Interrupting chains of respiratory infections via remote patient monitoring in ambulatory care - a randomized controlled trial during the 2020/21 infection season

Aim of the study

The aim of the study was to investigate patient satisfaction, saving of time and the possible reduction of visits to medical practices that use Remote Patient Monitoring (RPM) during treatment compared to usual care.

Methods

In a randomized controlled trial between October 2020 and May 2021, the participating medical practices were randomized into three groups (two different RPM systems, one control). Doctors were required to enroll patients ≥18 years with acute respiratory infection in possession of a web-enabled device, such as a laptop, tablet or computer. After a three-month study phase, doctors were asked to describe the treatment of their patients via online survey. Patients were also questioned. The analysis was carried out descriptively and through group comparisons.

Results

51 practices with 121 patients were included. Overall, the results generally show a positive assessment of digital care on the patient side. As for the doctors, handling and integrating the systems into established practice routines seem to be a challenge. Further, the number of patient visits to the medical practice was not reduced by using the systems. Doctors did not save time, but the relationship to the patients was intensified.

Conclusion

While there was no indication for an increase in efficiency by using RPM systems, participating doctors indicated their potential for an enhanced interaction between doctor and patient. In particular, intensified interaction contact with patients with chronic diseases (e. g. COPD, long-COVID) could be of long-term interest and importance for doctors in ambulatory care.Trial Registration: DRKS00023553.

Test-retest reliability of center of pressure measures for postural control assessment in older cardiac patients

BACKGROUND

Elderly patients are a growing population in cardiac rehabilitation (CR). As postural control declines with age, assessment of impaired balance is important in older CR patients in order to predict fall risk and to initiate counteracting steps. Functional balance tests are subjective and lack adequate sensitivity to small differences, and are further subject to ceiling effects. A quantitative approach to measure postural control on a continuous scale is therefore desirable. Force plates are already used for this purpose in other clinical contexts, therefore could be a promising tool also for older CR patients. However, in this population the reliability of the assessment is not fully known.

RESEARCH QUESTION

Analysis of test-retest reliability of center of pressure (CoP) measures for the assessment of postural control using a force plate in older CR patients.

METHODS

156 CR patients (≥75 years) were enrolled. CoP measures (path length (PL), mean velocity (MV), and 95% confidence ellipse area (95CEA)) were analyzed twice with an interval of two days in between (bipedal narrow stance, eyes open (EO) and closed (EC), three trials for each condition, 30 s per trial), using a force plate. For test-retest reliability estimation absolute differences (Δ: T0-T1), intraclass correlation coefficients (ICC) with 95% confidence intervals, standard error of measurement and minimal detectable change were calculated.

RESULTS

Under EO condition ICC were excellent for PL and MV (0.95) and good for 95CEA (0.88) with Δ of 10.1 cm (PL), 0.3 cm/sec (MV) and 1.5 cm² (95CEA) respectively. Under EC condition ICC were excellent (≥ 0.95) for all variables with larger Δ (PL: 21.7 cm; MV: 0.7 cm/sec; 95CEA: 2.4 cm²).

SIGNIFICANCE

In older CR patients, the assessment of CoP measures using a force plate shows good to excellent test-retest reliability.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Developmental speed affects ecological stoichiometry and adult fat reserves in Drosophila melanogaster

The elemental composition of organisms belongs to a suite of functional traits that change during development in response to environmental conditions. However, associations between adaptive variations in developmental speed and elemental body composition are not well understood. We compared body mass, elemental body composition, food uptake and fat metabolism of Drosophila melanogaster male fruit flies in relation to their larval development speed. Slowly developing flies had higher body carbon concentration than rapidly developing and intermediate flies. Rapidly developing flies had the highest body nitrogen concentration, while slowly developing flies had higher body nitrogen levels than flies with intermediate speed of development. The carbon-to-nitrogen ratio was therefore lower in rapidly developing flies than in slow and intermediate flies. We also had a group of flies grown individually and their body mass and elemental body composition were similar to those of rapidly developing individuals grown in groups. This suggests that rapid growth is not suppressed by stress. Feeding rates were lowest in the slowly developing flies. The amount of triacylglycerides was highest in the flies with intermediate developmental speed which optimizes development under many climatic conditions. Although low food intake slows down developmental speed and the accumulation of body fat reserves in slowly developing flies, their phenotype conceivably facilitates survival under higher stochasticity of their environments. Rapidly developing flies grew with less emphasis on storage build-up. Overall, this study shoes that a combination of bet-hedging, adaptive tracking and developmental plasticity enables fruit flies to respond adaptively to environmental uncertainty.

