Acute hemorrhagic edema of young children: a concise narrative review

Acute hemorrhagic edema of young children is an uncommon but likely underestimated cutaneous leukocytoclastic vasculitis. The condition typically affects infants 6-24 months of age with a history of recent respiratory illness with or without course of antibiotics. The diagnosis is made in children, mostly nontoxic in appearance, presenting with nonpruritic, large, round, red to purpuric plaques predominantly over the cheeks, ears, and extremities, with relative sparing of the trunk, often with a target-like appearance, and edema of the distal extremities, ears, and face that is mostly non-pitting, indurative, and tender. In boys, the lesions sometimes involve the scrotum and, more rarely, the penis. Fever, typically of low grade, is often present. Involvement of body systems other than skin is uncommon, and spontaneous recovery usually occurs within 6-21 days without sequelae. In this condition, laboratory tests are non-contributory: total blood cell count is often normal, although leukocytosis and thrombocytosis are sometimes found, clotting studies are normal, erythrocyte sedimentation rate and C-reactive protein test are normal or slightly elevated, complement level is normal, autoantibodies are absent, and urinalysis is usually normal. Experienced physicians rapidly consider the possible diagnosis of acute hemorrhagic edema when presented with a nontoxic young child having large targetoid purpuric lesions and indurative swelling, which is non-pitting in character, and make the diagnosis either on the basis of clinical findings alone or supported by a skin biopsy study.

Combination of Psychological Intervention and Phosphodiesterase-5 Inhibitors for Erectile Dysfunction: A Narrative Review and Meta-Analysis

INTRODUCTION Erectile dysfunction (ED) is an increasing health problem that demands effective treatment. There is evidence that phosphodiesterase-5 inhibitors (PDE5-Is) and psychological intervention (PI) are effective treatment options; however, little is known about their comparative efficacy and the efficacy of combined treatments. AIM The aim of this systematic review and meta-analysis is to evaluate the comparative efficacy of PI, PDE5-Is, and their combination in the treatment of ED. MAIN OUTCOME MEASURES Primary outcome was ED symptoms, and secondary outcome was sexual satisfaction of the patient. METHODS A systematic literature search was conducted in order to identify relevant articles published between 1998 and 2012. We included randomized controlled trials and controlled trials comparing PI with PDE5-I treatment or one of them against a combination of both. RESULTS Eight studies with a total number of 562 patients were included in the meta-analysis. The results of the included studies are inconclusive, though they show a trend towards a larger effect of combined treatment compared with PI or PDE5-I treatment alone. The meta-analysis found that, overall, combined treatment was more efficacious for ED symptoms than PDE5-I treatment or PI alone. Combined treatment was more efficacious than PDE5-I use alone on sexual satisfaction. No differences were found between PDE5-Is and PI as stand-alone treatments. None of the moderators (treatment duration, methodological quality, or researcher allegiance) altered the effects. CONCLUSIONS The combination of PI and PDE5-Is is a promising strategy for a favorable outcome in ED and can be considered as a first-choice option for ED patients. Stronger RCTs are required to confirm this initial finding. Schmidt HM, Munder T, Gerger H, Frühauf S, and Barth J. Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: A narrative review and meta-analysis. J Sex Med **;**:**-**.

Na(+), K(+), Cl(-), acid-base or H2O homeostasis in children with urinary tract infections: a narrative review.

Guidelines on the diagnosis and management of urinary tract infections in childhood do not address the issue of abnormalities in Na(+), K(+), Cl(-) and acid-base balance. We have conducted a narrative review of the literature with the aim to describe the underlying mechanisms of these abnormalities and to suggest therapeutic maneuvers. Abnormalities in Na(+), K(+), Cl(-) and acid-base balance are common in newborns and infants and uncommon in children of more than 3 years of age. Such abnormalities may result from factitious laboratory results, from signs and symptoms (such as excessive sweating, poor fluid intake, vomiting and passage of loose stools) of the infection itself, from a renal dysfunction, from improper parenteral fluid management or from the prescribed antimicrobials. In addition, two transient renal tubular dysfunctions may occur in infants with infectious renal parenchymal involvement: a reduced capacity to concentrate urine and pseudohypoaldosteronism secondary to renal tubular unresponsiveness to aldosterone that presents with hyponatremia, hyperkalemia and acidosis. In addition to antimicrobials, volume resuscitation with an isotonic solution is required in these children. In secondary pseudohypoaldosteronism, isotonic solutions (such as 0.9 % saline or lactated Ringer) correct not only the volume depletion but also the hyperkalemia and acidosis. In conclusion, our review suggests that in infants with infectious renal parenchymal involvement, non-renal and renal causes concur to cause fluid volume depletion and abnormalities in electrolyte and acid-base balance, most frequently hyponatremia.

