Publications by authors named "Christian Lottspeich"

32 Publications

Salivary profiles of 11-oxygenated androgens follow a diurnal rhythm in patients with congenital adrenal hyperplasia.

J Clin Endocrinol Metab 2021 Jun 24. Epub 2021 Jun 24.

Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany.

Context: Several studies have highlighted the importance of the 11oxygenated 19carbon (11oxC19) adrenalderived steroids as potential biomarkers for monitoring patients with 21hydroxylase deficiency (21OHD).

Objective: To analyze circadian rhythmicity of 11oxC19 steroids in saliva profiles and evaluate their relevance as potential monitoring parameters in 21OHD.

Design, Setting, And Participants: Cross-sectional single center study including 59 patients with classic 21OHD (men=30; women=29) and 49 BMI- and agematched controls (men=19; women=30).

Outcome Measures: Salivary concentrations of the following steroids were analyzed by LCMS/MS: 17hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11βhydroxyandrostenedione (11OHA4) and 11ketotestosterone (11KT).

Results: Similar to the previously described rhythmicity of 17OHP, 11OHA4 and 11KT concentrations followed a distinct diurnal rhythm in both patients and controls with highest concentrations in the early morning and declining throughout the day (11-OHA4: mean reduction of hormone concentrations between timepoint one and five (Δmean) in male patients = 66 %; male controls Δmean = 83 %; female patients Δmean = 47 %; female controls Δmean = 86 %; 11KT: male patients Δmean = 57 %; male controls Δmean = 63 %; female patients Δmean = 50 %; female controls Δmean = 76 %). Significant correlations between the area under the curve (AUC) for 17OHP and 11KT (r pmale = 0.773 <0.0001; r pfemale = 0.737 <0.0001), and 11OHA4 (r pmale = 0.633 0.0002; r pfemale = 0.564 0.0014) were observed in patients but not present or reduced in controls.

Conclusions: Adrenal 11oxC19 androgens are secreted following a diurnal pattern. This should be considered when evaluating their utility for monitoring treatment control.
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http://dx.doi.org/10.1210/clinem/dgab446DOI Listing
June 2021

11-oxygenated androgens and their relation to hypothalamus-pituitary-gonadal-axis disturbances in adults with congenital adrenal hyperplasia.

J Steroid Biochem Mol Biol 2021 May 28;212:105921. Epub 2021 May 28.

Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany. Electronic address:

Context: Hypothalamus-pituitary-gonadal (HPG)-axis disturbances are a common phenomenon in patients with classic congenital adrenal hyperplasia (CAH). 11-oxygenated androgens have been suggested to play a role in this context.

Design: Cross-sectional single center study including 89 patients (N = 42 men, N = 55 women) with classic CAH.

Main Outcome Measures: Differences in steroid markers in men with hypogonadism and women with secondary amenorrhea with a special focus on 11-ketotestosterone (11KT) and 11β-hydroxyandrostenedione (11OHA4).

Results: Hypogonadotropic hypogonadism was present in 23 % of men and 61 % of those women currently not on contraceptives suffered from irregular menstrual cycles or amenorrhea. Testicular adrenal rest tumor (TART) was documented in 28 % of men. 11KT (3.5x) and 11OHA4 (5.7x) among other adrenal steroids were significantly elevated in men with hypogonadism and in women with amenorrhea in comparison to those with a regular cycle (11KT: 5.2x; 11OHA4: 3.7x). 11-oxygenated androgens were not higher in men with TART than in those without. There was a negative association of 11KT and 11OHA4 with FSH but not with LH in men. As expected, all steroids were strongly correlated with each other and cases of disproportionally elevated 11-oxygenated androgens that could explain for HPG-disturbances or TART in otherwise controlled patients were rare and also found in eugonadal individuals.

Conclusions: In CAH, 11-oxygenated androgens are elevated in women with menstrual disturbances and in men with hypogonadotropic hypogonadism. Due to the close correlation of 11-oxygenated androgens with other adrenal steroids it remains to be shown if their measurement is superior to conventional markers of androgen control.
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http://dx.doi.org/10.1016/j.jsbmb.2021.105921DOI Listing
May 2021

Simulated ward round training in the medical curriculum Munich.

GMS J Med Educ 2021 15;38(4):Doc75. Epub 2021 Apr 15.

Ludwig-Maximilians-Universität München, LMU Klinikum, Medizinische Klinik und Poliklinik IV, Munich, Germany.

Conducting a ward round in a structured and goal-oriented manner is one of the central competencies of a physician's work. Despite its relevance, ward round competence was only addressed in an unstructured way in the Medical Curriculum Munich (MeCuM) prior to 2011. Therefore, the project's aim was to implement an evidence-based course on medical ward round competence. This project report provides a guideline for developing such a training course. Project planning and development was guided by the steps of the "Kern cycle", beginning with needs assessment, learning objectives definition, and selection of appropriate teaching methods, and ending with implementation and evaluation.
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http://dx.doi.org/10.3205/zma001471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136345PMC
April 2021

A Diagnostic Algorithm Based on a Simple Clinical Prediction Rule for the Diagnosis of Cranial Giant Cell Arteritis.

