Emergent biomarker derived from next-generation sequencing to identify pain patients requiring uncommonly high opioid doses

Next-generation sequencing (NGS) provides unrestricted access to the genome, but it produces 'big data' exceeding in amount and complexity the classical analytical approaches. We introduce a bioinformatics-based classifying biomarker that uses emergent properties in genetics to separate pain patients requiring extremely high opioid doses from controls. Following precisely calculated selection of the 34 most informative markers in the OPRM1, OPRK1, OPRD1 and SIGMAR1 genes, pattern of genotypes belonging to either patient group could be derived using a k-nearest neighbor (kNN) classifier that provided a diagnostic accuracy of 80.6±4%. This outperformed alternative classifiers such as reportedly functional opioid receptor gene variants or complex biomarkers obtained via multiple regression or decision tree analysis. The accumulation of several genetic variants with only minor functional influences may result in a qualitative consequence affecting complex phenotypes, pointing at emergent properties in genetics.

[Cross-sectional subject 14--training in pain]

The introduction of pain medicine (cross-sectional subject 14, QF 14) into the Human Medicine study program is a great opportunity. A knowledge gap concerning the treatment of pain patients outside of specialized pain centers has been recognized for many years. This gap might be closed or at least reduced by a compulsory curriculum in pain medicine. If implementation of new lessons for QF 14 is not possible, pain medicine could be represented by labelled elements in the existing curriculum, in order to highlight the field. The core curriculum must now be converted into appropriate teaching and test formats. Due to the autonomy and heterogeneity of German medical faculties, no uniform solution will be achieved. In contrast, this diversity and the entirely new implementation of the cross-sectional subject will allow structured evaluation of different teaching and examination formats with respect to teaching outcome in benchmarking investigations in the coming semesters. Practically experienced lecturers and theory-driven medical educationalists are called upon to get involved with the development, implementation, and evaluation of pain medicine in undergraduate education in Germany. Teaching enthusiasts are encouraged to dedicate themselves to the strenuous, but stimulating task of implementing QF 14. The Deutsche Schmerzgesellschaft (German Pain Society) will offer support for this.

Human neural precursor cells promote neurologic recovery in a viral model of multiple sclerosis

Using a viral model of the demyelinating disease multiple sclerosis (MS), we show that intraspinal transplantation of human embryonic stem cell-derived neural precursor cells (hNPCs) results in sustained clinical recovery, although hNPCs were not detectable beyond day 8 posttransplantation. Improved motor skills were associated with a reduction in neuroinflammation, decreased demyelination, and enhanced remyelination. Evidence indicates that the reduced neuroinflammation is correlated with an increased number of CD4⁺CD25⁺FOXP3⁺ regulatory T cells (Tregs) within the spinal cords. Coculture of hNPCs with activated T cells resulted in reduced T cell proliferation and increased Treg numbers. The hNPCs acted, in part, through secretion of TGF-β1 and TGF-β2. These findings indicate that the transient presence of hNPCs transplanted in an animal model of MS has powerful immunomodulatory effects and mediates recovery. Further investigation of the restorative effects of hNPC transplantation may aid in the development of clinically relevant MS treatments.

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Spinal cord transplantation of hNPCs results in recovery in a viral model of MS

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hNPC-mediated recovery occurs in the absence of engrafted cells

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hNPCs are immunomodulatory through increasing the frequency of Tregs in the CNS

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hNPCs increase Treg frequency via a TGF-β1- and TGF-β2-dependent pathway

Dermoscopy of acral melanoma: a multicenter study on behalf of the international dermoscopy society

BACKGROUND

Most studies on dermoscopy of acral lesions were conducted in Asian populations. In this study, we analyzed these features in a predominantly Caucasian population.

OBJECTIVE

Estimate the prevalence of dermoscopic features in acral lesions, and assess their level of agreement between observers.

METHODS

In this retrospective multicenter study, 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians, via a secured Internet platform.

RESULTS

Parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty.

CONCLUSION

Lesions with a diameter >1 cm were more likely to be melanoma. We found as well that a benign pattern can be seen in parts of melanomas. For this reason one should evaluate an acral lesion for the presence of malignant patterns first.