Computer-based summative assessment of clinical reasoning in clerkships: A mixed-method comparison of key feature problems with case-based multiple choice questions

Background: It is yet unclear if there are differences between using electronic key feature problems (KFPs) or electronic case-based multiple choice questions (cbMCQ) for the assessment of clinical decision making. Summary of Work: Fifth year medical students were exposed to clerkships which ended with a summative exam. Assessment of knowledge per exam was done by 6-9 KFPs, 9-20 cbMCQ and 9-28 MC questions. Each KFP consisted of a case vignette and three key features (KF) using “long menu” as question format. We sought students’ perceptions of the KFPs and cbMCQs in focus groups (n of students=39). Furthermore statistical data of 11 exams (n of students=377) concerning the KFPs and (cb)MCQs were compared. Summary of Results: The analysis of the focus groups resulted in four themes reflecting students’ perceptions of KFPs and their comparison with (cb)MCQ: KFPs were perceived as (i) more realistic, (ii) more difficult, (iii) more motivating for the intense study of clinical reasoning than (cb)MCQ and (iv) showed an overall good acceptance when some preconditions are taken into account. The statistical analysis revealed that there was no difference in difficulty; however KFP showed a higher discrimination and reliability (G-coefficient) even when corrected for testing times. Correlation of the different exam parts was intermediate. Conclusions: Students perceived the KFPs as more motivating for the study of clinical reasoning. Statistically KFPs showed a higher discrimination and higher reliability than cbMCQs. Take-home messages: Including KFPs with long menu questions into summative clerkship exams seems to offer positive educational effects.

Computerbasierte Prüfung von klinischem Denken in der klinischen Ausbildung: Ein Mixed-Method Vergleich von Key Feature Problemen mit fallbasierten Multiple Choice Typ A Fragen

Fragestellung/Einleitung: Es ist unklar inwiefern Unterschiede bestehen im Einsatz von Key Feature Problemen (KFP) mit Long Menu Fragen und fallbasierten Typ A Fragen (FTA) für die Überprüfung des klinischen Denkens (Clinical Reasoning) in der klinischen Ausbildung von Medizinstudierenden. Methoden: Medizinstudierende des fünften Studienjahres nahmen an ihrer klinischen Pädiatrie-Rotation teil, die mit einer summativen Prüfung endete. Die Überprüfung des Wissen wurde pro Prüfung elektronisch mit 6-9 KFP [1], [3], 9-20 FTA und 9-28 nichtfallbasierten Multiple Choice Fragen (NFTA) durchgeführt. Jedes KFP bestand aus einer Fallvignette und drei Key Features und nutzen ein sog. Long Menu [4] als Antwortformat. Wir untersuchten die Perzeption der KFP und FTA in Focus Gruppen [2] (n of students=39). Weiterhin wurden die statistischen Kennwerte der KFP und FTA von 11 Prüfungen (n of students=377) verglichen. Ergebnisse: Die Analyse der Fokusgruppen resultierte in vier Themen, die die Perzeption der KFP und deren Vergleich mit FTA darstellten: KFP wurden als 1. realistischer, 2. schwerer, und 3. motivierender für das intensive Selbststudium des klinischen Denkens als FTA aufgenommen und zeigten 4. insgesamt eine gute Akzeptanz sofern gewisse Voraussetzungen berücksichtigt werden. Die statistische Auswertung zeigte keinen Unterschied im Schwierigkeitsgrad; jedoch zeigten die KFP eine höhere Diskrimination und Reliabilität (G-coefficient) selbst wenn für die Prüfungszeit korrigiert wurde. Die Korrelation der verschiedenen Prüfungsteile war mittel. Diskussion/Schlussfolgerung: Die Studierenden erfuhren die KFP als motivierenden für das Selbststudium des klinischen Denkens. Statistisch zeigten die KFP eine grössere Diskrimination und höhere Relibilität als die FTA. Der Einbezug von KFP mit Long Menu in Prüfungen des klinischen Studienabschnitts erscheint vielversprechend und einen „educational effect“ zu haben.

