Fostering needs assessment and access to medical rehabilitation for patients with chronic disease and endangered work ability: protocol of a multilevel evaluation on the effectiveness and efficacy of a CME intervention for general practitioners

Background

Studies show that endangered work ability (EWA) can be maintained or restored through medical rehabilitation (MR). For patients, general practitioners (GP) represent an important point of access to MR in outpatient care. However, many different barriers and shortcomings hinder GPs in both timely detection of the need for MR and the recognition of its potentials for their EWA-patients. These are necessary if GPs are to adequately inform patients about MR options and successfully support applications for MR. This study describes the evaluation of a continuing medical education (CME) module designed to improve rehabilitation-related practical performance of GPs regarding a) subjective satisfaction of GPs with the CME module, b) stability of attitudes and knowledge over time regarding rehabilitation, and c) subjective and objective changes in MR-related competencies needed to support MR applications.

Methods

This study is an open, non-randomised, pre-post-intervention study. The intervention involves a CME module for GPs (n = 1365) in the German state of Saxony-Anhalt on the topic of medical rehabilitation in connection with the federal German pension fund (Deutsche Rentenversicherung). The module will be initially held as regularly scheduled meetings in moderated GP quality circles (QC), and then offered as a written self-study unit. At the end it will be evaluated by the GPs. The study’s primary focus is on the organizational practice as measured by the number of approved MR applications supported by medical reports submitted by the participating GPs in the 6 months before and 6 months after the CME module. Other study aims involve measuring self-perceived competencies of GPs, as well as their attitudes towards and knowledge of rehabilitation (both upon completing the CME and 6 months later). In addition, the level of satisfaction with the CME module will be analysed among participating GPs and QC moderators (as CME facilitators).

Discussion

Implementing targeted CME on complex topics such as those involving barriers is possible, even promising, when using QCs and their moderators. Of particular importance is how aware moderating physicians are of the relevance of MR need detection and access.

Ethics and dissemination

The ethics committee of the Martin-Luther-Universität Halle-Wittenberg has registered this study under the number 2014–13. The study will be reported on in peer-reviewed journals and at national and international conferences. The results will be available to current and future initiatives aiming to improve detection of MR need and making MR accessible to EWEC patients needing such support to minimize the effects of chronic disease on their livess.

Trial registration number

German Clinical Trials Register (ID number DRKS00006188) and WHO International Clinical Trials Registry Platform, Universal Trial Number (UTN) U1111–1158-8334.

     

Evidence for adenosine receptor-mediated isoprenaline-antagonistic effects of the adenosine analogs PIA and NECA on force of contraction in guinea-pig atrial and ventricular cardiac preparations

Summary The effects of the adenosine agonists (–)-N⁶-phenylisopropyladenosine (PIA) and 5-N-ethylcarboxamideadenosine (NECA) on force of contraction, adenylate cyclase activity and normal as well as slow action potentials were studied in guinea-pig isolatedatrial (left auricles) andventricular preparations (papillary muscles).Inauricles PIA and NECA exerted concentration-dependent negative inotropic effects with similar potenticies (mean EC₅₀:0.05 mol l^–1 for PIA and 0.03 mol l^–1 for NECA). Similar results were obtained in the presence of isoprenaline.Inpapillary muscles PIA and NECA alone had no effect on force of contraction but produced negative inotropic effects in the presence of isoprenaline (mean EC₅₀:0.19 mol l^–1 for PIA and 0.10 mol l^–1 for NECA).In both preparations, the negative inotropic effects of PIA and NECA in the presence of isoprenaline were antagonized by the adenosine receptor antagonist 8-phenyltheophylline.In both preparations, PIA and NECA did not affect adenylate cyclase activity, both in the absence and presence of isoprenaline.Inauricles the negative inotropic effects of both nucleosides were accompanied by shortening of the action potential. This effect was also observed in the presence of isoprenaline. Inpapillary muscles the adenosine analogs did not detectably alter the shape of the normal action potential. Ca²⁺-dependent slow action potentials elicited in potassium-depolarized preparations also remained unaltered in the presence of PIA or NECA alone. However, the isoprenaline-induced enhancement of the maximal rate of depolarization of slow action potentials was attenuated by PIA or NECA.It is concluded that in guinea-pig atrial and ventricular cardiac preparations the adenosine analogs PIA and NECA exert isoprenaline-antagonistic effects on force of contraction via adenosine receptors the existence of which can thus be shown in a functional way. These receptors are not detectably coupled to the adenylate cyclase. The negative inotropic effect in theauricle is most likely due to a shortening of the action potential resulting from an activation of potassium channels, which in turn indirectly reduces the Ca²⁺ influx during the action potential. In theventricle the adenosine receptor is either not linked to these potassium channels or adenosine-sensitive potassium channels do not exist in the ventricle. Instead the activation of the receptor causes a decrease of the slow Ca²⁺ inward current but this effect is observed only when the slow Ca²⁺ inward current had previously been enhanced by a cyclic AMP-dependent mechanism.     