Palliative Care teaching in Germany - concepts and future developments

BACKGROUND

Following recent modifications of the Medical Licensure Act (ÄApprO) in the year 2009, palliative care was introduced as a compulsory 13(th) cross-disciplinary subject (Q13) in the undergraduate curriculum. Its implementation must have taken place before the beginning of the final year ('practical year') in August 2013 and has to be substantiated for the medical exams taking place in October 2014. Very diverse structures pertaining to palliative care teaching were described in previous surveys at various medical faculties in Germany. As a result, the current and future plans and concepts related to content and exams of a mandatory Q13 course at the respective faculty sites should be ascertained.

METHODS

Since 2006, the German Medical Students' Association (bvmd) has been carrying out a bi-annual survey at all medical faculties in Germany regarding the current situation of teaching in the field of palliative care. After designing and piloting an online survey in May 2010, a one-month online survey took place. The data was assessed using a descriptive approach.

RESULTS

31 of 36 medical faculties took part in the survey. At the time of questioning, 15 faculties already taught courses according to the requirements of the new ÄApprO; at three sites the Q13 is yet to be introduced commencing in 2012. A teaching curriculum for Q13 already existed at 15 faculty sites, partly based on the curricular requirements of the German Association for Palliative Medicine (DGP). Six sites described an implementation process as yet without an independent curriculum. Most of the faculties aim for 21-40 course hours, which will for the most part be provided as lectures, seminars or less often in more assisted and intense formats. The majority of the participating faculties intend an examination containing multiple choice questions. At 8 universities there is an independent Chair for palliative medicine (5 more are planned); this was linked with a higher degree of mandatory teaching in alignment with the requirements of the ÄApprO. A broad spectrum of educationally-involved occupational groups, specialist disciplines and external co-operating partners, were mentioned.

CONCLUSION

The infrastructural prerequisites of the present curricular concepts and the degree of implementation of the Q13 according to the requirements of the new ÄApprO diverge significantly among the various medical faculties. The efforts made to produce a qualitatively high standard of teaching with regard to the multifaceted questions concerning the support for severely and terminally ill patients is as much reflected in the survey, as the special implications of an independent Chair for palliative medicine for the implementation of the requirements by law. The participation of various occupational groups in this survey as well as the broad spectrum of those involved highlights the interdisciplinary and multi-professional dimension of teaching in palliative care.

Correlation of in vitro and in vivo models for the oral absorption of peptide drugs

The aim of this study was to evaluate two in vitro models, Caco-2 monolayer and rat intestinal mucosa, regarding their linear correlation with in vivo bioavailability data of therapeutic peptide drugs after oral administration in rat and human. Furthermore the impact of molecular mass (Mm) of the according peptides on their permeability was evaluated. Transport experiments with commercially available water soluble peptide drugs were conducted using Caco-2 cell monolayer grown on transwell filter membranes and with freshly excised rat intestinal mucosa mounted in Using type chambers. Apparent permeability coefficients (P (app)) were calculated and compared with in vivo data derived from the literature. It was shown that, besides a few exceptions, the Mm of peptides linearly correlates with permeability across rat intestinal mucosa (R (2) = 0.86; y = -196.22x + 1354.24), with rat oral bioavailability (R (2) = 0.64; y = -401.90x + 1268.86) as well as with human oral bioavailability (R (2) = 0.91; y = -359.43x + 1103.83). Furthermore it was shown that P (app) values of investigated hydrophilic peptides across Caco-2 monolayer displayed lower permeability than across rat intestinal mucosa. A correlation between P (app) values across rat intestinal mucosa and in vivo oral bioavailability in human (R (2) = 0.98; y = 2.11x + 0.34) attests the rat in vitro model to be a very useful prediction model for human oral bioavailability of hydrophilic peptide drugs. Presented correlations encourage the use of the rat in vitro model for the prediction of human oral bioavailabilities of hydrophilic peptide drugs.

Schmerztherapie in der gastroenterologischen Onkologie

Abdominal cancer is commonly associated with pain needing medical attention. Effective pain management is available to control pain. Oral opioids are the foundation of analgesic therapy. With adequate implementation of therapeutic guidelines into clinical practice including the use of co-analgesics, adjuvants and non-pharmacological treatment options the quality of life of abdominal cancer patients can be considerably improved. Only in a minority of patients with refractory pain more sophisticated options of pain management will be necessary, e. g., epidural, intrathecal or neurolytic techniques. In this situation the consultation of a pain therapist is recommended.