Causes, forms and consequences of the professionalization of international sport federa-tions in Switzerland: Conceptual framework and first results

Synopsis: Sport organisations are facing multiple challenges originating from an increasingly complex and dynamic environment in general, and from internal changes in particular. Our study seeks to reveal and analyse the causes for professionalization processes in international sport federations, the forms resulting from it, as well as related consequences. Abstract: AIM OF ABSTRACT/PAPER - RESEARCH QUESTION Sport organisations are facing multiple challenges originating from an increasingly complex and dynamic environment in general, and from internal changes in particular. In this context, professionalization seems to have been adopted by sport organisations as an appropriate strategy to respond to pressures such as becoming more “business-like”. The ongoing study seeks to reveal and analyse the internal and external causes for professionalization processes in international sport federations, the forms resulting from it (e.g. organisational, managerial, economic) as well as related consequences on objectives, values, governance methods, performance management or again rationalisation. THEORETICAL BACKGROUND/LITERATURE REVIEW Studies on sport as specific non-profit sector mainly focus on the prospect of the “professionalization of individuals” (Thibault, Slack & Hinings, 1991), often within sport clubs (Thiel, Meier & Cachay, 2006) and national sport federations (Seippel, 2002) or on organisational change (Griginov & Sandanski, 2008; Slack & Hinings, 1987, 1992; Slack, 1985, 2001), thus leaving broader analysis on governance, management and professionalization in sport organisations an unaccomplished task. In order to further current research on above-mentioned topics, our intention is to analyse causes, forms and consequences of professionalisation processes in international sport federations. The social theory of action (Coleman, 1986; Esser, 1993) has been defined as appropriate theoretical framework, deriving in the following a multi-level framework for the analysis of sport organisations (Nagel, 2007). In light of the multi-level framework, sport federations are conceptualised as corporative actors whose objectives are defined and implemented with regard to the interests of member organisations (Heinemann, 2004) and/or other pressure groups. In order to understand social acting and social structures (Giddens 1984) of sport federations, two levels are in the focus of our analysis: the macro level examining the environment at large (political, social, economic systems etc.) and the meso level (Esser, 1999) examining organisational structures, actions and decisions of the federation’s headquarter as well as member organisations. METHODOLOGY, RESEARCH DESIGN AND DATA ANALYSIS The multi-level framework mentioned seeks to gather and analyse information on causes, forms and consequences of professionalization processes in sport federations. It is applied in a twofold approach: first an exploratory study based on nine semi-structured interviews with experts from umbrella sport organisations (IOC, WADA, ASOIF, AIOWF, etc.) as well as the analysis of related documents, relevant reports (IOC report 2000 on governance reform, Agenda 2020, etc.) and important moments of change in the Olympic Movement (Olympic revenue share, IOC evaluation criteria, etc.); and secondly several case studies. Whereas the exploratory study seeks more the causes for professionalization on an external, internal and headquarter level as depicted in the literature, the case studies rather focus on forms and consequences. Applying our conceptual framework, the analysis of forms is built around three dimensions: 1) Individuals (persons and positions), 2) Processes, structures (formalisation, specialisation), 3) Activities (strategic planning). With regard to consequences, we centre our attention on expectations of and relationships with stakeholders (e.g. cooperation with business partners), structure, culture and processes (e.g. governance models, performance), and expectations of and relationships with member organisations (e.g. centralisation vs. regionalisation). For the case studies, a mixed-method approach is applied to collect relevant data: questionnaires for rather quantitative data, interviews for rather qualitative data, as well as document and observatory analysis. RESULTS, DISCUSSION AND IMPLICATIONS/CONCLUSIONS With regard to causes of professionalization processes, we analyse the content of three different levels: 1. the external level, where the main pressure derives from financial resources (stakeholders, benefactors) and important turning points (scandals, media pressure, IOC requirements for Olympic sports); 2. the internal level, where pressure from member organisations turned out to be less decisive than assumed (little involvement of member organisations in decision-making); 3. the headquarter level, where specific economic models (World Cups, other international circuits, World Championships), and organisational structures (decision-making procedures, values, leadership) trigger or hinder a federation’s professionalization process. Based on our first analysis, an outline for an economic model is suggested, distinguishing four categories of IFs: “money-generating IFs” being rather based on commercialisation and strategic alliances; “classical Olympic IFs” being rather reactive and dependent on Olympic revenue; “classical non-Olympic IFs” being rather independent of the Olympic Movement; and “money-receiving IFs” being dependent on benefactors and having strong traditions and values. The results regarding forms and consequences will be outlined in the presentation. The first results from the two pilot studies will allow us to refine our conceptual framework for subsequent case studies, thus extending our data collection and developing fundamental conclusions. References: Bayle, E., & Robinson, L. (2007). A framework for understanding the performance of national governing bodies of sport. European Sport Management Quarterly, 7, 249–268 Chantelat, P. (2001). La professionnalisation des organisations sportives: Nouveaux débats, nouveaux enjeux [Professionalisation of sport organisations]. Paris: L’Harmattan. Dowling, M., Edwards, J., & Washington, M. (2014). Understanding the concept of professionalization in sport management research. Sport Management Review. Advance online publication. doi: 10.1016/j.smr.2014.02.003 Ferkins, L. & Shilbury, D. (2012). Good Boards Are Strategic: What Does That Mean for Sport Governance? Journal of Sport Management, 26, 67-80. Thibault, L., Slack, T., & Hinings, B. (1991). Professionalism, structures and systems: The impact of professional staff on voluntary sport organizations. International Review for the Sociology of Sport, 26, 83–97.