Geriatric or cardiac rehabilitation? Predictors of treatment pathways in advanced age patients after transcatheter aortic valve implantation

Background

Aim of the study was to find predictors of allocating patients after transcatheter aortic valve implantation (TAVI) to geriatric (GR) or cardiac rehabilitation (CR) and describe this new patient group based on a differentiated characterization.

Methods

From 10/2013 to 07/2015, 344 patients with an elective TAVI were consecutively enrolled in this prospective multicentric cohort study. Before intervention, sociodemographic parameters, echocardiographic data, comorbidities, 6-min walk distance (6MWD), quality of life and frailty (score indexing activities of daily living [ADL], cognition, nutrition and mobility) were documented. Out of these, predictors for assignment to CR or GR after TAVI were identified using a multivariable regression model.

Results

After TAVI, 249 patients (80.7 ± 5.1 years, 59.0% female) underwent CR (n = 198) or GR (n = 51). GR patients were older, less physically active and more often had a level of care, peripheral artery disease as well as a lower left ventricular ejection fraction. The groups also varied in 6MWD. Furthermore, individual components of frailty revealed prognostic impact: higher values in instrumental ADL reduced the probability for referral to GR (OR:0.49, p <  0.001), while an impaired mobility was positively associated with referral to GR (OR:3.97, p = 0.046). Clinical parameters like stroke (OR:0.19 of GR, p = 0.038) and the EuroSCORE (OR:1.04 of GR, p = 0.026) were also predictive.

Conclusion

Advanced age patients after TAVI referred to CR or GR differ in several parameters and seem to be different patient groups with specific needs, e.g. regarding activities of daily living and mobility. Thus, our data prove the eligibility of both CR and GR settings.

The Effectiveness of Telerehabilitation as a Supplement to Rehabilitation in Patients After Total Knee or Hip Replacement: Randomized Controlled Trial

Background

Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare.

Objective

The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare.

Methods

From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints.

Results

Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note.

Conclusions

The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.

Trial Registration

German Clinical Trials Register DRKS00010009; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010009

Childhood cerebral X-linked adrenoleukodystrophy with atypical neuroimaging abnormalities and a novel mutation

Childhood cerebral X-linked adrenoleukodystrophy (XALD) typically manifests with symptoms of adrenocortical insufficiency and a variety of neurocognitive and behavioral abnormalities. A major diagnostic clue is the characteristic neuroinflammatory parieto-occipital white matter lesions on magnetic resonance imaging. This study reports a 5-year 10-month old boy presenting with generalized skin hyperpigmentation since 3 years of age. Over the past 9 months, he had developed right-sided hemiparesis and speech and behavioral abnormalities, which had progressed over 5 months to bilateral hemiparesis. Retrospective analyses of serial brain magnetic resonance images revealed an unusual pattern of lesions involving the internal capsules, corticospinal tracts in the midbrain and brainstem, and cerebellar white matter. The clinical diagnosis of childhood cerebral adrenoleukodystrophy was confirmed by elevated basal levels of adrenocorticotropin hormone and plasma very long chain fatty acid levels. Additionally, sequencing of the ABCD1 gene revealed a novel mutation. The only specific palliative therapy that could be offered after diagnosis was dietary intervention. The patient died within 16 months of onset of neurological symptoms. Awareness that childhood cerebral XALD can present with atypical neuroimaging patterns early in its course may aid diagnosis at a stage when definitive treatment can be attempted and timely genetic counseling be offered to the family.

Mobile phone-based surveillance for animal disease in rural communities: implications for detection of zoonoses spillover

