Structured health care for subjects with diabetic foot ulcers results in a reduction of major amputation rates

OBJECTIVE: We tested the effects of structured health care for the diabetic foot in one region in Germany aiming to reduce the number of major amputations. RESEARCH DESIGN AND METHODS: In a prospective study we investigated patients with diabetic foot in a structured system of outpatient, in-patient and rehabilitative treatment. Subjects were recruited between January 1(st), 2000 and December 31, 2007. All participants underwent a two-year follow-up. The modified University of Texas Wound Classification System (UT) was the basis for documentation and data analysis. We evaluated numbers of major amputations, rates of ulcer healing and mortality. In order to compare the effect of the structured health care program with usual care in patients with diabetic foot we evaluated the same parameters at another regional hospital without interdisciplinary care of diabetic foot (controls). RESULTS: 684 patients with diabetic foot and 508 controls were investigated. At discharge from hospital 28.3% (structured health care program, SHC) vs. 23.0% (controls) of all ulcers had healed completely. 51.5% (SHC) vs. 49.8% (controls) were in UT grade 1. Major amputations were performed in 32 subjects of the structured health care program group (4.7%) vs. 110 (21.7%) in controls (p<0.0001). Mortality during hospitalization was 2.5% (SHC) vs. 9.4% in controls (p<0.001). CONCLUSIONS: With the structured health care program we achieved a significant reduction of major amputation rates by more than 75% as compared to standard care

Gammaherpesvirus-Driven Plasma Cell Differentiation Regulates Virus Reactivation from Latently Infected B Lymphocytes

Gammaherpesviruses chronically infect their host and are tightly associated with the development of lymphoproliferative diseases and lymphomas, as well as several other types of cancer. Mechanisms involved in maintaining chronic gammaherpesvirus infections are poorly understood and, in particular, little is known about the mechanisms involved in controlling gammaherpesvirus reactivation from latently infected B cells in vivo. Recent evidence has linked plasma cell differentiation with reactivation of the human gammaherpesviruses EBV and KSHV through induction of the immediate-early viral transcriptional activators by the plasma cell-specific transcription factor XBP-1s. We now extend those findings to document a role for a gammaherpesvirus gene product in regulating plasma cell differentiation and thus virus reactivation. We have previously shown that the murine gammaherpesvirus 68 (MHV68) gene product M2 is dispensable for virus replication in permissive cells, but plays a critical role in virus reactivation from latently infected B cells. Here we show that in mice infected with wild type MHV68, virus infected plasma cells (ca. 8% of virus infected splenocytes at the peak of viral latency) account for the majority of reactivation observed upon explant of splenocytes. In contrast, there is an absence of virus infected plasma cells at the peak of latency in mice infected with a M2 null MHV68. Furthermore, we show that the M2 protein can drive plasma cell differentiation in a B lymphoma cell line in the absence of any other MHV68 gene products. Thus, the role of M2 in MHV68 reactivation can be attributed to its ability to manipulate plasma cell differentiation, providing a novel viral strategy to regulate gammaherpesvirus reactivation from latently infected B cells. We postulate that M2 represents a new class of herpesvirus gene products (reactivation conditioners) that do not directly participate in virus replication, but rather facilitate virus reactivation by manipulating the cellular milieu to provide a reactivation competent environment

Value of the TTM risk score for early prognostication of comatose patients after out-of-hospital cardiac arrest in a Swiss university hospital.

Comatose patients admitted to the intensive care unit (ICU) after out-of-hospital cardiac arrest frequently die after withdrawal of life support. Guidelines recommend scheduling prognostication no sooner than 96 hours after cardiac arrest, and strict withdrawal criteria leave many patients waiting for improvement for days without ever reaching a favourable outcome. In clinical practice, physicians are frequently confronted with vague living wills expressed by next of kin or an imprecise advance care directive soon after cardiac arrest. Often a decision to admit a patient to an ICU or limiting ICU treatment in terms of time or intensity is made early, based on the patient&rsquo;s preferences. The Target Temperature Management (TTM) risk score is an imperfect measure that predicts outcome early, at the time of ICU admission. It was developed on a data set of 939 patients included in the TTM Trial, a study in which unconscious patients after cardiac arrest were randomised into two temperature management arms. Patient selection in that trial might impede generalisability. We aimed to validate the TTM risk score with 100 consecutive patients treated in our ICU. Although we had different survival rates, reflecting a different patient population, we were able to confirm the score&rsquo;s albeit imperfect ability to predict outcome early after cardiac arrest. The suggested cut-off values of 10 and 16 can be used as a basis for discussion with the family; in particular, a risk score value below 10 predicts a favourable outcome and might guide early discussion. As in the original study, the outcome of an individual patient cannot be predicted. (ClinicalTrials.gov Identifier: NCT02722460)

An Experimental Test of the Public Goods Crowing Out Hypothesis when Taxation Is Endogenous

Andreoni (1993) has shown in an experimental study that crowding out is incomplete when an involuntary lump-sum tax is levied exogenously on individuals to finance the provision of a public good. In this paper, we (i) replicate Andreoni's experimental conditions, and (ii) introduce treatments where subjects vote on a tax, which is (iii) either below or above the Nash equilibrium. We find almost complete crowding out with exogenous taxation. Voting behavior with respect to the tax in the endogenous treatment has high predictive power for voluntary contributions, but only when voting on a tax that is below the Nash equilibrium of the game.taxation, public goods, crowding out, voting, experiment

Outcome prediction with resting-state functional connectivity after cardiac arrest.