J Clin Med 2021 Mar 10;10(6). Epub 2021 Mar 10.

Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, 80336 Munich, Germany.

Background: Risk stratification based on pre-test probability may improve the diagnostic accuracy of temporal artery high-resolution compression sonography (hrTCS) in the diagnostic workup of cranial giant cell arteritis (cGCA).

Methods: A logistic regression model with candidate items was derived from a cohort of patients with suspected cGCA ( = 87). The diagnostic accuracy of the model was tested in the derivation cohort and in an independent validation cohort ( = 114) by receiver operator characteristics (ROC) analysis. The clinical items were composed of a clinical prediction rule, integrated into a stepwise diagnostic algorithm together with C-reactive protein (CRP) values and hrTCS values.

Results: The model consisted of four clinical variables (age > 70, headache, jaw claudication, and anterior ischemic optic neuropathy). The diagnostic accuracy of the model for discrimination of patients with and without a final clinical diagnosis of cGCA was excellent in both cohorts (area under the curve (AUC) 0.96 and AUC 0.92, respectively). The diagnostic algorithm improved the positive predictive value of hrCTS substantially. Within the algorithm, 32.8% of patients (derivation cohort) and 49.1% (validation cohort) would not have been tested by hrTCS. None of these patients had a final diagnosis of cGCA.

Conclusion: A diagnostic algorithm based on a clinical prediction rule improves the diagnostic accuracy of hrTCS.
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http://dx.doi.org/10.3390/jcm10061163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001831PMC
March 2021

Implementation of self-directed learning within clinical clerkships.

GMS J Med Educ 2021 15;38(2):Doc43. Epub 2021 Feb 15.

Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany.

The main aim of medical curricula is to prepare students for the first day at the work place. While teaching clinical competence is pivotal, clinical clerkships are often the last chance to close knowledge gaps with the help of clinical teachers. Self-directed learning is a dynamic field for research within medical education, though its curricular implementation is rare. This study focuses on the needs assessment of clinical clerkships using the concept of self-directed learning. The study comprised an educational experience at the Ludwig-Maximilians Universität (LMU) Munich. Medical students (n=1446, 59% female) in their second clinical year were instructed to specify learning objectives (LOs) by Doran`s SMART criteria and to gauge the probability of their fulfilment prior to the mandatory clerkship. In a second questionnaire one week later, the students rated the actual subjective fulfilment of the LOs. Data was coded with regards to the German National Catalogue of Competence-Based Learning Objectives for Undergraduate Medical Education (NKLM) and investigated qualitatively. Factors that determine goal achievement were collected and coded binary (barrier vs. enabler). Univariate analysis was used when appropriate. The acquisition of "clinically practical abilities" (29%), "diagnostic methods" (21%) and "professional communication" (13%) were the LOs mentioned most. Throughout the week, subjective fulfilment diminished. Rich (vs. poor) availability to "practical exercise" (31%), "engagement of the physicians and other medical staff" (27%) and "personal initiative" (23%) resulted in higher subjective fulfilment. The self-chosen LOs reflect the needs of students for which the clinical teacher should be prepared. Considering these findings, it seems possible to close practical training gaps. We support the consideration of establishing curricular anchored self-directed learning in clinical clerkships. Further empirical studies would be beneficial in revealing its positive effects on the learning progress.
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http://dx.doi.org/10.3205/zma001439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958912PMC
February 2021

Transocular sonography in acute arterial occlusions of the eye in elderly patients: Diagnostic value of the spot sign.

PLoS One 2021 12;16(2):e0247072. Epub 2021 Feb 12.

Department of Ophthalmology, Klinikum der Universität München, LMU München, Munich, Germany.

Purpose: To characterize the diagnostic yield of the spot sign in the diagnostic workup of acute arterial occlusions of the eye in elderly patients.

Methods: Clinical characteristics of consecutive patients aged ≥ 50 years with acute central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or anterior ischemic optic neuropathy (AION) were recorded. Videos of transocular sonography were assessed for the presence of the spot sign by two blinded readers. Group comparisons were made between CRAO-patients with and without the spot sign. Two experienced cardiovascular physicians allocated CRAO-cases to a presumed aetiology, without and with knowledge on the presence/absence of the spot sign.

Results: One-hundred-twenty-three patients were included, 46 of whom suffered from CRAO. A spot sign was seen in 32 of 46 of patients with CRAO and in 7 of 23 patients with BRAO. Interobserver agreement was excellent (Cohen`s kappa 0.98). CRAO-patients with the spot sign significantly more frequently had a medical history of cardiovascular disease (62.8 vs. 21.4%, p = 0.03) and left heart valve pathologies (51.9 vs. 10%, p = 0.03). The spot sign was not found in any of the three patients with CRAO secondary to cranial giant cell arteritis. The assumed CRAO aetiology differed in 37% of cases between two cardiovascular physicians, regardless whether transocular sonography findings were known or not.