Improving the speed of outbreak detection and reporting at the community level are critical in managing the threat of emerging infectious diseases, many of which are zoonotic. The widespread use of mobile phones, including in rural areas, constitutes a potentially effective tool for real-time surveillance of infectious diseases. Using longitudinal data from a disease surveillance system implemented in 1500 households in rural Kenya, we test the effectiveness of mobile phone animal syndromic surveillance by comparing it with routine household animal health surveys, determine the individual and household correlates of its use and examine the broader implications for surveillance of zoonotic diseases. A total of 20 340 animal and death events were reported from the community through the two surveillance systems, half of which were confirmed as valid disease events. The probability of an event being valid was 2.1 times greater for the phone-based system, compared with the household visits. Illness events were 15 times (95% CI 12.8, 17.1) more likely to be reported through the phone system compared to routine household visits, but not death events (OR 0.1 (95% CI 0.09, 0.11)). Disease syndromes with severe presentations were more likely to be reported through the phone system. While controlling for herd and flock sizes owned, phone ownership was not a determinant of using the phone-based surveillance system, but the lack of a formal education, and having additional sources of income besides farming were associated with decreased likelihood of reporting through the phone system. Our study suggests that a phone-based surveillance system will be effective at detecting outbreaks of diseases such as Rift Valley fever that present with severe clinical signs in animal populations, but in the absence of additional reporting incentives, it may miss early outbreaks of diseases such as avian influenza that present primarily with mortality.

This article is part of the theme issue ‘Dynamic and integrative approaches to understanding pathogen spillover’.

Reliability and validity of the Kinect V2 for the assessment of lower extremity rehabilitation exercises

BACKGROUND

Besides its initial use as a video gaming system the Kinect might also be suitable to capture human movements in the clinical context. However, the system's reliability and validity to capture rehabilitation exercises is unclear.

RESEARCH QUESTION

The purpose of this study was to evaluate the test-retest reliability of lower extremity kinematics during squat, hip abduction and lunge exercises captured by the Kinect and to evaluate the agreement to a reference 3D camera-based motion system.

METHODS

Twenty-one healthy individuals performed five repetitions of each lower limb exercise on two different days. Movements were simultaneously assessed by the Kinect and the reference 3D motion system. Joint angles and positions of the lower limb were calculated for sagittal and frontal plane. For the inter-session reliability and the agreement between the two systems standard error of measurement (SEM), bias with limits of agreement (LoA) and Pearson Correlation Coefficient (r) were calculated.

RESULTS

Parameters indicated varying reliability for the assessed joint angles and positions and decreasing reliability with increasing task complexity. Across all exercises, measurement deviations were shown especially for small movement amplitudes. Variability was acceptable for joint angles and positions during the squat, partially acceptable during the hip abduction and predominately inacceptable during the lunge. The agreement between systems was characterized by systematic errors. Overestimations by the Kinect were apparent for hip flexion during the squat and hip abduction/adduction during the hip abduction exercise as well as for the knee positions during the lunge. Knee and hip flexion during hip abduction and lunge were underestimated by the Kinect.

SIGNIFICANCE

The Kinect system can reliably assess lower limb joint angles and positions during simple exercises. The validity of the system is however restricted. An application in the field of early orthopedic rehabilitation without further development of post-processing techniques seems so far limited.

Return to work in heart failure patients with suspected viral myocarditis

Background:

Endomyocardial biopsy is considered as the gold standard in patients with suspected myocarditis. We aimed to evaluate the impact of bioptic findings on prediction of successful return to work.

Methods:

In 1153 patients (48.9 ± 12.4 years, 66.2% male), who were hospitalized due to symptoms of left heart failure between 2005 and 2012, an endomyocardial biopsy was performed. Routine clinical and laboratory data, sociodemographic parameters, and noninvasive and invasive cardiac variables including endomyocardial biopsy were registered. Data were linked with return to work data from the German statutory pension insurance program and analyzed by Cox regression.

Results:

A total of 220 patients had a complete data set of hospital and insurance information. Three quarters of patients were virus-positive (54.2% parvovirus B19, other or mixed infection 16.7%). Mean invasive left ventricular ejection fraction was 47.1% ± 18.6% (left ventricular ejection fraction <45% in 46.3%). Return to work was achieved after a mean interval of 168.8 ± 347.7 days in 220 patients (after 6, 12, and 24 months in 61.3%, 72.2%, and 76.4%). In multivariate regression analysis, only age (per 10 years, hazard ratio, 1.27; 95% confidence interval, 1.10–1.46; p = 0.001) and left ventricular ejection fraction (per 5% increase, hazard ratio, 1.07; 95% confidence interval, 1.03–1.12; p = 0.002) were associated with increased, elevated work intensity (heavy vs light, congestive heart failure, 0.58; 95% confidence interval, 0.34–0.99; p < 0.049) with decreased probability of return to work. None of the endomyocardial biopsy–derived parameters was significantly associated with return to work in the total group as well as in the subgroup of patients with biopsy-proven myocarditis.