Unified concept of solubilization in water by hydrotropes and cosolvents

In the present work hydrophobic dyes, i.e. disperse red 13 (DR-13; (2-[4-(2-chloro-4-nitrophenylazo)-N-ethylphenylamino]ethanol) and Jaune au gras W1201 (1H-indene-1,3(2H)-dione,2-(2-quinolinyl)), are solubilized in water with the help of different additives: acetone and 1-propanol as typical cosolvents, sodium xylene sulfonate (SXS) as a representative of a classical hydrotrope, sodium dodecyl sulfate (SDS) as a typical surfactant, and finally some "solvosurfactants" [ propylene glycol monoalkyl ether derivatives (CiPOj: i = 1, j = 1 and 3; i = 3, j = 1 and 2; i = 4 and tertio-butyl, j = 1) and 1-propoxy-2-ethanol (C3EO1)]. These solvosurfactants are short amphiphiles that do not form well-defined structures in water such as micelles. For all additives an exponential increase in the solubilizations of the two studied hydrophobic dyes was observed when their concentrations in water were increased. Except for the SDS solution, no difference in the overall shapes of the solubilization curves (dye solubility against additive concentration) was found. All the studied molecules were classified according to their hydrotropic efficiencies, i.e., their abilities to solubilize a hydrophobic, sparingly soluble compound in water. The volume of the hydrophobic parts of the studied additives, roughly evaluated by simple calculations, was found to influence strongly the hydrotropic efficiency; i.e. the larger the hydrophobic part of the additive, the better the hydrotropic efficiency. By contrast, the hydrophilic part carrying a charge or not is of minor importance. Taking the hydrophobic part of the molecules as the key parameter, the water solubilization efficiency of cosolvents, hydrotropes, and solvosurfactants can be described in a coherent way.

Free fatty acids exert a greater effect on ocular and skin blood flow than triglycerides in healthy subjects

BACKGROUND

Free fatty acids (FFAs) and triglycerides (TGs) can cause vascular dysfunction and arteriosclerosis. Acute elevation of plasma FFA and TG concentration strongly increase ocular and skin blood flow. This study was designed to discriminate whether FFA or TG independently induce hyperperfusion by measuring regional and systemic haemodynamics.

METHODS

In a balanced, randomized, placebo-controlled, double-blind, three-way, crossover study nine healthy subjects received either Intralipid (Pharmacia and Upjohn, Vienna, Austria) with heparin, Intralipid alone or placebo control. Pulsatile choroidal blood flow was measured with laser interferometry, retinal blood flow and retinal red blood cell velocity with laser Doppler velocimetry, and skin blood flow with laser Doppler flowmetry during an euglycaemic insulin clamp.

RESULTS

A sevenfold increase of FFA during Intralipid/heparin infusion was paralleled by enhanced choriodal, retinal, and skin blood flow by 17 +/- 4%, 26 +/- 5% (P < 0.001), and 47 +/- 19% (P = 0.03) from baseline, respectively. In contrast, a mere threefold increase of FFA by infusion of Intralipid alone did not affect outcome parameters, despite the presence of plasma TG levels of 250-700 mg dL(-1); similar to those obtained during combined Intralipid/heparin infusion. Systemic haemodynamics were not affected by drug infusion.

CONCLUSIONS

Present findings demonstrate a concentration-dependent increase in ocular and skin blood flow by FFA independently of elevated TG plasma concentrations. As vasodilation of resistance vessels occur rapidly, FFA may play a role in the development of continued regional hyperperfusion and deteriorate microvascular function.

[Opioid therapy in chronic non-malignant pain]

In long-term treatment opioids seem to have only minimal side-effects compared with other analgesics and co-analgesics.Nevertheless, some risks have to be considered. While immunosuppression, neurotoxicity, teratogenity, tolerance and addiction are clinically not relevant or very rare, cognitive impairment, sedation and obstipation may have a clinical impact.However, these symptoms can usually be managed by adjuvant medication and patient education. Treatment of non-malignant pain with opioids can only be considered on an individual basis. Scientific evidence for general treatment with opioids, treatment of specific pain syndromes or treatment with certain opioids is not available. In conclusion, only recommendations regarding opioid treatment for certain chronic pain syndromes can be made. In only a minority of patients can a long-term analgesic effect be expected.Therefore, careful evaluation of alternative options of pain management is necessary before opioid therapy is started. With standardized documentation responders may be distinguished from non-responders. For clinical practice of long-term opioid therapy in non-malignant pain a specialized knowledge in pain management is a prerequisite. Future studies with more sophisticated methodology will be necessary to advocate more precise guidelines.However, the therapeutic recommendations from the DGSS consensus conference allow a safer,well structured and validated use of opioids for chronic non-malignant pain.