Conclusion: The spot sign is a simple sonographic finding with excellent interobserver agreement, which proofs the embolic nature of CRAO, but does not allow exact attribution of the underlying aetiology.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247072PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880485PMC
February 2021

Atherosclerotic Burden and Arterial Stiffness are Not Increased in Patients with Milder Forms of Primary Aldosteronism Compared to Patients with Essential Hypertension.

Horm Metab Res 2021 Mar 13;53(3):178-184. Epub 2021 Jan 13.

Medizinische Klinik und Poliklinik IV, LMU München, Munich, Germany.

Patients with primary aldosteronism (PA) are at increased cardiovascular risk, compared to patients with essential hypertension (EH). Cardiovascular damage could depend on PA phenotype, potentially being lower in milder forms of PA. Our aim was to assess atherosclerotic burden and arterial stiffness in 88 prospectively recruited patients, including 44 patients with mild PA and EH respectively. All patients underwent a structured study program, including measurements of ankle-brachial index, oscillometric measurement of central pulse wave velocity (cPWV) and vascular ultrasound examination of the supraaortic arteries, the abdominal aorta, and the femoropopliteal arteries. A plaque score was calculated to estimate atherosclerotic burden for each patient. This is a prospective case-control study set at a tertiary care hospital. Patients with PA and EH matched well for age, gender, blood pressure, BMI, and cardiovascular risk factors such as diabetes mellitus and smoking status. Common carotid intima-media thickness (0.77 vs. 0.75 mm; p=0.997) and cPWV (7.2 vs. 7.1 m/s; p=0.372) were comparable between patients with PA and EH. The atherosclerotic burden, as expressed by the plaque score, did not differ between the two groups (p=0.159). However, after initiation of treatment cPWV was significantly decreased in patients with PA (p=0.017). This study shows that subclinical atherosclerotic burden and arterial stiffness in patients with milder forms of PA is comparable to patients with EH. Nevertheless, specific treatment for PA significantly improved cPWV, which argues for a more liberal use of mineralocorticoid receptor antagonists in patients with arterial hypertension.
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http://dx.doi.org/10.1055/a-1326-2164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924991PMC
March 2021

Temporal artery compression sonography for the diagnosis of giant cell arteritis in elderly patients with acute ocular arterial occlusions.

Rheumatology (Oxford) 2021 05;60(5):2190-2196

Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV.

Objectives: To validate cut-off values of quantitative high-resolution temporal artery compression sonography (TCS) for the diagnosis of cranial GCA (cGCA) in patients with acute arterial ocular occlusions and in an independent control group.

Methods: Consecutive patients who underwent TCS as part of the diagnostic workup of acute arterial ocular occlusions and controls not suffering from ocular ischaemia/systemic vasculitis were included. The diagnostic accuracy of the established TCS cut-off value of maximum temporal artery wall thickness (≥0.7 mm) and a novel numeric TCS score incorporating the degree of wall thickening in the four temporal artery segments assessed (0-3 points per segment) was tested by receiver operating characteristics analysis. Subgroup analyses were performed for female and male patients and patients older and younger than age of 70 years.

Results: Of 114 patients with acute ocular arterial occlusions, 30 patients received a final clinical diagnosis of cGCA. The sensitivity and specificity of the ≥0.7 mm TCS cut-off for the diagnosis of cGCA were 100 and 84.5% in the overall cohort. The TCS score did not improve the diagnostic yield (cut-off ≥5; sensitivity 100%, specificity 85.7%). In male patients >70 years of age, the specificity of TCS was limited, secondary to age- and sex-related differences in temporal artery wall thickness, which we confirmed in the independent control group.

Conclusion: TCS yields high diagnostic accuracy in the diagnosis of cGCA in patients with acute ocular arterial occlusions. Age- and sex-related differences in temporal artery wall thickness influence the diagnostic accuracy of TCS.
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http://dx.doi.org/10.1093/rheumatology/keaa515DOI Listing
May 2021

[Diagnostic work-up in central retinal artery occlusion and ischemic optic neuropathy - what is important?]

Dtsch Med Wochenschr 2020 08 13;145(16):1112-1117. Epub 2020 Aug 13.

Medizinische Klinik und Poliklinik IV, Sektion Angiologie-Gefäßzentrum, Klinikum der Ludwigs-Maximilians-Universität, München.

Ischemia of the retina in central retinal artery occlusion (CRAO) and of the optic nerve in ischemic optic neuropathy (ION) are common causes of irreversible vision loss in elderly patients and require a thorough diagnostic work-up. First and foremost, giant cell arteritis should be confirmed or ruled out. The further work-up of non-arteritic CRAO and non-arteritic ION (nAION) aims to determine the cardiovascular risk profile. Patients with nAION should be screened for sleep apnoea. In non-arteritic CRAO, the search for embolic sources is the most important diagnostic task. A "white spot sign" seen on transorbital ultrasound confirms the diagnosis of embolic CRAO and rules out an arteritic etiology of CRAO.
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http://dx.doi.org/10.1055/a-1010-2039DOI Listing
August 2020

Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study.

Ultraschall Med 2021 Apr 14;42(2):178-186. Epub 2020 Jul 14.

Department of Internal Medicine, University Hospital Magdeburg, Germany.