Conclusion:

Added to established predictors, bioptic data demonstrated no additional impact for return to work probability. Thus, socio-medical evaluation of patients with suspected myocarditis furthermore remains an individually oriented process based primarily on clinical and functional parameters.

Nutrition and mobility predict all-cause mortality in patients 12 months after transcatheter aortic valve implantation

Background

The aim of the study was to determine pre-interventional predictors for all-cause mortality in patients after transcatheter aortic valve implantation (TAVI) with a 12-month follow-up.

Methods

From 10/2013 to 07/2015, 344 patients (80.9 ± 5.0 years, 44.5% male) with an elective TAVI were consecutively enrolled prospectively in a multicentre cohort study. Prior to the intervention, sociodemographic parameters, echocardiographic data and comorbidities were documented. All patients performed a 6-min walk test, Short Form 12 and a Frailty Index (score consisting of activities of daily living, cognition, nutrition and mobility). Peri-interventional complications were documented. Vital status was assessed over telephone 12 months after TAVI. Predictors for all-cause mortality were identified using a multivariate regression model.

Results

At discharge, 333 patients were alive (in-hospital mortality 3.2%; n = 11). During a follow-up of 381.0 ± 41.9 days, 46 patients (13.8%) died. The non-survivors were older (82.3 ± 5.0 vs. 80.6 ± 5.1 years; p = 0.035), had a higher number of comorbidities (2.6 ± 1.3 vs. 2.1 ± 1.3; p = 0.026) and a lower left ventricular ejection fraction (51.0 ± 13.6 vs. 54.6 ± 10.6%; p = 0.048). Additionally, more suffered from diabetes mellitus (60.9 vs. 44.6%; p = 0.040). While the global Frailty Index had no predictive power, its individual components, particularly nutrition (OR 0.83 per 1 pt., CI 0.72–0.95; p = 0.006) and mobility (OR 5.12, CI 1.64–16.01; p = 0.005) had a prognostic impact. Likewise, diabetes mellitus (OR 2.18, CI 1.10–4.32; p = 0.026) and EuroSCORE (OR 1.21 per 5%, CI 1.07–1.36; p = 0.002) were associated with a higher risk of all-cause mortality.

Conclusions

Besides EuroSCORE and diabetes mellitus, nutrition status and mobility of patients scheduled for TAVI offer prognostic information for 1-year all-cause mortality and should be advocated in the creation of contemporary TAVI risk scores.

Effectiveness of an interactive telerehabilitation system with home-based exercise training in patients after total hip or knee replacement: study protocol for a multicenter, superiority, no-blinded randomized controlled trial

Background

Total hip or knee replacement is one of the most frequently performed surgical procedures. Physical rehabilitation following total hip or knee replacement is an essential part of the therapy to improve functional outcomes and quality of life. After discharge from inpatient rehabilitation, a subsequent postoperative exercise therapy is needed to maintain functional mobility. Telerehabilitation may be a potential innovative treatment approach. We aim to investigate the superiority of an interactive telerehabilitation intervention for patients after total hip or knee replacement, in comparison to usual care, regarding physical performance, functional mobility, quality of life and pain.

Methods/design

This is an open, randomized controlled, multicenter superiority study with two prospective arms. One hundred and ten eligible and consenting participants with total knee or hip replacement will be recruited at admission to subsequent inpatient rehabilitation. After comprehensive, 3-week, inpatient rehabilitation, the intervention group performs a 3-month, interactive, home-based exercise training with a telerehabilitation system. For this purpose, the physiotherapist creates an individual training plan out of 38 different strength and balance exercises which were implemented in the system. Data about the quality and frequency of training are transmitted to the physiotherapist for further adjustment. Communication between patient and physiotherapist is possible with the system. The control group receives voluntary, usual aftercare programs. Baseline assessments are investigated after discharge from rehabilitation; final assessments 3 months later. The primary outcome is the difference in improvement between intervention and control group in 6-minute walk distance after 3 months. Secondary outcomes include differences in the Timed Up and Go Test, the Five-Times-Sit-to-Stand Test, the Stair Ascend Test, the Short-Form 36, the Western Ontario and McMaster Universities Osteoarthritis Index, the International Physical Activity Questionnaire, and postural control as well as gait and kinematic parameters of the lower limbs. Baseline-adjusted analysis of covariance models will be used to test for group differences in the primary and secondary endpoints.

