Audiovisual Teleconsultation For Patients With Epilepsy In Primary Care In Rural Germany: A Pilot Study On Feasibility And Acceptance

Background: In rural areas, epilepsy patients have limited access to specialised care. They usually have to put up with travel and waiting times of several hours. In addition, often the communication between general practitioners (GP) and specialized epileptologists about diagnosis and treatment is complicated by the high workload on both sides and the different prioritization of treatment goals. Therefore, the aim of this study was to investigate the feasibility of an interprofessional audio-visual patient-doctor teleconsultation and its acceptance in clinical practice in patients with epilepsy in a rural region in Germany.Method: Ten patients participated in telemedicine consultations in their GP practice. The practice was located in a sparsely populated region of Mecklenburg- Western Pomerania and equipped with technical equipment specifically procured for project-related purposes. An explorative qualitative interview was conducted with all participants. We based this paper on the consolidated criteria for reporting qualitative research (COREQ). Results: Despite initial uncertainties on the part of the patients regarding the consultation setting, all participants found the teleconsultation helpful. Some patients were initially intimidated and felt slightly overwhelmed by the attention provided and the technology used (multiple HD cameras, large high-resolution screens). However, during the consultation they felt supported by their GP and were satisfied that their needs were addressed in a satisfactory and timely manner. The hardware used was not felt to be a nuisance or to interfere with the conversation between doctor and patient. Patients also appreciated the time saved and the organisational convenience compared to a visit to a university outpatient clinic. Most consultations led to therapeutic consequences. Some patients seemed to benefit particularly, e.g. those who needed a change in their medication. Conclusion: This pilot study provides first evidence that teleconsultations between patients, specialists and GPs are possible in rural areas. Interprofessional collaboration between GPs and epileptologists can improve the care of patients with epilepsy. Further research should investigate the effectiveness and efficiency of interprofessional telemedicine consultations for epilepsy and other conditions.

Inherent P2X7 Receptors Regulate Macrophage Functions during Inflammatory Diseases

Macrophages are mononuclear phagocytes which derive either from blood-borne monocytes or reside as resident macrophages in peripheral (Kupffer cells of the liver, marginal zone macrophages of the spleen, alveolar macrophages of the lung) and central tissue (microglia). They occur as M1 (pro-inflammatory; classic) or M2 (anti-inflammatory; alternatively activated) phenotypes. Macrophages possess P2X7 receptors (Rs) which respond to high concentrations of extracellular ATP under pathological conditions by allowing the non-selective fluxes of cations (Na+, Ca2+, K+). Activation of P2X7Rs by still higher concentrations of ATP, especially after repetitive agonist application, leads to the opening of membrane pores permeable to ~900 Da molecules. For this effect an interaction of the P2X7R with a range of other membrane channels (e.g., P2X4R, transient receptor potential A1 [TRPA1], pannexin-1 hemichannel, ANO6 chloride channel) is required. Macrophage-localized P2X7Rs have to be co-activated with the lipopolysaccharide-sensitive toll-like receptor 4 (TLR4) in order to induce the formation of the inflammasome 3 (NLRP3), which then activates the pro-interleukin-1β (pro-IL-1β)-degrading caspase-1 to lead to IL-1β release. Moreover, inflammatory diseases (e.g., rheumatoid arthritis, Crohn’s disease, sepsis, etc.) are generated downstream of the P2X7R-induced upregulation of intracellular second messengers (e.g., phospholipase A2, p38 mitogen-activated kinase, and rho G proteins). In conclusion, P2X7Rs at macrophages appear to be important targets to preserve immune homeostasis with possible therapeutic consequences.