Predicting outcome in comatose patients after successful cardiopulmonary resuscitation is challenging. Our primary aim was to assess the potential contribution of resting-state-functional magnetic resonance imaging (RS-fMRI) in predicting neurological outcome. RS-fMRI was used to evaluate functional and effective connectivity within the default mode network in a cohort of 90 comatose patients and their impact on functional neurological outcome after 3 months. The RS-fMRI processing protocol comprises the evaluation of functional and effective connectivity within the default mode network. Seed-to-voxel and ROI-to-ROI feature analysis was performed as starting point for a supervised machine-learning approach. Classification of the Cerebral Performance Category (CPC) 1-3 (good to acceptable outcome) versus CPC 4-5 (adverse outcome) achieved a positive predictive value of 91.7%, sensitivity of 90.2%, and accuracy of 87.8%. A direct link to the level of consciousness and outcome after 3 months was identified for measures of segregation in the precuneus, in medial and right frontal regions. Thalamic connectivity appeared significantly reduced in patients without conscious response. Decreased within-network connectivity in the default mode network and within cortico-thalamic circuits correlated with clinical outcome after 3 months. Our results indicate a potential role of these markers for decision-making in comatose patients early after cardiac arrest

Topography of MR lesions correlates with standardized EEG pattern in early comatose survivors after cardiac arrest.

AIM Multimodal prognostication in comatose patients after cardiac arrest (CA) is complicated by the fact that different modalities are usually not independent. Here we set out to systematically correlate early EEG and MRI findings. METHODS 89 adult patients from a prospective register who underwent at least one EEG and one MRI in the acute phase after CA were included. The EEGs were characterized using pre-existent standardized categories (highly malignant, malignant, benign). For MRIs, the apparent diffusion coefficient (ADC) was computed in pre-defined regions. We then introduced a novel classification based on the topography of ADC reduction (MR-lesion pattern (MLP) 1: no lesion; MLP 2: purely cortical lesions; MLP 3: involvement of the basal ganglia; MLP 4 involvement of other deep grey matter regions). RESULTS EEG background reactivity and EEG background continuity were strongly associated with a higher MLP value (p < 0.001 and p = 0.003 respectively). The EEG categories highly malignant, malignant and benign were strongly correlated with the MLP values (rho = 0.46, p < 0.001). CONCLUSION The MRI lesions are highly correlated with the EEG pattern. Our results suggest that performing MRI in comatose patients after CA with either highly malignant or with a benign EEG pattern is unlikely to yield additional useful information for prognostication, and should therefore be performed in priority in patients with intermediate EEG patterns ("malignant pattern")

Soziales Kapital mobilisieren Gemeinwesenorientierung als Defizit und Chance lokaler Beschaeftigungspolitik

Das Gutachten wurde fuer die am 7. Juli 1995 vom Landtag von Nordrhein-Westfalen eingesetzte Enquete-Kommission 'Zukunft der Erwerbsarbeit' erstellt. Es kommt zu folgenden zentralen Aussagen: 1. Im Rahmen der Vielzahl an Programmen und Initiativen in der lokalen Arbeitsmarktpolitik besteht die Tendenz, sich auf berechenbare Ein-Ziel-Programme zu konzentrieren; deren Addition wird jedoch den komplexen Herausforderungen einer wachsenden Beschaeftigungsluecke und einem ruecklaeufigen Arbeitsplatzangebot fuer einfach Qualifizierte nur sehr bedingt gerecht. 2. Strategien zur Bekaempfung lokaler Arbeitslosigkeit sind als Teil einer breiteren Aufgabe und eines komplexeren Zielsystems zu begreifen - der Wiedergewinnung von sozial integrativen Modellen lokaler Wirtschafts- und Stadtentwicklung. 3. Lokale Strategien zur Beschaeftigung sollten sich zweier zentraler Ansatzpunkte bedienen: sozialer Unternehmen, die Innovationsbereitschaft, Initiative und die Verpflichtung auf soziale und gemeinwohlorientierte Ziele verbinden, und einer kooperativen Politik, die Operationsfelder und Ressourcen der Beteiligung erschliesst. 4. Unter dem Begriff des 'sozialen Kapitals' hat das Gutachten eine Reihe wesentlicher, aber oft uebersehener kritischer Erfolgsfaktoren fuer die Entwicklung sozialer Unternehmen und eines kooperativen Politikstils herausgestellt. 5. Die zentralen Empfehlungen des Gutachtens laufen darauf hinaus, den gesonderten Politik- und Aktionsbereich der lokalen Arbeitsmarkt- und Beschaeftigungspolitik staerker in Richtung auf diese Leitlinien zu entwickeln. (IAB2)SIGLEAvailable from IAB-90-0NW0-309000 BI 827 (2) / FIZ - Fachinformationszzentrum Karlsruhe / TIB - Technische InformationsbibliothekDEGerman