Discussion

We expect the intervention group to benefit from the interactive, home-based exercise training in many respects represented by the study endpoints. If successful, this approach could be used to enhance the access to aftercare programs, especially in structurally weak areas.

Trial registration

German Clinical Trials Register (DRKS), ID: DRKS00010009. Registered on 11 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2173-3) contains supplementary material, which is available to authorized users.

User Interest in Digital Health Technologies to Encourage Physical Activity: Results of a Survey in Students and Staff of a German University

Background

Although the benefits for health of physical activity (PA) are well documented, the majority of the population is unable to implement present recommendations into daily routine. Mobile health (mHealth) apps could help increase the level of PA. However, this is contingent on the interest of potential users.

Objective

The aim of this study was the explorative, nuanced determination of the interest in mHealth apps with respect to PA among students and staff of a university.

Methods

We conducted a Web-based survey from June to July 2015 in which students and employees from the University of Potsdam were asked about their activity level, interest in mHealth fitness apps, chronic diseases, and sociodemographic parameters.

Results

A total of 1217 students (67.30%, 819/1217; female; 26.0 years [SD 4.9]) and 485 employees (67.5%, 327/485; female; 42.7 years [SD 11.7]) participated in the survey. The recommendation for PA (3 times per week) was not met by 70.1% (340/485) of employees and 52.67% (641/1217) of students. Within these groups, 53.2% (341/641 students) and 44.2% (150/340 employees)—independent of age, sex, body mass index (BMI), and level of education or professional qualification—indicated an interest in mHealth fitness apps.

Conclusions

Even in a younger, highly educated population, the majority of respondents reported an insufficient level of PA. About half of them indicated their interest in training support. This suggests that the use of personalized mobile fitness apps may become increasingly significant for a positive change of lifestyle.

[User Interest in Digital Health Technologies to Enhance Physical Activity in Students and Staff of a University]

INTRODUCTION

Though health-enhancing effects of physical activity are well documented, the majority of the population is unable to implement present recommendations into daily routine. Mobile health (mHealth) technologies might be able to increase the physical activity level. However, the interest of potential users is a mandatory basis for this.

METHOD

We conducted an online-survey from 06-07/2015 by asking students and employees from the University of Potsdam for their activity level, interest in mHealth training support and other relevant parameters.

RESULTS

1 217 students and 485 employees (67.3% and 67.5% female, 26.0±4.9 and 42.7±11.7 years, respectively) participated in the survey. 70.1% of employees and 52.7% of students did not follow the recommendation for physical activity (3 times per week). 53.2% (students) and 44.2% (employees), independent of age, sex, BMI and level of education or professional qualification, indicated their interest in mHealth technology offering training support.

CONCLUSION

Even in a younger population with higher education, most respondents reported an insufficient level of physical activity. About half of them indicated their interest in training support. Therefore, the use of personalized mHealth technology may be of increasing significance for a positive change of lifestyle.

Advances in cardiac rehabilitation: cardiac rehabilitation after transcatheter aortic valve implantation

Due to the demographic change and an aging population, the prevalence of the most frequent valve disease, aortic stenosis (AS), is still rising.

Cardiopulmonary exercise testing is predictive of return to work in cardiac patients after multicomponent rehabilitation

BACKGROUND

Return to work (RTW) is a pivotal goal of cardiac rehabilitation (CR) in patients after acute cardiac event. We aimed to evaluate cardiopulmonary exercise testing (CPX) parameters as predictors for RTW at discharge after CR.

METHODS

We analyzed data from a registry of 489 working-age patients (51.5 ± 6.9 years, 87.9 % men) who had undergone inpatient CR predominantly after percutaneous coronary intervention (PCI 62.6 %), coronary artery bypass graft (CABG 17.2 %), or heart valve replacement (9.0 %). Sociodemographic and clinical parameters, noninvasive cardiac diagnostic (2D echo, exercise ECG, 6MWT) and psychodiagnostic screening data, as well as CPX findings, were merged with RTW data from the German statutory pension insurance program and analyzed for prognostic ability.