A review on medicinal plants as potential sources of natural immunomodulatory action

The concept of immunomodulation was proposed by Edward Jenner, while working on polio vaccine in 1796. A brawny, fine-functioning immune system is the keystone of excellent health. Immune replies are the consequence of an effectual interaction among innate (natural and non-specific) and acquired (adaptive and specific) components of the immune system. Inequity or failure of the immune systems is connected with a variety of chronic illness counting allergies, autoimmune diseases, cancers and furthers. Diverse innate and adaptive immune cells that are incorporated in this multifaceted networking organization may symbolize talented targets for expanding immunotherapeutics for treating specific immune illness. An assorted array of natural, synthetic, and recombinant compounds is accessible with both advantages and demerits. A range of phytochemicals have been remote, differentiated and customized for expansion and employ as avoidance or cure of human diseases, but the request of customary or novel medicinal plants for employ as immunomodulators in indulgencing immune diseases is still comparatively limited. At present, there is much-growing interest in the use of medicinal plants as modulators of the complex immune system. Numerous therapeutic consequences of plant extracts have been recommended to be because of their extensive assortment of immunomodulatory effects and persuade on the immune system of the human body. In present review paper, various medicinal plants, their resultant crude or fractionated phyto extracts and the precise phytochemicals remote from them are conversed in terms of their immunomodulatory bioactivities. We also review their possible for future expansion as immunomodulatory or inflammation-regulatory therapeutics or agents. Keywords: Immunomodulation, Immune system, Phytochemicals, Medicinal plant, Plant extracts

Endoscopic tissue sampling – Part 2: Lower gastrointestinal tract. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Recommendations 1 ESGE suggests performing segmental biopsies (at least two from each segment), which should be placed in different specimen containers (ileum, cecum, ascending, transverse, descending, and sigmoid colon, and rectum) in patients with clinical and endoscopic signs of colitis.Weak recommendation, low quality of evidence. 2 ESGE recommends taking two biopsies from the right hemicolon (ascending and transverse colon) and, in a separate container, two biopsies from the left hemicolon (descending and sigmoid colon) when microscopic colitis is suspected.Strong recommendation, low quality of evidence. 3 ESGE recommends pancolonic dye-based chromoendoscopy or virtual chromoendoscopy with targeted biopsies of any visible lesions during surveillance endoscopy in patients with inflammatory bowel disease. Strong recommendation, moderate quality of evidence. 4 ESGE suggests that, in high risk patients with a history of colonic neoplasia, tubular-appearing colon, strictures, ongoing therapy-refractory inflammation, or primary sclerosing cholangitis, chromoendoscopy with targeted biopsies can be combined with four-quadrant non-targeted biopsies every 10 cm along the colon. Weak recommendation, low quality of evidence. 5 ESGE recommends that, if pouch surveillance for dysplasia is performed, visible abnormalities should be biopsied, with at least two biopsies systematically taken from each of the afferent ileal loop, the efferent blind loop, the pouch, and the anorectal cuff.Strong recommendation, low quality of evidence. 6 ESGE recommends that, in patients with known ulcerative colitis and endoscopic signs of inflammation, at least two biopsies be obtained from the worst affected areas for the assessment of activity or the presence of cytomegalovirus; for those with no evident endoscopic signs of inflammation, advanced imaging technologies may be useful in identifying areas for targeted biopsies to assess histologic remission if this would have therapeutic consequences. Strong recommendation, low quality of evidence. 7 ESGE suggests not biopsying endoscopically visible inflammation or normal-appearing mucosa to assess disease activity in known Crohn’s disease.Weak recommendation, low quality of evidence. 8 ESGE recommends that adequately assessed colorectal polyps that are judged to be premalignant should be fully excised rather than biopsied.Strong recommendation, low quality of evidence. 9 ESGE recommends that, where endoscopically feasible, potentially malignant colorectal polyps should be excised en bloc rather than being biopsied. If the endoscopist cannot confidently perform en bloc excision at that time, careful representative images (rather than biopsies) should be taken of the potential focus of cancer, and the patient should be rescheduled or referred to an expert center.Strong recommendation, low quality of evidence. 10 ESGE recommends that, in malignant lesions not amenable to endoscopic excision owing to deep invasion, six carefully targeted biopsies should be taken from the potential focus of cancer.Strong recommendation, low quality of evidence.