Effectiveness of exercise therapy in patients with myofascial pain dysfunction syndrome

Twenty consecutive patients suffering from myofascial pain dysfunction (MPD) were assigned to a waiting-list, serving as a no-treatment control period. Inclusion criteria were: (i) pain in the temporomandibular region for at least 3 months, (ii) no evidence of internal derangement or osteoarthritis and (iii) symptoms of postural dysfunction. Treatment consisted of active and passive jaw movement exercises, correction of body posture and relaxation techniques. The following main outcome measures were evaluated: (i) pain at rest, (ii) pain at stress, (iii) impairment, (iv) mouth opening at base-line, before and after treatment and at 6-month follow-up. All patients completed the study and no adverse effects occurred. During control period no significant changes occurred. After treatment six patients had no pain at all (chi-square: P < 0.01) and seven patients experienced no impairment (chi-square: P < 0.005). Pain at stress, impairment and incisal edge clearance improved significantly (Wilcoxon test P < 0.001). This result did not change until follow up, except pain at stress, which further improved significantly (Wilcoxon test P < 0.03). At follow up 16 patients experienced no pain at all, 13 patients were not impaired and only three patients had a restricted mouth opening, in contrast to 12 before treatment (chi-square test P < 0.001).

CONCLUSION

Exercise therapy seems to be useful in the treatment of MPD Syndrome.

Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint

This study intended in evaluating the effectiveness of exercise therapy in patients with craniomandibular disorders (CMD). Twenty consecutive patients suffering from CMD with anterior disc displacement without reduction consulting a CMD service were included in the study if they met following criteria: (i) pain in the temporomandibular region, (ii) reduced incisal edge clearance (<35 mm), (iii) magnet resonance imaging confirmed anterior disc displacement without reduction and (iv) evidence of postural dysfunction. All patients were assigned to a waiting list, serving as a no-treatment control period, according to a before-after trial. The treatment consisted of active and passive jaw movement exercises, correction of body posture and relaxation techniques. A total of 18 patients completed the study, no adverse effects occurred. Following main outcome measures were evaluated: (1) pain at rest (2) pain at stress (3) impairment (4) mouth opening at base-line, before and after treatment and at 6 month follow-up. As a result of treatment pain, impairment and mouth opening improved significantly more than during control period (paired samples t-test P < 0.05). After treatment four patients had no pain at all (chi-square: P < 0.05) and only seven patients revealed an impaired incisal edge clearance after treatment. (chi-square Test, P < 0.001). At follow up, seven patients had no pain and experienced no impairment. Exercise therapy seems to be useful in the treatment of anterior disc displacement without reduction.

[Sonographic findings in interstitial lung diseases]

Up to now, sonography of the thorax has not been taken into consideration in cases of interstitial lung disease because of its technical limitations. This study was aimed at examining pleural and subpleural alterations in cases of interstitial lung disease and comparing the sonographic method with the usual imaging procedures such as x-ray and computer tomography.

PATIENTS AND METHODS

24 patients, aged 25 to 70 who were diagnosed as suffering from an interstitial lung disease and underwent sonography of the thorax, were analysed with regard to the following criteria: 1 pleural effusions, 2 pleural fragmentations, 3 subpleural infiltrations > 2 mm, 4 pleural nodules.

RESULTS

Six patients were diagnosed to have small pleural effusions which had not been visible on x-ray-scans. 14 patients showed pleural fragmentations, 10 patients had subpleural infiltrations, and in one patient pleural nodules could be detected. Out of the 24 patients suffering interstitial lung disease, sonographic alterations were diagnosed in 17 cases (= 71%). Among the 9 patients definitively suffering from sarcoidosis, five had had a completely inconspicuous ultrasonic result, four of them with sarcoidosis stage I.

CONCLUSION

Sonography of the thorax has proved to be an excellent complementing examination method in cases of interstitial lung disease. The advantages lie in the possible detection of small pleural effusions and small subpleural infiltrations, where this method can also be used to monitor therapy.