[Psychosomatic medicine and arterial hypertension - love it or leave it?]

Over the last two decades modern psychosomatic research has found multiple evidence for an impact of psychosocial factors on the control of arterial blood pressure as well as the development of arterial hypertension. This narrative review focuses first on the current stress concept and factors that influence the degree of blood pressure change following a psychosocial stressor. Second, relevant psychosocial factors associated with blood pressure are presented such as marital status, social support, socioeconomic status and work conditions. In addition, the influence of personality and cognition on blood pressure will be discussed. The second part focuses on the outcome of cognitive-behavioral therapies and relaxation techniques as a means to effectively control blood pressure. In conclusion, there is now good evidence showing that psychosocial factors and stressors may increase blood pressure. The working environment, the socioeconomic status as well as aspects of personality and cognitive factors like rumination may also impact blood pressure with to an extent that is clinically relevant. With respect to therapeutic options, cognitive-behavioral interventions, combined with relaxation techniques all fitting the needs of the individual patient best can offer a clinically meaningful contribution of an effective blood pressure control.

Validity and clinical significance of biomechanical testing of implant/bone interface

Purpose: The aim of this paper was to review the clinical literature on the Resonance frequency analysis (RFA) and Periotest techniques in order to assess the validity and prognostic value of each technique to detect implants at risk for failure. Material and methods: A search was made using the PubMed database to find clinical studies using the RFA and/or Periotest techniques. Results: A limited number of clinical reports were found. No randomized-controlled clinical trials or prospective cohort studies could be found for validity testing of the techniques. Consequently, only a narrative review was prepared to cover general aspects of the techniques, factors influencing measurements and the clinical relevance of the techniques. Conclusions: Factors such as bone density, upper or lower jaw, abutment length and supracrestal implant length seem to influence both RFA and Periotest measurements. Data suggest that high RFA and low Periotest values indicate successfully integrated implants and that low/decreasing RFA and high/increasing Periotest values may be signs of ongoing disintegration and/or marginal bone loss. However, single readings using any of the techniques are of limited clinical value. The prognostic value of the RFA and Periotest techniques in predicting loss of implant stability has yet to be established in prospective clinical studies. To cite this article: Aparicio C, Lang N P, Rangert B. Validity and clinical significance of biomechanical testing of implant/bone interface. Clin. Oral Imp. Res., 17 (Suppl. 2), 2006; 2-7.

Ecosystem service trade-offs and stakeholder claims - a meso-scale study from a Madagascar biodiversity hotspot