Importance of Hip-Spine Syndrome in Hip Arthroplasty: Influence on the Outcome and Therapeutic Consequences

Correct interaction between the spine, pelvis, and hip is an essential condition for successful progress after total hip replacement. Spinal pathologies, such as degeneration, fractures, and spinopelvic imbalance with and without lumbar fusions, are closely associated with an increased risk of impingement or even dislocation of the prosthesis. To significantly reduce this risk, various parameters are required to quantify the risk groups. Knowledge on the presence of stiffness of the spine (change in pelvic tilt between standing and sitting at < 10°) and sagittal spinal deformity (pelvic incidence–lumbar lordosis mismatch > 10° or 20°) is essential in identifying patients with corresponding risk. The individual risk profile can be assessed through a specific history and examination. Before total hip arthroplasty, a routine preoperative workup is recommended for high-risk patients: using information from standardised preoperative radiographs while sitting and standing (pelvis, anteroposterior view, lying and standing; spine and pelvis, lateral view, standing and sitting). Important changes can be made during the surgery. If the spine is stiff, attention should be paid to the position of the cup, with increased anteversion, sufficient offset, and larger head that is secure to dislocation – to reduce the risk of dislocation. In the case of a sagittal spinal deformity, the functional coronary pelvic level must be carefully controlled so that it is better to use double mobility cups. Digital systems, such as navigation and robotics, can optimise component positioning although, so far, there is little evidence that the complication rate decreased. Therefore, further studies are warranted.

Therapeutic Assessment as an Interventional Model of Psychological Evaluation: Case Study

Therapeutic Assessment is a model of psychological evaluation that adopts a collaborative approach and a semi-structured systematization to the extent that it has well-defined steps. Considering its intervention nature, Therapeutic Assessment seeks to bring about positive changes in the lives of clients and/or people close to them. The present study aimed to evaluate how the Therapeutic Assessment process presented therapeutic consequences, using the case study as a research method. The description of the results was based on the assistance of a client using the Therapeutic Assessment model. The findings corroborate the hypotheses related to the therapeutic benefits of the Therapeutic Assessment, providing the clients with increased self-knowledge and self-reflection and changes in the way they deal with difficult situations. We conclude that more research on Therapeutic Assessment should be developed to verify other possible benefits of the model.

Severity, timeline, and management of complications after stereotactic brain biopsy

OBJECTIVE The literature shows discrepancies in stereotactic brain biopsy complication rates, severities, and outcomes. Little is known about the timeline of postbiopsy complications. This study aimed to analyze 1) complications following brain biopsies, using a graded severity scale, and 2) a timeline of complication occurrence. The secondary objectives were to determine factors associated with an increased risk of complications and to assess complication-related management and extra costs. METHODS The authors retrospectively examined 1500 consecutive stereotactic brain biopsies performed in adult patients at their tertiary medical center between April 2009 and April 2019. RESULTS Three hundred eighty-one biopsies (25.4%) were followed by a complication, including 88.2% of asymptomatic hemorrhages. Symptomatic complications involved 3.0% of the biopsies, and 0.8% of the biopsies were fatal. The severity grading scale had a 97.6% interobserver reproducibility. Twenty-three (51.1%) of the 45 symptomatic complications occurred within the 1st hour following the biopsy, while 75.6% occurred within the first 6 hours. Age ≥ 65 years, second biopsy procedures, gadolinium-enhanced lesions, glioblastomas, and lymphomas were predictors of biopsy-related complications. Brainstem biopsy-targeted lesions and cerebral toxoplasmosis were predictive of mortality. Asymptomatic hemorrhage was associated with delayed (> 6 hours) symptomatic complications. Symptomatic complications led to extended hospitalization in 86.7% of patients. The average extra cost for management of a patient with postbiopsy symptomatic complication was $35,702. CONCLUSIONS Symptomatic complications from brain biopsies are infrequent but associated with substantial adverse effects and cost implications for the healthcare system. The use of a severity grading scale, as the authors propose in this article, helps to classify complications according to the therapeutic consequences and the patient’s outcome. Because this study indicates that most complications occur within the first few hours following the biopsy, postbiopsy monitoring can be tailored accordingly. The authors therefore recommend systematic monitoring for 2 hours in the recovery unit and a CT scan 2 hours after the end of the biopsy procedure. In addition, they propose a modern algorithm for optimal postoperative management of patients undergoing stereotactic biopsy.