[Differential diagnosis of pain experience. Chronic pain and depression]

Chronic pain and depressive symptoms often occur together. The relationships between these two conditions are, however, still controversial. On the neurobiological level, features common to both disorders are to be found. Mental coping patterns favor the development of depressive symptomatology in patients suffering from pain, or of pain within the framework of a psychiatric illness. For the diagnostic work-up, the case history, exploration, organic investigations and, where indicated, psychological tests are employed. A well-proven strategy in the areas of diagnosis and therapy is interdisciplinary cooperation involving physicians, psychologists and--within relevant institutions--nursing staff.

An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis

The background and purpose of this investigation was to evaluate the use of a treatment protocol which included active and passive jaw movements, manual therapy techniques, correction of body posture, and relaxation techniques for the treatment of temporomandibular joint (TMJ) osteoarthrosis (OA). Twenty consecutive patients suffering from TMJ OA participated in this study.

INCLUSION CRITERIA

a. pain in the temporomandibular region; b. symptoms lasting at least three months; and c. radiologically proven OA. All patients were assigned to a waiting list, serving as a no treatment control period. Nineteen patients completed the study. No adverse effects occurred. During the control period (mean duration 35 days), the parameters did not change significantly. After treatment (mean duration 46 days) pain, impairment, and incisal edge clearance improved significantly (Wilcoxon test p < 0.001). At follow-up, pain and impairment were further reduced. The number of patients experiencing no pain at rest (80%), chi-square test p = 0.02) and stress (47%), chi-square test p = 0.03), and no impairment (37%), chi-square test p = 0.05) increased significantly. This therapeutic treatment protocol seems to be useful treatment for the symptoms of clinical dysfunction in OA of the TMJ.

Novel drugs for neuropathic pain

Neuropathic pain is often inadequately controlled by conventional analgesics. Because the aetiology of neuropathic pain is only partially understood, specific treatment approaches have not been defined. A variety of pharmacological treatments have been proposed. However, for only a small minority of drugs used in neuropathic pain has the scientific evidence been evaluated in a satisfactory manner. The present review of the recent literature reveals the potential of certain novel drugs in treatment of neuropathic pain.

Exercise therapy for craniomandibular disorders

OBJECTIVE

To evaluate the use of exercise therapy for the treatment of craniomandibular disorders (CMDs).

DESIGN

Before-after trial. All patients were assigned to a waiting list, serving as a no-treatment control period.

SETTING

Outpatient clinic for physical medicine and rehabilitation of the University of Vienna.

PATIENTS

Thirty consecutive patients suffering from CMD with anteridr disc displacement with reduction who were consulting a CMD service.

INCLUSION CRITERIA

(1) symptoms lasting at least 3 months, (2) pain in the temporomandibular region, (3) a positive axiography, and (4) evidence of postural dysfunction. Twenty-six patients completed the study; no adverse effects occurred.

INTERVENTIONS

Active and passive jaw movement exercises, correction of body posture, and relaxation techniques.

MAIN OUTCOME MEASURES

(1) Pain at rest, (2) pain at stress, (3) impairment, and (4) mouth opening at baseline, before and after treatment, and at 6-month follow-up.

RESULTS

During the control period, no changes occurred. After the treatment, pain and impairment were significantly reduced (Wilcoxon test, p < .001). Four patients had a restricted mouth opening, in contrast to 15 before treatment (chi2 test, p < .005). Joint clicking vanished in 13.3% and was reduced in another 13.3% (chi2 test, p < .01). These results did not change until follow-up. Seventy-five percent of the patients were treated successfully.

CONCLUSION

Exercise therapy seems to be useful in the treatment of anterior disc displacement with reduction.

Pyruvate formate-lyase-activating enzyme: strictly anaerobic isolation yields active enzyme containing a [3Fe-4S](+) cluster

Pyruvate formate-lyase-activating enzyme (PFL-AE) from Escherichia coli (E. coli) catalyzes the stereospecific abstraction of a hydrogen atom from Gly734 of pyruvate formate-lyase (PFL) in a reaction that is strictly dependent on the cosubstrate S-adenosyl-l-methionine (AdoMet). Although PFL-AE is an iron-dependent enzyme, isolation of the enzyme with its metal center intact has proven difficult due to the oxygen sensitivity and lability of the metal center. We report here the first isolation of PFL-AE under nondenaturing, strictly anaerobic conditions. Iron and sulfide analysis as well as UV-visible, EPR, and resonance Raman data support the presence of a [3Fe-4S](+) cluster in the purified enzyme. The isolated native enzyme, but not apo-enzyme, exhibits a high specific activity (31 U/mg) in the absence of added iron, indicating that the native cluster is necessary and sufficient for enzymatic activity.