Background:  This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients.

Methods:  Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System).

Results:  321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site.

Conclusion:  This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.
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http://dx.doi.org/10.1055/a-1198-4874DOI Listing
April 2021

Unilateral Hippocratic Fingers and Macaroni Sign.

Arthritis Rheumatol 2020 09 13;72(9):1570. Epub 2020 Jul 13.

Dr. von Hauner Children's Hospital Hospital of the Ludwig-Maximilians-University, Munich, Germany.

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http://dx.doi.org/10.1002/art.41313DOI Listing
September 2020

Retrobulbar Spot Sign in Metachronous Bilateral Central Retinal Artery Occlusion of Cardioembolic Origin.

J Neuroophthalmol 2021 03;41(1):e105-e106

Division of Vascular Medicine (CL, AK, UH, MC), Medical Clinic and Policlinic IV, University Hospital, Ludwig-Maximilians-University, Munich, Germany; Department of Ophthalmology (MJM), University Hospital, Ludwig-Maximilians-University, Munich, Germany; and Medical Clinic and Policlinic I (AB), University Hospital, Ludwig-Maximilians-University, Munich, Germany.

Abstract: A 78-year-old man suffered sudden visual loss of his right eye. Five years earlier, he had experienced vision loss of his left eye due to central retinal artery occlusion (CRAO); back then, the etiology for the CRAO was not established. Current ocular ultrasound depicted a hyperechoic spot within the optic nerve in both eyes. Echocardiography identified a calcified mass adherent to the mitral valve as the embolic source of the CRAO. This case shows the value of ocular B-mode ultrasound in demonstration and proof of the etiology for CRAO.
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http://dx.doi.org/10.1097/WNO.0000000000000956DOI Listing
March 2021

A horse and a zebra: an atypical clinical picture including Guillain-Barré syndrome, recurrent fever and mesenteric lymphadenopathy caused by two concomitant infections.

Infection 2020 Jun 3;48(3):471-475. Epub 2020 Mar 3.

Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, LMU München, Munich, Germany.

Background: While Campylobacter jejuni represents the most common cause of bacterial gastroenteritis, Yersinia pseudotuberculosis infections are very rarely diagnosed in adults.

Case: We report on a previously healthy patient who presented several times at our hospital with fever, Guillain-Barré syndrome, recurrent abdominal symptoms and distinct mesenteric lymphadenopathy, respectively. This complicated and diagnostically challenging course of disease was caused by a C. jejuni and Y. pseudotuberculosis coinfection. Antibiotic treatment with doxycycline was effective.

Conclusion: Broad serology testing was crucial to discover that two concomitant infections were causing the symptoms. This case demonstrates that when a clinical picture is not fully explained by one known infection, another infection with the same underlying risk factor has to be considered, hence "a horse and a zebra".
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http://dx.doi.org/10.1007/s15010-020-01397-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256024PMC
June 2020

Guessing right - whether and how medical students give incorrect reasons for their correct diagnoses.

GMS J Med Educ 2019 15;36(6):Doc85. Epub 2019 Nov 15.

Ludwig-Maximilians-University (LMU) Munich, Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, München, Germany.

Clinical reasoning is one of the central competencies in everyday clinical practice. Diagnostic competence is often measured based on diagnostic accuracy. It is implicitly assumed that a correct diagnosis is based on a proper diagnostic process, although this has never been empirically tested. The frequency and nature of errors in students' diagnostic processes in correctly solved cases was analyzed in this study. 148 medical students processed 15 virtual patient cases in internal medicine. After each case, they were asked to state their final diagnosis and justify it. These explanations were qualitatively analyzed and assigned to one of the following three categories: correct explanation, incorrect explanation and diagnosis guessed right. The correct diagnosis was made 1,135 times out of 2,080 diagnostic processes. The analysis of the associated diagnostic explanations showed that 92% (1,042) reasoning processes were correct, 7% (80) were incorrect, and 1% (13) of the diagnoses were guessed right. Causes of incorrect diagnostic processes were primarily a lack of pathophysiological knowledge (50%) and a lack of diagnostic skills (30%). Generally, if the diagnosis is correct, the diagnostic process is also correct. The rate of guessed diagnoses is quite low at 1%. Nevertheless, about every 14th correct diagnosis is based on a false diagnostic explanation and thus, a wrong diagnostic process. To assess the diagnostic competence, both the diagnosis result and the diagnostic process should be recorded.
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http://dx.doi.org/10.3205/zma001293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905369PMC
May 2020

Ocular ischaemic complications in giant cell arteritis: CHADS2-score predicts risk of permanent visual impairment.

Clin Exp Rheumatol 2019 Mar-Apr;37 Suppl 117(2):61-64. Epub 2019 May 21.

Department of Ophthalmology, University Hospital, Ludwig- Maximilians-University, Munich, Germany.

Objectives: To identify independent risk factors for permanent visual loss (PVL) in patients with giant cell arteritis (GCA), with a special focus on sonographic findings of the temporal, carotid and subclavian/axillary arteries, and on established scoring systems of ischaemia risk assessment.

