developed comprehensive observation checklist for the EPA conducting a ward round in internal medicine is presented. The checklist is a valuable tool for providing elaborated feedback in undergraduate and graduate medical education. Focussing on multi-institutional validation and the cut offs of the checklist to determine the levels of entrustment are recommended for future research.

[Current trends in diagnosis and treatment of giant cell arteritis]

Giant cell arteritis (GCA) is the most common form of the primary large vessel vasculitides and typically occurs in individuals aged ≥ 50 years. This concise review article discusses current trends in the management of GCA, including important developments in sonographic assessment (B-mode sonography, contrast enhanced ultrasound) and medical treatment (biological treatment with the interleukin-6 receptor alpha inhibitor tocilizumab).

Structured Reporting of CT Angiography Runoff Examinations of the Lower Extremities

OBJECTIVES

The aim was to evaluate the effect of structured reporting of computed tomography angiography (CTA) runoff studies on clarity, completeness, clinical relevance, usefulness of the radiology reports, further testing, and therapy in patients with known or suspected peripheral arterial disease.

METHODS

Conventional reports (CRs) and structured reports (SRs) were generated for 52 patients who had been examined with a CTA runoff examination of the lower extremities. The sample size was based on power calculations with a power of 95% and a significance level of .007 (adjusted for multiple testing). CRs were dictated in a free text form; SRs contained a consistent ordering of observations with standardised subheadings. CRs were compared with SRs. Two vascular medicine specialists and two vascular surgeons rated the reports regarding their satisfaction with clarity, completeness, clinical relevance, and usefulness as well as overall satisfaction. Additionally, they made hypothetical decisions on further testing and therapy. Median ratings were compared using the Wilcoxon signed rank test and generalised linear mixed effects models.

RESULTS

SRs received higher ratings for satisfaction with clarity (median rating 9.0 vs. 7.0, p < .0001) and completeness (median rating 9.0 vs. 7.5, p < .0001) and were judged to be of greater clinical relevance (median rating 9.0 vs. 8.0, p < .0001) and usefulness (median rating 9.0 vs. 8.0, p < .0001). Overall satisfaction was also higher for SRs (median rating 9.0 vs. 7.0, p < .0001) than CRs. There were no significant differences in further testing or therapy.

CONCLUSION

Referring clinicians perceive SRs of CTA runoff examinations of the lower extremities as offering superior clarity, completeness, clinical relevance, and usefulness than CRs. Structured reporting does not appear to alter further testing or therapy in patients with known or suspected peripheral arterial disease.

Relapses in three patients with Takayasu arteritis under tocilizumab treatment detected by contrast enhanced ultrasound

Abstract. Takayasu arteritis (TA) is a rare large vessel vasculitis, affecting the aorta and its major branches, typically in young women. In this case report, we present three cases of young women of Caucasian descent who experienced relapses while under treatment with the monoclonal humanized antibody to the interleukin 6 receptor, tocilizumab. Active vasculitic lesions of the supraaortic (common carotid and axillary) arteries were detected and characterized via high resolution contrast enhanced ultrasound. Based on these cases, we discuss the potential role of contrast enhanced ultrasound in the diagnosis and follow-up of TA as well as the current data on the efficacy of tocilizumab in the treatment of TA.

Representation scaffolds improve diagnostic efficiency in medical students

CONTEXT

Diagnostic efficiency is important in daily clinical practice as doctors have to face problems within a limited time frame. To foster the clinical reasoning of students is a major challenge in medical education research. Little is known about students' diagnostic efficiency. On the basis of current theories, scaffolds for case representation (statement of the case as far as it is summarised in the mind) could be a promising approach to make the diagnostic reasoning of intermediate medical students more efficient.

METHODS

Clinical case processing of 88 medical students in their fourth and fifth years was analysed in a randomised, controlled laboratory study. Cases dealing with dyspnoea were provided in an electronic learning environment (CASUS). Students could freely choose the time, amount and sequence of clinical information. During the learning phase the intervention group was asked to write down case representation summaries while working on the cases. In the assessment phase diagnostic efficiency was operationalised as the number of correct diagnoses divided by the time spent on diagnosing.

RESULTS

Diagnostic efficiency was significantly improved by the representation scaffolding (M = 0.12 [SD = 0.07], M = 0.09 [SD = 0.06] correct cases/time, p = 0.045), whereas accuracy remained unchanged (M = 2.28 [SD = 1.10], M = 2.09 [SD = 1.08], p = 0.52). Both groups screened the same amount of clinical information, but the scaffolding group did this faster (M = 20.8 minutes [SD = 7.15], M = 24.6 minutes [SD = 7.42], p = 0.01; Cohen's d = 0.5).