RESULTS

During a mean follow-up of 26.5 ± 11.9 months, 373 (76.3 %) patients returned to work, 116 (23.7 %) did not, and 60 (12.3 %) retired. After adjustment for covariates, elective CABG (HR 0.68, 95 % CI 0.47-0.98; p = 0.036) and work intensity (per level HR 0.83, 95 % CI 0.73-0.93; p = 0.002) were negatively associated with the probability of RTW. Exercise capacity in CPX (in Watts) and the VE/VCO2-slope had independent prognostic significance for RTW. A higher work load increased (HR 1.17, 95 % CI 1.02-1.35; p = 0.028) the probability of RTW, while a higher VE/VCO2 slope decreased (HR 0.85, 95 % CI 0.76-0.96; p = 0.009) it. CPX also had prognostic value for retirement: the likelihood of retirement decreased with increasing exercise capacity (HR 0.50, 95 % CI 0.30-0.82; p = 0.006).

CONCLUSION

CPX is a valid tool for assessing patients' ability to return to work. Therefore, it may be an essential part of functional assessment during CR for predicting participation in employment.

Impact of training methods and patient characteristics on exercise capacity in patients in cardiovascular rehabilitation

AIM

We aimed to identify patient characteristics and comorbidities that correlate with the initial exercise capacity of cardiac rehabilitation (CR) patients and to study the significance of patient characteristics, comorbidities and training methods for training achievements and final fitness of CR patients.

METHODS

We studied 557 consecutive patients (51.7 ± 6.9 years; 87.9% men) admitted to a three-week in-patient CR. Cardiopulmonary exercise testing (CPX) was performed at discharge. Exercise capacity (watts) at entry, gain in training volume and final physical fitness (assessed by peak O2 utilization (VO2peak) were analysed using analysis of covariance (ANCOVA) models.

RESULTS

Mean training intensity was 90.7 ± 9.7% of maximum heart rate (81% continuous/19% interval training, 64% additional strength training). A total of 12.2 ± 2.6 bicycle exercise training sessions were performed. Increase of training volume by an average of more than 100% was achieved (difference end/beginning of CR: 784 ± 623 watts × min). In the multivariate model the gain in training volume was significantly associated with smoking, age and exercise capacity at entry of CR. The physical fitness level achieved at discharge from CR as assessed by VO2peak was mainly dependent on age, but also on various factors related to training, namely exercise capacity at entry, increase of training volume and training method.

CONCLUSION

CR patients were trained in line with current guidelines with moderate-to-high intensity and reached a considerable increase of their training volume. The physical fitness level achieved at discharge from CR depended on various factors associated with training, which supports the recommendation that CR should be offered to all cardiac patients.

[Sonographic diagnosis of parathyroid carcinoma]

Prognosis and survival of patients suffering from parathyroid carcinoma are completely dependent on correct surgical therapy in form of an en-bloc resection of the tumour. A correct preoperative diagnosis of this rare carcinoma is therefore absolutely mandatory in order to perform a curative operation. We demonstrate a case of parathyroid carcinoma in which scintigraphy and CT diagnostics did not produce the right diagnosis. Preoperative high-resolution ultrasound (8 MHz) in combination with power-Doppler-sonography, however, led to the right diagnosis by demonstrating the correct topography, signs of malignancy and the feeding vessels of the tumour. As it could be demonstrated that the inferior thyroid artery was displaced by the tumour and was not a tumour feeding artery, the inferior thyroid artery was an important additional landmark for making the decision between thyroid or parathyroid carcinoma. The use of power-Doppler-sonography for identification of feeding arteries associated with parathyroid carcinoma in addition to high-resolution small parts sonography is of great value for the distinction between thyroid or parathyroid tumour.

Bilateral human fetal striatal transplantation in Huntington's disease

BACKGROUND

Transplanted striatal cells have been demonstrated to survive, grow, establish afferent and efferent connections, and improve behavioral signs in animal models of Huntington's disease (HD).

OBJECTIVE

To evaluate feasibility and safety and to provide preliminary information regarding the efficacy of bilateral human fetal striatal transplantation in HD.

METHODS

Seven symptomatic patients with genetically confirmed HD underwent bilateral stereotactic transplantation of two to eight fetal striata per side in two staged procedures. Tissue was dissected from the lateral half of the lateral ventricular eminence of donors 8 to 9 weeks postconception. Subjects received cyclosporine for 6 months.