Methods: Consecutive patients with a diagnosis of GCA between 2002 and 2013 were retrospectively identified from a prospectively maintained database. Data on clinical characteristics including ophthalmological findings, laboratory values, and sonographic findings of the temporal, carotid an axillary arteries were extracted. CHADS2- and CHA2DS2-VASc-score were calculated. Clinical, laboratory and sonographic characteristics of patients with and without PVL were compared. Multiple logistic regression models were calculated to identify variables independently associated with PVL.

Results: One-hundred-fifty-two patients were included in the analysis. PVL occurred in 30.2% of patients, with anterior ischaemic optic neuropathy as predominant underlying cause (91.3%). The frequency of PVL was strongly dependent on the age at diagnosis, with a significant increase after the age of 70 years. In multivariate analysis, axillary artery vasculitis with an odds ratio (OR) of 0.3 and constitutional symptoms with an OR of 0.1 were negatively associated with PVL. A CHADS2-score of 1 (OR 10.7) or ≥2 (OR 25) was associated with a significantly increased risk of PVL.

Conclusions: The risk of PVL secondary to GCA increases with age but is lower in patients presenting with constitutional symptoms and/or exhibiting axillary artery involvement. The CHADS2-score may help to discriminate patients with low vs. high risk of PVL.
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June 2019

Ward round competences in surgery and psychiatry - a comparative multidisciplinary interview study.

BMC Med Educ 2019 May 8;19(1):137. Epub 2019 May 8.

Institut für Didaktik und Ausbildungsforschung in der Medizin, Klinikum der LMU München, Ziemssenstrasse 1, 80336, Munich, Germany.

Background: The ward round is a key element in everyday hospital inpatient care irrespective of the medical speciality. The underperformance in conducting ward rounds of junior clinicians has already been described. Therefore, necessary skills and competences of clinicians need to be defined, taught and delivered for curricular instruction. In addition to published data on ward round competences in internal medicine this study aims to determine the common competences for surgical and psychiatric ward rounds in order to find differences depending on the speciality.

Methods: Semi-structured interviews with surgical (N = 30) and psychiatric ward staff (N = 30) of a university hospital and five community hospitals were conducted. Competences necessary for performing ward rounds as well as structural aspects were identified by systematic content analysis and frequency analysis, supported by adequate statistics.

Results: Relevant competences for both fields are: collaborative clinical reasoning, communication with the patient and the team, organization, teamwork, management of difficult situations, self-management, error-management, teaching, empathy, nonverbal communication, patient-management and professionalism. Clinical skills were mentioned more often in surgical interviews, while nonverbal communication was described more often in psychiatric interviews. Empathy and communication with the team were more frequently attributed to psychiatric residents.

Conclusion: The competences which were identified as necessary for conducting a ward round in surgery and psychiatry are similar and correspond to previously reported competences in internal medicine. Clinical skills are of greater importance in surgery than in psychiatry. Concerning empathy and nonverbal communication, further research is needed to determine whether they are of minor importance in surgery or whether there is a lack of awareness of these competences.
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http://dx.doi.org/10.1186/s12909-019-1554-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506958PMC
May 2019

[Thyroid nodules: What now?]

MMW Fortschr Med 2019 04;161(7):38-43

Med. Klinik und Poliklinik IV, Klinikum der Univ. München, Campus Großhadern und Campus Innenstadt, München, Deutschland.

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http://dx.doi.org/10.1007/s15006-019-0406-yDOI Listing
April 2019

Three Cases of Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia-A Diagnostic and Therapeutic Challenge.

Urology 2019 Jul 19;129:24-28. Epub 2019 Mar 19.

Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.urology.2019.03.005DOI Listing
July 2019

Scaffolding clinical reasoning of medical students with virtual patients: effects on diagnostic accuracy, efficiency, and errors.

Diagnosis (Berl) 2019 06;6(2):137-149

Medizinische Klinik und Polklinik IV, University Hospital, LMU Munich, Munich, Germany.

Background Understanding clinical reasoning is a major challenge in medical education research. Little is known about the influence of scaffolding and feedback on the clinical reasoning of medical students. The aim of this study was to measure the effects of problem representation (cognitive representation of a clinical case) and structured scaffolding for reflection with or without feedback on the diagnostic efficiency and characterization of diagnostic errors of medical students. Methods One hundred and forty-eight advanced medical students were randomly assigned to one of five groups (2 × 2 design with a control group). They worked on 15 virtual clinical cases (five learning cases, five initial assessment cases, and five delayed assessment cases) in an electronic learning environment. After each case, they stated their presumed diagnosis and explained their diagnostic conclusion. Diagnostic accuracy, efficiency, and error distribution were analyzed. Results The diagnostic accuracy (number of correctly solved cases) and efficiency (solved cases/total time) did not differ significantly between any of the groups in the two different assessment phases [mean = 2.2-3.3 (standard deviation [SD] = 0.79-1.31), p = 0.08/0.27 and mean = 0.07-0.12 (SD = 0.04-0.08), p = 0.16/0.32, respectively]. The most important causes for diagnostic errors were a lack of diagnostic skills (20%), a lack of knowledge (18%), and premature closure (17%). Conclusions Neither structured reflections nor representation scaffolding improved diagnostic accuracy or efficiency of medical students compared to a control group when working with virtual patients.
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http://dx.doi.org/10.1515/dx-2018-0090DOI Listing
June 2019

Assessment of Disease Activity in Takayasu Arteritis: Potential Role of Contrast-Enhanced Ultrasound.