CONCLUSION

Diagnostic efficiency is an important outcome variable in clinical reasoning research as it corresponds to workplace challenges. Scaffolding for case representations significantly improved the diagnostic efficiency of fourth and fifth-year medical students, most likely because of a more targeted screening of the available information.

Ultrasound imaging in the diagnosis of large vessel vasculitis

Abstract. Nowadays noninvasive vascular imaging has an important role in the diagnostic work-up of the large vessel vasculitides (LVV), most importantly giant cell arteritis (GCA) and Takayasu arteritis. Among the imaging modalities available, ultrasound (US) has several important advantages, including low costs, rapid and repetitive availability without exposure to radiation, and high spatial resolution for assessment of large and medium-sized arteries. Therefore, US can be regarded the first line imaging method in suspected LVV. In patients with suspected GCA, US can replace temporal artery biopsy in certain clinical scenarios, and the application of US early in the diagnostic work-up of suspected GCA in specialized fast track clinics has been suggested to reduce the rate of visual ischaemic complications and associated costs. In other LVV such as Takayasu arteritis and chronic periaortitis, the diagnostic accuracy in comparison to other noninvasive imaging methods has not been formally tested but can be considered to be excellent. However, quality of US is highly dependent on the operator’s experience, and assessment of the thoracic aorta which is frequently involved in GCA and TA is limited. The role of US in the follow-up of LVV under treatment is unclear. In view of the promising data supporting its value on the one hand and several uncertainties and controversies on the other hand, the present review article provides a comprehensive overview on current evidence for the application of US in the diagnosis and follow up of LVV. Recent multicentre study results and emerging trends such as the application of compression sonography in the diagnosis of GCA and the use of contrast enhanced ultrasound in disease activity assessment in Takayasu arteritis are discussed.

B-mode sonography wall thickness assessment of the temporal and axillary arteries for the diagnosis of giant cell arteritis: a cohort study

OBJECTIVES

We aimed to determine the diagnostic accuracy of B-mode compression sonography of the temporal arteries (tempCS) and B-mode sonographic measurement of the axillary artery intima media thickness (axIMT) for the diagnosis of giant cell arteritis (GCA).

METHODS

After having established measurement of tempCS and axIMT in our routine diagnostic workup, 92 consecutive patients with a suspected diagnosis of GCA were investigated. Clinical characteristics were recorded and wall thickening of the temporal arteries (tempCS) and axillary arteries (axIMT) was measured (mm). Using the final clinical diagnosis as the reference standard, receiver operator characteristics (ROC) analysis was performed. In a subgroup of 26 patients interobserver agreement was assessed using Spearman's rank correlation.

RESULTS

Cranial GCA, extracranial GCA, and combined cranial/extracranial GCA were diagnosed in 18, 7, and 9 individuals, respectively. For the diagnosis of cranial GCA, tempCS had an excellent area under the curve (AUC) of 0.95, with a cut-off of ≥0.7 mm offering a sensitivity and specificity of 85% and 95%. The AUC of axIMT for the diagnosis of extracranial GCA was 0.91 (cut-off ≥1.2 mm: sensitivity and specificity 81.3 and 96.1%). Applying a combined tempCS/axIMT cut-off of ≥0.7mm/1.2 mm, we calculated an overall sensitivity and specificity for the final clinical diagnosis of cranial and/or extracranial GCA of 85.3% and 91.4%. Interobserver agreement was strong for both parameters assessed (Spearman's rho 0.72 and 0.77, respectively).

CONCLUSIONS

The combination of tempCS/axIMT allows objective sonographic assessment in suspected GCA with promising diagnostic accuracy.

Medical ward round competence in internal medicine - an interview study towards an interprofessional development of an Entrustable Professional Activity (EPA)

BACKGROUND

The medical ward round is a central but complex activity that is of relevance from the first day of work. However, difficulties for young doctors have been reported. Instruction of ward round competence in medical curricula is hampered by the lack of a standardized description of the procedure. This paper aims to identify and describe physicians' tasks and relevant competences for conducting a medical ward round on the first day of professional work.

METHODS

A review of recent literature revealed known important aspects of medical ward rounds. These were used for the development of a semi-structured interview schedule. Medical ward round experts working at different hospitals were interviewed. The sample consisted of 14 ward physicians (M = 8.82 years of work experience) and 12 nurses (M = 14.55 years of work experience) working in different specializations of internal medicine. All interviews were audiotaped, fully transcribed, and analyzed using an inductive-deductive coding scheme.