Positive inotropic effect of bay K 8644: cAMP-independence and lack of inhibitory effect of adenosine

Summary The aim of the present study was to characterize the positive inotropic effect of the Ca²⁺ channel activator Bay K 8644. In isolated guinea-pig papillary muscles we investigated whether adenosine and the R site adenosine receptor agonist (–)-N⁶-phenylisopropyladenosine (PIA) were able to antagonize the positive inotropic effect of Bay K 8644. The effect of Bay K 8644 and adenosine or PIA on myocardial cAMP content was also measured. The influence of adenosine and PIA on the positive inotropic effect of the -adrenoceptor agonist isoprenaline and of the phosphodiesterase inhibitor amrinone was studied for comparison.Adenosine and PIA antagonized the positive inotropic effects of isoprenaline and amrinone in a concentration-dependent manner. In contrast, adenosine or PIA did not affect the positive inotropic effect of Bay K 8644.The positive inotropic effect of Bay K 8644 was not accompanied by a change in the cAMP content of the papillary muscles. Additionally applied adenosine or PIA also failed to affect the cAMP content.It is concluded that an increased myocardial cAMP content is not involved in the positive inotropic effect of Bay K 8644. Moreover, the results support the view that adenosine and PIA only antagonize the positive inotropic effects of drugs known to increase myocardial cAMP content and that an increased myocardial cAMP content is a prerequisite for the manifestation of a negative inotropic effect of the nucleosides in ventricular cardiac muscle.     

First look at changes in flood hazard in the Inter-Sectoral Impact Model Intercomparison Project ensemble

Climate change due to anthropogenic greenhouse gas emissions is expected to increase the frequency and intensity of precipitation events, which is likely to affect the probability of flooding into the future. In this paper we use river flow simulations from nine global hydrology and land surface models to explore uncertainties in the potential impacts of climate change on flood hazard at global scale. As an indicator of flood hazard we looked at changes in the 30-y return level of 5-d average peak flows under representative concentration pathway RCP8.5 at the end of this century. Not everywhere does climate change result in an increase in flood hazard: decreases in the magnitude and frequency of the 30-y return level of river flow occur at roughly one-third (20–45%) of the global land grid points, particularly in areas where the hydrograph is dominated by the snowmelt flood peak in spring. In most model experiments, however, an increase in flooding frequency was found in more than half of the grid points. The current 30-y flood peak is projected to occur in more than 1 in 5 y across 5–30% of land grid points. The large-scale patterns of change are remarkably consistent among impact models and even the driving climate models, but at local scale and in individual river basins there can be disagreement even on the sign of change, indicating large modeling uncertainty which needs to be taken into account in local adaptation studies.     

Interaction between deglutition,tongue posture,and malocclusion: A comparison of intraoral compartment formation in subjects with neutral occlusion or different types of malocclusion

Objective:To test the null hypothesis of no significant difference in terms of intraoral pressure curve characteristics assessed simultaneously at the subpalatal space (SPS) and the vestibular space (VS), during different oral postures, between four groups with either an Angle Class II/1 (II1), Angle Class II/2 (II2), anterior open bite (O) malocclusion, or a neutral occlusion control group (I).Materials and Methods:Intraoral pressure recordings were performed simultaneously in the VS and SPS of 69 consecutive subjects (n_II1  =  15; n_II2  =  17; n_O  =  17; n_I  =  20; mean age/standard deviation 18.43/6.60 years). Assessments included defined sections of open mouth posture (OMP, 30 seconds), anteriorly closed mouth condition (60 seconds), dynamics by a tongue-repositioning maneuver (TRM, 60 seconds), swallowing, and positive pressure generation (PP, 10 seconds). Interactions of malocclusion, compartment location, and posture on pressure curve characteristics were analyzed by Kruskal-Wallis and Mann-Whitney U-tests, adopting an α level of 5%.Results:Globally significant group differences were detected at the VS (plateau duration and median peak heights during TRM; area under pressure curve [AUC] during PP) and SPS (AUC during TRM and PP). Subjects with anteriorly nonopen dental configurations (groups I and II2) were able to keep negative pressure levels at the VS for longer time periods during TRM, compared to groups O and II1.Conclusions:The null hypothesis was rejected for mean VS plateau durations and peak heights and for SPS AUC. Negative pressures at the VS may stabilize outer soft tissues passively and may explain the dental arch form shaping effect by mimic muscles.     

18F]fluoro-deoxy-glucose positron emission tomography ([18F]FDG-PET) voxel intensity-based intensity-modulated radiation therapy (IMRT) for head and neck cancer.

BACKGROUND AND PURPOSE: Focused dose escalation may improve local control in head and neck cancer. Planning results of [(18)F]fluoro-deoxy-glucose positron emission tomography ([(18)F]FDG-PET) voxel intensity-based intensity-modulated radiation therapy (IMRT) were compared with those of PET contour-based IMRT. PATIENTS AND METHODS: PET contour-based IMRT aims to deliver a homogeneous boost dose to a PET-based subvolume of the planning target volume (PTV), called PTV(PET). The present PET voxel intensity-based planning study aims to prescribe the boost dose directly as a function of PET voxel intensity values, while leaving the dose distribution outside the PTV unchanged. Two escalation steps (2.5 and 3 Gy/fraction) were performed for 15 patients. RESULTS: PTV(PET) was irradiated with a homogeneous dose in the contour-based approach. In the voxel intensity-based approach, one or more sharp dose peaks were created inside the PTV, following the distribution of PET voxel intensity values. CONCLUSIONS: While PET voxel intensity-based IMRT had a large effect on the dose distribution within the PTV, only small effects were observed on the dose distribution outside this PTV and on the dose delivered to the organs at risk. Therefore both methods are alternatives for boosting subvolumes inside a selected PTV.