Melanoma in a psoriatic plaque

This is the first reported case of a melanoma in a psoriatic plaque. The clinical, dermoscopic, and histologic features of this case are detailed. A review of the risk of melanoma among patients treated with psoralen-ultraviolet A is presented.

Spitz nevus: a case report

The case of a 2-mm Spitz nevus is reported. We comment on the case and describe the skin-surface microscopy features.

[Co-analgesics in the treatment of chronic pain]

Opioids do not yield adequate analgesic effects in at least one-third of all patients suffering from chronic pain. Nonetheless, in contrast to former opinion there is no type of pain that is principally resistant to opioids, which means that the individual patient's response to opioid administration has to be investigated to determine adequate treatment. Opioids fail most frequently in cases of neuropathic, osseous or sympathetically maintained pain. In these cases there is an indication for early use of co-analgesics. The analgesic potency of anticonvulsives and tricyclic antidepressants has been best documented. A differential indication of the large number of possible coanalgesics should be determined with the help of a detailed pain history focussing on the pain quality. Similar to the WHO analgesic ladder used in (tumor) pain therapy, co-analgesic therapy should only be supplemented by invasive therapeutic procedures after various combinations and alternative substances have proven fruitless. Experience shows that this is necessary only for a small number of patients.

Reliability of surface electromyographic measurements

OBJECTIVES

The aim of the study was to investigate short-term, intermediate-term and long-term reliability of surface electromyographic (EMG) measurements.

METHODS

Eighteen healthy subjects performed 810 isometric knee extension tests. Reliability for maximum voluntary contraction (MVC) and 50% MVC was assessed with retest intervals of 3 min, 90 min and 6 weeks. Reliability for sustained contractions was assessed with retest intervals of 90 min and 6 weeks. EMG was recorded from the rectus femoris, vastus lateralis and vastus medialis muscles. The root mean square (RMS) and the median frequency (MF) parameters were extracted. At sustained contraction tasks, estimated linear regression values of both parameters were analyzed. Bland-Altman-plots, coefficient of repeatability, Pearson's coefficient of correlation and intra class correlation (ICC) procedures were applied to assess test-retest reliability.

RESULTS

EMG recordings taken at short-term intervals were generally better reproducible than those of the longer-term intervals. Moreover, 50% MVC EMG recordings demonstrated better reproducibility than 100% MVC measurements, and EMG recorded from the rectus femoris were more constant than that from the vastus lateralis or vastus medialis. The MF parameter recorded from the rectus femoris was the only reliable parameter of EMG fatigue change.

CONCLUSION

In our set up, EMG measurement is best suited for clinical applications if submaximal MVC measurements are performed and signal is taken from rectus femoris muscle.

Chest ultrasound in diagnosis of pulmonary embolism in comparison to helical CT

To many people die because of undiagnosed pulmonary embolism. Common pulmonary embolism is the most unexpected mortal event in necropsy, antemortem correctly diagnosed in 18-39%. The diagnostic value of chest ultrasound (CUS) has been investigated.

METHODS

117 (68 women, 49 men) patients with clinical suspicion of pulmonary embolism underwent chest sonography and spiral computed tomography (CT). Final diagnosis has been made by CT respective with echo-cardiography, venous duplex sonography and fibrin dimer tests.

RESULTS

Finally, 70 patients suffered from pulmonary embolism. The chest sonograms showed averaged 1.5 x 2.8 cm (0.5-8.5) large triangular or rounded hypoechoic lesions, mean 2.6 pro patient, similar in form and size as in CT. Fresh reperfusionable infarcts were homogenous and hypoechoic. Older infarcts were well demarcated, mainly wedge shaped. A hyperechoic reflex in the center corresponds to the bronchiole: a sign of segmental involvement. The sensitivity of chest ultrasound was 94%, the specificity 87%, positive predictive value 92%, negative predictive value 91%, accuracy 91%. Overall 61 patients had PE in CT, in 47 (67%) cases a direct emboli detection was possible. 14 patients had peripheral lung consolidations without detectable emboli, but fibrin-dimer tests were positive in all cases, there was deep vein thrombosis diagnosed and they showed signs of PE in echocardiography. Spiral CT showed a sensitivity of 85%, a specificity and a positive predictive value of 100%, a negative predictive value of 83% and an accuracy of 92%.