RESULTS

Nine fields of competences with 18 related sub-competences and 62 observable tasks were identified as relevant for conducting a medical ward round. Over 70 % of the experts named communication, collaborative clinical reasoning and organization as essential competences. Deeper analysis further unveiled the importance of self-management, management of difficult situations, error management and teamwork.

CONCLUSION

The study is the first to picture ward round competences and related tasks in detail and to define an EPA "Conducting an internal medicine ward round" based on systematic interprofessional expert interviews. It thus provides a basis for integration of ward round competences in the medical curricula in an evidence based manner and gives a framework for the development of instructional intervention studies and comparative studies in other medical fields.

Hypothenar hammer syndrome

The diagnosis of hypothenar hammer syndrome (HHS) should be considered in the case of hand ischemia in people who occupationally or recreationally use the hypothenar region literally as a “hammer”. Routine diagnostics should consist of physical examination including Allen’s test, acral plethysmography and duplex sonography. According to the prevailing opinion angiography remains the «gold standard test» for establishing the diagnosis of HHS. Early diagnosis allows more effective therapeutic strategies and is important to prevent long-term negative medical sequelae. Several basic principles apply to all patients, for example hand protection and smoking cessation. The optimal treatment options, particularly the indication for surgery, remain controversial due to a lack of sound data from case series or prospective randomized trials.

Evaluation of a novel rapid one-step monoclonal chromatographic immunoassay for detection of Helicobacter pylori in stool from children

A new rapid office-based one-step monoclonal immunoassay (RAPID Hp StAR, DakoCytomation, Cambridge, UK) for detection of Helicobacter pylori antigen in stool was evaluated in children against invasive diagnostic methods and compared to the results of a monoclonal EIA targeting the same antigen (Amplified IDEIA Hp StAR, DakoCytomation, Cambridge, UK). Coded stool samples from 118 symptomatic children (0.3-18.8 years) were investigated prior to any anti-H. pylori therapy. Fifty-four children were H. pylori infected defined by positive culture and/or two other positive tests ((13)C-urea breath test, histology, rapid urea test), the remaining 64 children showed concordant negative results. Thirty-four infected children (4.8-17.8 years) were monitored with (13)C-urea breath test (five remained positive) and stool test 6-8 weeks after anti-H. pylori therapy. The immunoassays were independently read by two investigators. The monoclonal EIA showed excellent sensitivity and specificity before (98% and 100%, respectively) and after therapy (100%; 96.2%). The rapid immunoassay was invalid for technical reasons in nine samples (5.9%). The two observers agreed in 31 positive and 93 negative results, but had discordant results in 17 samples (11.2%). Overall, the rapid test showed a poor sensitivity (63.8%-71.1%), but a good specificity (91.1%-96.2%) before treatment. We conclude that the new office based monoclonal enzyme immunoassay for diagnosis of H. pylori should be modified to improve sensitivity, inter-observer-variability and some technical problems. In contrast, the monoclonal EIA stool test is highly reliable, both pre- and post therapy, and equivalent to the (13)C-urea breath test.

Evaluation of the novel Helicobacter pylori ClariRes real-time PCR assay for detection and clarithromycin susceptibility testing of H. pylori in stool specimens from symptomatic children

The aim of the present study was to evaluate the Helicobacter pylori ClariRes assay (Ingenetix, Vienna, Austria) for the detection of H. pylori infection and the simultaneous clarithromycin susceptibility testing of the H. pylori isolates in stool samples from 100 symptomatic children. The results obtained by this novel biprobe real-time PCR method were directly compared with the results obtained from histological examination of gastric biopsy specimens, culturing, the [13C]urea breath test, and a monoclonal antibody-based stool antigen enzyme immunoassay (EIA). Fecal specimens from all 54 children who were shown to be noninfected by "gold standard" tests gave true-negative PCR results (specificity, 100%). Of the remaining 46 individuals with a positive H. pylori status, 29 were found to be positive by real-time PCR (sensitivity, 63%). For these 29 cases, the H. pylori ClariRes assay confirmed all results from phenotypic clarithromycin susceptibility testing by Etest. In summary, this investigation demonstrates that detection of Helicobacter DNA in stool samples by real-time PCR is a difficult task and that this method cannot replace the stool antigen EIA (sensitivity, 95.7%) for the accurate diagnosis of H. pylori infection in children.