Ultraschall Med 2019 Oct 23;40(5):638-645. Epub 2019 Jan 23.

Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwigs-Maximilians-University, Munich, Germany.

Purpose:  To assess the diagnostic value of intima media thickness measurements and contrast-enhanced ultrasound (CEUS) of the supraaortic arteries in the assessment of disease activity in Takayasu arteritis (TA).

Materials And Methods:  Patients with TA and involvement of the carotid and/or subclavian/axillary arteries underwent CEUS imaging in addition to B-mode and color duplex ultrasound. The maximum IMT (mIMT) was measured and high-resolution CEUS of the most prominently thickened vessel segment was performed. Two blinded readers reviewed the CEUS movies, with semiquantitative assessment of microbubble enhancement of the arterial wall (grade 0: no or minimal; grade 1: moderate; grade 2: pronounced). Clinical symptoms, acute phase reactants, and established indices of clinical disease activity (NIH criteria, ITAS score) were recorded.

Results:  40 examinations in 17 patients were analyzed. According to clinical judgement, 27 and 13 cases were classified as clinically inactive and active, respectively. An mIMT-cutoff of > 2.7 mm identified active disease with a sensitivity and specificity of 69.2 % and 88.9 %, respectively (area under the curve 0.83). The interobserver agreement of CEUS analysis was substantial (Cohen's kappa 0.76). By consensus reading, 17, 15, and 8 cases were classified as uptake grade 0, grade 1 and grade 2, respectively. Grade 0 uptake was exclusively present in 17 clinically inactive patients. Grade 1 uptake was seen in 10 patients with clinically inactive disease and 5 patients with clinically active disease. Grade 2 uptake was exclusively present in 8 patients with active disease.

Conclusion:  Both sonographic IMT measurements and high-resolution CEUS are promising in the ad-hoc assessment of disease activity in patients with TA.
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http://dx.doi.org/10.1055/a-0817-5423DOI Listing
October 2019

Ward rounds in internal medicine: Validation of an Entrustable Professional Activity (EPA) observation checklist.

GMS J Med Educ 2018;35(2):Doc17. Epub 2018 May 15.

Klinikum der Universität München, Institut für Didaktik und Ausbildungsforschung in der Medizin, München, Germany.

Ward rounds serve a crucial daily activity in hospitals. Building on the Entrustable Professional Activity "Conducting internal medicine ward rounds" consisting of ten competencies and 25 corresponding activities, this study aims at assessing content and external validity of an observation checklist for this EPA. A focus group aimed at content validation of the checklist. Five participants therefore evaluated it with respect to comprehensiveness and comprehensibility. To investigate external validity, 14 authentic ward rounds were video-taped and rated by two raters with the adapted observation checklist in terms of the appearance of certain activities in the videos. After some adaptions, participants of the focus group agreed on a checklist consisting of nine competencies, 25 activities and 110 examples of observable behaviours supporting content validity. External validity was studied by using the observation checklist for ratings of ward round videos. The checklist was regarded as a valuable tool to structure observation. Along with the high frequencies of observed behaviour and interrater-reliability, external validity can be assumed. The first scientifically developed comprehensive observation checklist for the EPA is presented. The checklist is a valuable tool for providing elaborated feedback in undergraduate and graduate medical education. Focussing on multi-institutional validation and the cut offs of the checklist to determine the levels of entrustment are recommended for future research.
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http://dx.doi.org/10.3205/zma001164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022584PMC
November 2018

Structured Reporting of CT Angiography Runoff Examinations of the Lower Extremities.

Eur J Vasc Endovasc Surg 2018 05 4;55(5):679-687. Epub 2018 Apr 4.

Department of Radiology, University Hospital, LMU Munich, Germany; Department of Diagnostic and Interventional Radiology, Rostock University Medical Centre, Rostock, Germany.

Objectives: The aim was to evaluate the effect of structured reporting of computed tomography angiography (CTA) runoff studies on clarity, completeness, clinical relevance, usefulness of the radiology reports, further testing, and therapy in patients with known or suspected peripheral arterial disease.

Methods: Conventional reports (CRs) and structured reports (SRs) were generated for 52 patients who had been examined with a CTA runoff examination of the lower extremities. The sample size was based on power calculations with a power of 95% and a significance level of .007 (adjusted for multiple testing). CRs were dictated in a free text form; SRs contained a consistent ordering of observations with standardised subheadings. CRs were compared with SRs. Two vascular medicine specialists and two vascular surgeons rated the reports regarding their satisfaction with clarity, completeness, clinical relevance, and usefulness as well as overall satisfaction. Additionally, they made hypothetical decisions on further testing and therapy. Median ratings were compared using the Wilcoxon signed rank test and generalised linear mixed effects models.