CONCLUSION

CUS can improve diagnosis of pulmonary embolism. Sonography also reveals small infarcts which remain undetected with other imaging procedure such as helical CT.

The role of the biarticular agonist and cocontracting antagonist pair in isometric muscle fatigue

Isometric knee extensions until exhaustion at 30%, 50%, and 70% of maximum voluntary contraction were performed by 18 healthy subjects. During muscle fatigue, surface electromyographic activity was recorded from the knee-extensors vastus lateralis, vastus medialis, and rectus femoris, and the coactive antagonistic biceps femoris. The electromyographic parameter median frequency (MF) served as a measure of fatigue. Coefficients of regression of the MF fatigue changes were analyzed statistically. MF fatigue occurred within the coactive biceps femoris and was significantly more pronounced than in the quadriceps. When the MF fatigue shifts of the coactive biceps femoris were compared with each of the three investigated parts of the quadriceps separately, MF fatigue shifts were similar in shape for the biarticular coactive biceps femoris and the biarticular rectus femoris, but differed significantly between the biceps femoris and the two monoarticular muscles, vastus medialis and vastus lateralis. As both the biarticular agonist and coactive antagonist muscles fatigued at a higher rate than the two monoarticular muscles, it seems likely that this biarticular agonist/antagonist pair determines the time to the limit of endurance.

[Clinical gait analysis--methods, limitations and possible applications]

Human gait is a complex and cyclic movement. Gait analysis of human walking can be done either without any technical support, or in combination with complex and expensive equipment. Modern gait analysis is based on the integration of multiple components to derive a complete analysis of gait. These methods may include observation, videotaping, electromyography, kinematics, kinetics and energetics. The results gained from these methods may then be used to determine the treatment course of a subject with gait abnormalities or to document the effects of therapeutical intervention. The purpose of this article is to provide an overview of the most common used methods in gait analysis. Emphasis will be placed on the type of information that can be derived from each component and how this information can be used clinically.

[Can pleurisy be detected with ultrasound?]

PURPOSE

It was the aim of this study to examine whether chest sonography is a useful method for diagnosing infective pleuritis. We assessed the pleural surface, the presence of subpleural consolidations and of pleural effusions.

METHOD

47 consecutive patients with the clinical diagnosis of pleuritis were examined by means of a 7 MHz linear transducer. We studied the pleural surface, the presence of subpleural consolidations and of pleural effusions.

RESULTS

Pathologic findings could be seen in 43 patients (91%). The smooth echogenic pleural line was interrupted and was rough in appearance in 42 patients (89%). Subpleural consolidations from 0.2 to 2 cm in size were observed in 30 cases (63.8%). In 11 (23.4%) of these lesions, colour Doppler signals could be demonstrated. Pleural effusions were visible either as localised pleural effusions (24 patients, 51%) or as basal effusions (11 cases, 23.4%). Aspiration of pleural fluid was performed twice. In one case the diagnosis of tuberculosis could be proven by fast acid stain, in another patient a pleural empyema was drained successfully under ultrasound guidance. In 5 patients therapeutic consequences resulted from sonographic findings.

CONCLUSION

We conclude that chest sonography is a sensitive and cost effective imaging method for the diagnosis of pleuritis. Aspiration of pleural fluid for further diagnostic or therapeutic procedures can be safely performed.

[Importance and physiologic nutritional requirement of the selenium trace element within the scope of parenteral nutrition (TPN)]

BASIS

Selenium-responsive clinical manifestations of selenium deficiency and elucidation of the biochemical and molecular biological basis of the essentiality of selenium give evidence for the biological importance of the trace element in human nutrition.

CONCLUSION

The dietary parenteral selenium requirement can be calculated on the basis of the maximal gene expression of the selenoprotein plasma glutathione peroxidase (plGPx). In total parenteral nutrition a daily requirement of 0.01 mumol/kg body weight for adults and 0.025 mumol/kg body weight for children can be seen as adequate and safe.

The actinic comedonal plaque

A case of actinic comedonal plaque is reported. We comment on the case as well as describe the skin surface microscopic features.

[Ultrasound diagnosis of rib and sternum fractures]

PURPOSE

Lesions of the thoracic skeleton can sometimes be a problem in radiological diagnosis. Aim of the study was to investigate the value of ultrasound in the diagnosis of thoracic trauma in clinical practice.

METHOD

Patients with thoracic trauma and suspected rib or sternal fracture were entered in the study. The results of the thoracic x-ray including a special target film and thoracic sonography were compared.