RESULTS

Three subjects developed subdural hemorrhages (SDHs) and two required surgical drainage. One subject died 18 months after surgery from probable cardiac arrhythmia secondary to severe atherosclerotic cardiac disease. Autopsy demonstrated clearly demarcated grafts of typical developing striatal morphology, with host-derived dopaminergic fibers extending into the grafts and no evidence of immune rejection. Other adverse events were generally mild and transient. Mean Unified HD Rating Scale (UHDRS) motor scores were 32.9 plus minus 6.2 at baseline and 29.7 plus minus 7.5 12 months after surgery (p = 0.24). Post-hoc analysis, excluding one subject who experienced cognitive and motor deterioration after the development of symptomatic bilateral SDHs, found that UHDRS motor scores were 33.8 plus minus 6.2 at baseline and 27.5 plus minus 5.2 at 12 months (p = 0.03).

CONCLUSIONS

Transplantation of human fetal striatal cells is feasible and survival of transplanted cells was demonstrated. Patients with moderately advanced HD are at risk for SDH after transplantation surgery.

Development of symbionts in triatomine bugs and the effects of infections with trypanosomatids

In the intestinal tract of fifth instars of the hematophagous reduviid bugs Rhodnius prolixus and Triatoma infestans blood ingestion induced an initial decrease of the concentration of the respective symbiotic bacteria Rhodococcus rhodnii and Nocardia sp. and then within 10 days a 15- or 18-fold increase of the total population/bug to about 0.8 x 10(9) colony-forming units in R. prolixus and 1.8 x 10(9) colony-forming units in T. infestans. About 95-99% of the total populations of both symbionts developed in the anterior midgut regions, i.e., cardia and stomach. The passage from the blood-storing stomach to the digesting small intestine caused a considerable breakdown of symbiont populations, and only about 0.01% of the total population was present in the rectum. These were excreted mainly within 4 h after a blood meal. After infection with three species of trypanosomatids, R. rhodnii, the symbiont of R. prolixus, was affected by Trypanosoma rangeli, but not by Blastocrithidia triatomae or Trypanosoma cruzi. On the other hand, in T. infestans the concentration of Nocardia sp. was reduced after infection with B. triatomae, but not by T. rangeli nor T. cruzi. In long-term B. triatomae-infected T. infestans, this reduction and a reduced diuretic activity after feeding synergistically lowered the symbiont concentration in the singly deposited feces/urine drops drastically compared to uninfected controls. These data strongly support the theory of the mechanisms of pathogenicity of T. rangeli and B. triatomae for R. prolixus and T. infestans, respectively, that the primal point of attack is the host-specific symbiont, R. rhodnii and Nocardia sp., respectively.

A recombinant virus assay using full-length envelope sequences to detect changes in HIV-1 co-receptor usage

The clinical management of HIV-1 infection has benefited enormously from molecular characterization of drug resistance as well as determination of the viral phenotype in vitro. HIV-1 infected individuals on HAART are currently monitored for the development of drug resistance variants allowing clinicians to redesign drug regimens. An understanding of the molecular basis of the evolution of drug resistance in vivo allows the improvement of the drugs as well as in vitro evaluation of new antiviral compounds alone or in combination with those currently approved. New findings suggest that viral envelopes could be a target to inhibit infection and replication. Therefore the generation of a recombinant virus assay (RVA) to allow the phenotypic determination of drug resistance against entry inhibitors (EI) is anticipated. We constructed an env-deleted clone of HIV-1 using the molecular clone NL-4.3. PCR amplified complete envelope genes (NL-4.3, BaL, primary envelope-genes) were ligated in vitro with a deletion clone (pNL-deltaK) and PM1-cells, supporting the replication of R5- and X4-tropic viruses, were transfected. Determination of co-receptor usage of the harvested recombinant virus-swarm revealed no difference compared to the molecular clones derived individually from three different patients. These results clearly show that an envelope-based RVA is practicable to monitor HIV-co-receptor usage at a given time point. Furthermore, this assay will allow to monitor resistance development against existing and future entry inhibitors and will aid to improve the management of HIV-therapy.