Results: SRs received higher ratings for satisfaction with clarity (median rating 9.0 vs. 7.0, p < .0001) and completeness (median rating 9.0 vs. 7.5, p < .0001) and were judged to be of greater clinical relevance (median rating 9.0 vs. 8.0, p < .0001) and usefulness (median rating 9.0 vs. 8.0, p < .0001). Overall satisfaction was also higher for SRs (median rating 9.0 vs. 7.0, p < .0001) than CRs. There were no significant differences in further testing or therapy.

Conclusion: Referring clinicians perceive SRs of CTA runoff examinations of the lower extremities as offering superior clarity, completeness, clinical relevance, and usefulness than CRs. Structured reporting does not appear to alter further testing or therapy in patients with known or suspected peripheral arterial disease.
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http://dx.doi.org/10.1016/j.ejvs.2018.01.026DOI Listing
May 2018

[Current trends in diagnosis and treatment of giant cell arteritis].

Dtsch Med Wochenschr 2018 Apr 3;143(7):446-450. Epub 2018 Apr 3.

Med. Klinik und Poliklinik IV, Sektion Angiologie-Gefäßzentrum, Klinikum der Ludwig-Maximilians-Universität, München.

Giant cell arteritis (GCA) is the most common form of the primary large vessel vasculitides and typically occurs in individuals aged ≥ 50 years. This concise review article discusses current trends in the management of GCA, including important developments in sonographic assessment (B-mode sonography, contrast enhanced ultrasound) and medical treatment (biological treatment with the interleukin-6 receptor alpha inhibitor tocilizumab).
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http://dx.doi.org/10.1055/s-0043-114848DOI Listing
April 2018

Relapses in three patients with Takayasu arteritis under tocilizumab treatment detected by contrast enhanced ultrasound.

Vasa 2018 Feb 22;47(2):149-152. Epub 2017 Dec 22.

3 Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, Munich, Germany.

Takayasu arteritis (TA) is a rare large vessel vasculitis, affecting the aorta and its major branches, typically in young women. In this case report, we present three cases of young women of Caucasian descent who experienced relapses while under treatment with the monoclonal humanized antibody to the interleukin 6 receptor, tocilizumab. Active vasculitic lesions of the supraaortic (common carotid and axillary) arteries were detected and characterized via high resolution contrast enhanced ultrasound. Based on these cases, we discuss the potential role of contrast enhanced ultrasound in the diagnosis and follow-up of TA as well as the current data on the efficacy of tocilizumab in the treatment of TA.
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http://dx.doi.org/10.1024/0301-1526/a000679DOI Listing
February 2018

Representation scaffolds improve diagnostic efficiency in medical students.

Med Educ 2017 Nov 6;51(11):1118-1126. Epub 2017 Jun 6.

Department of Internal Medicine, University Hospital, Ludwig-Maximilian University (LMU), Munich, Germany.

Context: Diagnostic efficiency is important in daily clinical practice as doctors have to face problems within a limited time frame. To foster the clinical reasoning of students is a major challenge in medical education research. Little is known about students' diagnostic efficiency. On the basis of current theories, scaffolds for case representation (statement of the case as far as it is summarised in the mind) could be a promising approach to make the diagnostic reasoning of intermediate medical students more efficient.

Methods: Clinical case processing of 88 medical students in their fourth and fifth years was analysed in a randomised, controlled laboratory study. Cases dealing with dyspnoea were provided in an electronic learning environment (CASUS). Students could freely choose the time, amount and sequence of clinical information. During the learning phase the intervention group was asked to write down case representation summaries while working on the cases. In the assessment phase diagnostic efficiency was operationalised as the number of correct diagnoses divided by the time spent on diagnosing.

Results: Diagnostic efficiency was significantly improved by the representation scaffolding (M = 0.12 [SD = 0.07], M = 0.09 [SD = 0.06] correct cases/time, p = 0.045), whereas accuracy remained unchanged (M = 2.28 [SD = 1.10], M = 2.09 [SD = 1.08], p = 0.52). Both groups screened the same amount of clinical information, but the scaffolding group did this faster (M = 20.8 minutes [SD = 7.15], M = 24.6 minutes [SD = 7.42], p = 0.01; Cohen's d = 0.5).

Conclusion: Diagnostic efficiency is an important outcome variable in clinical reasoning research as it corresponds to workplace challenges. Scaffolding for case representations significantly improved the diagnostic efficiency of fourth and fifth-year medical students, most likely because of a more targeted screening of the available information.
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http://dx.doi.org/10.1111/medu.13355DOI Listing
November 2017

B-mode sonography wall thickness assessment of the temporal and axillary arteries for the diagnosis of giant cell arteritis: a cohort study.

Clin Exp Rheumatol 2017 Mar-Apr;35 Suppl 103(1):128-133. Epub 2017 Apr 4.

Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximilians-University, Munich, Germany.

Objectives: We aimed to determine the diagnostic accuracy of B-mode compression sonography of the temporal arteries (tempCS) and B-mode sonographic measurement of the axillary artery intima media thickness (axIMT) for the diagnosis of giant cell arteritis (GCA).