RESULTS

103 patients took part in the study (32 women, 71 men, average age 54.3 years). In x-ray the diagnosis of rib fracture was certain in 27 patients (30%). In US 56 patients (58%) had definitive signs of rib fracture. Because of multiple fractures in the same patients the total number of radiologically found rib fractures was 49, whereas 101 fractures could be detected by sonography. Also minimal pleural effusions could be found in 31 patients (32%) sonographically, only 18 of them were seen in x-ray. Larger effusions in six patients (6%) with serial rib fractures and haematothorax could all be diagnosed in x-ray and also US. The seven patients with suspected sternum fracture showed clear fracture signs in x-ray as well as US.

CONCLUSIONS

Rib fractures could be found about twice as often US than x-ray. There was no difference in the diagnosis of sternal fracture. Detection of fluids (local haematoma and pleural effusion) is better via US than by x-ray. Therapeutical consequences may follow a quick bed-side diagnosis by US in a patient who needs intensive care. Other aspects after detection of a rib fracture US apart from thoracic contusion are psychological effects for the patients (usually they can cope better with their pain), the importance in the interpretation of the duration of incapacity to work and the additional information provided by expert opinions.

Comparison of two insole materials using subjective parameters and pedobarography (pedar-system)

INTRODUCTION:: The objective of this trial was to investigate two commonly used insole materials prescribed for shock-absorption and cushioning concerning subjective and pedobarographic parameters. The design was prospective, controlled, randomized and single-blinded. MATERIAL AND METHODS:: A convenient sample of six healthy male adults without any history of leg or foot injury or pain wore -- in random order -- the custom-made insoles for one week. For both insoles the same base material (TEPEFON(R)) was used, insole 1 was covered with PLASTAZOTE(R) I, 3 mm, insole 2 with PPT, 3 mm. Both insoles had a metatarsal pad. After one week of wearing, in-shoe plantar pressures, measured at the same time of day and within the same type of indoor tennis shoes (sockliner removed), were obtained using the PEDAR-System(R) (Novel GmbH, Munich, Germany). Before each measurement the PEDAR-insoles were calibrated and the subject walked around for 5 minutes to get aquainted with the device. Three trials were performed for three different conditions and average values were determined: PEDAR-insole alone, with PLASTAZOTE(R) insole, with PPT(R) insole. Data were collected at self selected speed, gait velocity was determined using two optical switches on a 10 m walkway. Pressures were normalized to body weight. Main outcome parameters were 'Maximal Peak Pressure' (MPP) and 'Pressure Time Integral' (PTI). These parameters were determined for the whole footsole, medial and lateral heel, medial and lateral midfoot, medial, middle and lateral forefoot, hallux and toes II-V. Additionally the subjects filled in a questionnaire including: time wearing the insoles daily (in hours), sweating (visual analogue scale -- VAS), wearing comfort (VAS), perceived discomfort (location). Three months after the trial they were asked via telephone call whether they were still using the insoles. RESULTS:: 1. The overall MPP and PTI values did not differ significantly between the PEDAR-insole alone and the investigated inserts. There was a tendency for both insoles towards lower MPP and PTI values in all regions except for the toes, especially for the PPT(R) insole. 2. The questionaire showed a significantly higher wearing comfort for the PPT(R) insole in contrast to the PLASTAZOTE(R) insole, though all subjects sweated more with the PPT(R) material. Four of the six subjects experienced discomfort due to the metatarsal pad within the PLASTAZOTE(R) insole, only one within the PPT(R) insole. 3. None of the subjects continued to use the PLASTAZOTE(R) insole, but three continued to use the PPT(R) insoles. DISCUSSION:: Despite the significant differences in the subjective parameters, especially wearing comfort, no statistical significant difference for the overall MPP and PTI values between the PEDAR-insole alone and the investigated insoles or in between the insoles tested could be obtained. Yet there was a tendency for both insoles to lower MPP and PTI values in all regions except for the toes. This might be due to the thickness of the insoles and the reduced space within the toe box. The subjectively better tolerated PPT(R) insole tended to lower MPP and PTI more than the PLASTAZOTE(R) insole. CONCLUSION:: Wearing comfort and pedobarographic outcome measurements did not correlate significantly in this trial. Yet there was a tendency for the subjectively better tolerated PPT(R) insole to lower MPP and PTI more.