The north-eastern escarpment of Madagascar has been labelled a global biodiversity hotspot due to its extremely high rates of endemic species which are heavily threatened by accelerated deforestation rates and landscape change. The traditional practice of shifting cultivation or "tavy" used by the majority of land users in this area to produce subsistence rice is commonly blamed for these threats. A wide range of stakeholders ranging from conservation to development agencies, and from the private to the public sector has therefore been involved in trying to find solutions to protect the remaining forest fragments and to increase agricultural production. Consequently, provisioning, regulating and socio-cultural services of this forest-mosaic landscape are fundamentally altered leading to trade-offs between them and consequently new winners and losers amongst the stakeholders at different scales. However, despite a growing amount of evidence from case studies analysing local changes, the regional dynamics of the landscape and their contribution to such trade-offs remain poorely understood. This study therefore aims at using generalised landscape units as a base for the assessment of multi-level stakeholder claims on ecosystem services to inform negotiation, planning and decision making at a meso-scale. The presented study applies a mixed-method approach combining remote sensing, GIS and socio-economic methods to reveal current landscape dynamics, their change over time and the corresponding ecosystem service trade-offs induced by diverse stakeholder claims on the regional level. In a first step a new regional land cover classification for three points in time (1995, 2005 and 2011) was conducted including agricultural classes characteristic for shifting cultivation systems. Secondly, a novel GIS approach, termed “landscape mosaics approach” originally developed to assess dynamics of shifting cultivation landscapes in Laos was applied. Through this approach generalised landscape mosaics were generated allowing for a better understanding of changes in land use intensities instead of land cover. As a next step we will try to use these landscape units as proxies to map provisioning and regulating ecosystem services throughout the region. Through the overlay with other regional background data such as accessibility and population density and information from a region-wide stakeholder analysis, multiscale trade-offs between different services will be highlighted. The trade-offs observed on the regional scale will then be validated through a socio-economic ground-truthing within selected sites at the local scale. We propose that such meso-scale knowledge is required by all stakeholders involved in decision making towards sustainable development of north-eastern Madagascar.

Effect of comprehensive cardiac rehabilitation after heart valve surgery (CopenHeartVR): study protocol for a randomised clinical trial

Background Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising due to an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesise that a comprehensive cardiac rehabilitation programme can improve physical capacity and self-assessed mental health and reduce hospitalisation and healthcare costs after heart valve surgery. Methods A randomised clinical trial, CopenHeartVR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients, 1:1 intervention to control group, using central randomisation, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise, and a psycho-educational intervention comprising five consultations. Primary outcome is peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. Secondary outcome is self-assessed mental health measured by the standardised questionnaire Short Form 36. Also, long-term healthcare utilisation and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design is used to evaluate qualitative and quantitative findings encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study. Discussion The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015).

Intermediate hepatocellular carcinoma: current treatments and future perspectives

Current guidelines recommend transarterial chemoembolization (TACE) as the standard treatment of Barcelona-Clinic Liver Cancer (BCLC)-B patients. However, the long-term survival outcomes of patients managed with this technique do not appear fully satisfactory; in addition, intermediate-stage hepatocellular carcinoma (HCC) includes a heterogeneous population of patients with varying tumour burdens, liver function and disease aetiology. Therefore, not all patients with intermediate-stage HCC may derive similar benefit from TACE, and some patients may benefit from other treatment options, which are currently approved or being explored. These include different TACE modalities, such as selective TACE or drug-eluting beads TACE and radioembolization. The introduction of sorafenib in the therapeutic armamentarium for HCC has provided a new therapeutic option for the treatment of BCLC-B patients who are unsuitable to TACE or in whom TACE resulted in unacceptable toxicity. In addition, clinical trials aimed at investigating the potential role of this molecule in the treatment of patients with intermediate-stage HCC within combination therapeutic regimens are ongoing. This narrative review will present and discuss the most recent evidence on the locoregional or medical treatment with sorafenib in patients with intermediate-stage HCC.

Soft tissue wound healing around teeth and dental implants.

AIM To provide an overview on the biology and soft tissue wound healing around teeth and dental implants. MATERIAL AND METHODS This narrative review focuses on cell biology and histology of soft tissue wounds around natural teeth and dental implants. RESULTS AND CONCLUSIONS The available data indicate that: (a) Oral wounds follow a similar pattern. (b) The tissue specificities of the gingival, alveolar and palatal mucosa appear to be innately and not necessarily functionally determined. (c) The granulation tissue originating from the periodontal ligament or from connective tissue originally covered by keratinized epithelium has the potential to induce keratinization. However, it also appears that deep palatal connective tissue may not have the same potential to induce keratinization as the palatal connective tissue originating from an immediately subepithelial area. (d) Epithelial healing following non-surgical and surgical periodontal therapy appears to be completed after a period of 7–14 days. Structural integrity of a maturing wound between a denuded root surface and a soft tissue flap is achieved at approximately 14-days post-surgery. (e) The formation of the biological width and maturation of the barrier function around transmucosal implants requires 6–8 weeks of healing. (f) The established peri-implant soft connective tissue resembles a scar tissue in composition, fibre orientation, and vasculature. (g) The peri-implant junctional epithelium may reach a greater final length under certain conditions such as implants placed into fresh extraction sockets versus conventional implant procedures in healed sites.