Methods: After having established measurement of tempCS and axIMT in our routine diagnostic workup, 92 consecutive patients with a suspected diagnosis of GCA were investigated. Clinical characteristics were recorded and wall thickening of the temporal arteries (tempCS) and axillary arteries (axIMT) was measured (mm). Using the final clinical diagnosis as the reference standard, receiver operator characteristics (ROC) analysis was performed. In a subgroup of 26 patients interobserver agreement was assessed using Spearman's rank correlation.

Results: Cranial GCA, extracranial GCA, and combined cranial/extracranial GCA were diagnosed in 18, 7, and 9 individuals, respectively. For the diagnosis of cranial GCA, tempCS had an excellent area under the curve (AUC) of 0.95, with a cut-off of ≥0.7 mm offering a sensitivity and specificity of 85% and 95%. The AUC of axIMT for the diagnosis of extracranial GCA was 0.91 (cut-off ≥1.2 mm: sensitivity and specificity 81.3 and 96.1%). Applying a combined tempCS/axIMT cut-off of ≥0.7mm/1.2 mm, we calculated an overall sensitivity and specificity for the final clinical diagnosis of cranial and/or extracranial GCA of 85.3% and 91.4%. Interobserver agreement was strong for both parameters assessed (Spearman's rho 0.72 and 0.77, respectively).

Conclusions: The combination of tempCS/axIMT allows objective sonographic assessment in suspected GCA with promising diagnostic accuracy.
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July 2017

Ultrasound imaging in the diagnosis of large vessel vasculitis.

Vasa 2017 Jul 23;46(4):241-253. Epub 2017 Mar 23.

1 Division of Vascular Medicine, Medical Clinic and Policlinic IV Ludwig-Maximilians-University Hospital, Munich, Germany.

Nowadays noninvasive vascular imaging has an important role in the diagnostic work-up of the large vessel vasculitides (LVV), most importantly giant cell arteritis (GCA) and Takayasu arteritis. Among the imaging modalities available, ultrasound (US) has several important advantages, including low costs, rapid and repetitive availability without exposure to radiation, and high spatial resolution for assessment of large and medium-sized arteries. Therefore, US can be regarded the first line imaging method in suspected LVV. In patients with suspected GCA, US can replace temporal artery biopsy in certain clinical scenarios, and the application of US early in the diagnostic work-up of suspected GCA in specialized fast track clinics has been suggested to reduce the rate of visual ischaemic complications and associated costs. In other LVV such as Takayasu arteritis and chronic periaortitis, the diagnostic accuracy in comparison to other noninvasive imaging methods has not been formally tested but can be considered to be excellent. However, quality of US is highly dependent on the operator's experience, and assessment of the thoracic aorta which is frequently involved in GCA and TA is limited. The role of US in the follow-up of LVV under treatment is unclear. In view of the promising data supporting its value on the one hand and several uncertainties and controversies on the other hand, the present review article provides a comprehensive overview on current evidence for the application of US in the diagnosis and follow up of LVV. Recent multicentre study results and emerging trends such as the application of compression sonography in the diagnosis of GCA and the use of contrast enhanced ultrasound in disease activity assessment in Takayasu arteritis are discussed.
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http://dx.doi.org/10.1024/0301-1526/a000625DOI Listing
July 2017

Medical ward round competence in internal medicine - an interview study towards an interprofessional development of an Entrustable Professional Activity (EPA).

BMC Med Educ 2016 Jul 11;16:174. Epub 2016 Jul 11.

Institut für Didaktik und Ausbildungsforschung in der Medizin, Klinikum der LMU München, Ziemssenstrasse 1, 80336, Munich, Germany.

Background: The medical ward round is a central but complex activity that is of relevance from the first day of work. However, difficulties for young doctors have been reported. Instruction of ward round competence in medical curricula is hampered by the lack of a standardized description of the procedure. This paper aims to identify and describe physicians' tasks and relevant competences for conducting a medical ward round on the first day of professional work.

Methods: A review of recent literature revealed known important aspects of medical ward rounds. These were used for the development of a semi-structured interview schedule. Medical ward round experts working at different hospitals were interviewed. The sample consisted of 14 ward physicians (M = 8.82 years of work experience) and 12 nurses (M = 14.55 years of work experience) working in different specializations of internal medicine. All interviews were audiotaped, fully transcribed, and analyzed using an inductive-deductive coding scheme.

Results: Nine fields of competences with 18 related sub-competences and 62 observable tasks were identified as relevant for conducting a medical ward round. Over 70 % of the experts named communication, collaborative clinical reasoning and organization as essential competences. Deeper analysis further unveiled the importance of self-management, management of difficult situations, error management and teamwork.

Conclusion: The study is the first to picture ward round competences and related tasks in detail and to define an EPA "Conducting an internal medicine ward round" based on systematic interprofessional expert interviews. It thus provides a basis for integration of ward round competences in the medical curricula in an evidence based manner and gives a framework for the development of instructional intervention studies and comparative studies in other medical fields.
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http://dx.doi.org/10.1186/s12909-016-0697-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940908PMC
July 2016
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