Bacterial symbiosis and paratransgenic control of vector-borne Chagas disease

The triatomine vectors of Chagas disease are obligate haematophagous insects, feeding on vertebrate blood throughout their entire developmental cycle. As a result of obtaining their nutrition from a single food source, their diet is devoid of certain vitamins and nutrients. Consequently, these insects harbour populations of bacterial symbionts within their intestinal tract, which provide the required nutrients that are lacking from their diet. We have isolated and characterised symbiont cultures from various triatomine species and developed a method for genetically transforming them. We can then reintroduce them into their original host species, thereby producing stable paratransgenic insects in which we are able to express heterologous gene products. Using this methodology, we have generated paratransgenic Rhodnius prolixus that are refractory for infection with Trypanosoma cruzi. Two examples of potentially refractory genes are currently being expressed in paratransgenic insects. These include the insect immune peptide cecropin A and active single chain antibody fragments. We have also developed an approach that would allow introduction of genetically modified bacterial symbionts into natural populations of Chagas disease vectors. This approach utilises the coprophagic behaviour of these insects, which is the way in which the symbionts are transmitted among bug populations in nature. The production and ultimate release of transgenic or paratransgenic insects for public health applications is potentially very promising but also worthy of much careful consideration with respect to environmental, political, and human safety concerns.

[Content of minerals (Na,K,Ca,Mg) and of trace elements (Fe,Cu and Zn) in 13 different tissues of fallow deer (Dama dama L.) of various ages]

At male deer in the age of 15 and 27 months, at experimentally induced cryptorchids and at castrated animals analyses of the content of Na, K, Ca, Mg, Fe, Cu and Zn in 13 different tissues were performed. In the liver of newborn animals solely the content of Fe, Cu and Zn was determined. The significance of the content of the mentioned elements in the various tissues is described. In the liver of the newborn animals stores of Fe, Cu an Zn were identified. The values can be used as a basis for analyses at deer with a growth inhibition caused by a lack of sodium chloride Fe, Cu and Zn.

Software based digital signal processing and spectrum deconvolution in X-ray spectroscopy

Approaches for software based digital signal processing and numerical deconvolution of measured signals which overcome limitations of state-of-the-art systems are described. The basic technical equipment for digital signal processing consists of an energy resolving detector with a preamplifier followed by a fast sampling analogue-to-digital converter (ADC). The main idea is the numerical decomposition of the measured signal into contributions caused by single photon absorption using standard pulses. The latter can be obtained by measurements under definite conditions. The maximum pulse rate is then limited only by the ratio of sampling time to the time between two pulses which should be attributed to single events. Thus pulse overlaps do not require pulse rejection. At sampling rates of 10(8) samples per second theoretically a comparable photon rate can be detected at throughputs of 100%. Beyond that it is outlined that in a comparable manner a numerical deconvolution of measured energy spectra (statistic distribution functions of single events) into combinations of standard spectra, which can likewise be determined by measurement, offers outstanding possibilities, too. On the one hand the energy resolution attainable for individual events for a given detector can be improved drastically by the statistical treatment of spectra. On the other hand an energy resolving work principle becomes possible for certain detectors, which do not permit this conventionally due to their poor signal to noise ratio.

The effects of aposymbiosis and of an infection with Blastocrithidia triatomae (Trypanosomatidae) on the tracheal system of the reduviid bugs Rhodnius prolixus and Triatoma infestans

We have investigated the effects of the absence of symbionts and of infection with a trypanosome on the tracheal supply to different organs in larvae of the blood-sucking bugs, Rhodnius prolixus and Triatoma infestans. In bugs grown without symbionts there were extensive reductions in the tracheal supply to all the internal organs examined. These bugs also excreted less fluid after blood meals, perhaps because of a reduction in the oxygen supply to the Malpighian tubules. Inclusion of vitamin B in the diet of these affected insects reversed both the adverse effects on diuresis and on the extent of the respiratory supply to the different internal organs. The results of these studies suggest that vitamin B may play a key role in the development and maintenance of an adequate tracheal supply to the tissues in these insects. Infection with the trypanosome Blastocrithidia triatomae also greatly reduced the density of tracheoles supplying the rectum, small intestine and Malpighian tubules in infected T. infestans, but not in R. prolixus. It is possible, therefore, that the parasite exerts at least part of its pathogenic effect by causing a vitamin B deficiency, that in turn affects oxygen supply to the tissues.

The relationship between cardiovascular reactivity and heartbeat detection

This experiment tested the hypothesis that inotropic cardiovascular reactivity to stress is related to performance on heartbeat discrimination tasks. The experiment also compared the efficacy of a specific modification of two popular heartbeat discrimination paradigms, Whitehead's and Katkin's. Subjects were 48 male undergraduates who performed both discrimination tasks and then were subjected to mental arithmetic stress. Results indicated that high cardiovascular reactors were better detectors than low reactors. Results also indicated that subjects performed better on the modified Whitehead task than on the modified Katkin task.