TY - THES A1 - Sieber, Christian T1 - Neue Normwerte für ACE, sIL-2R, Lysozym und IL-8 in der Sarkoidose-Diagnostik T1 - New normal values for ACE, sIL-2R, Lysozyme and IL-8 in the Diagnostic of Sarcoidosis N2 - HINTERGRUND: Ziel der vorliegende Arbeit war, neue Normwerte für ACE, sIL-2R, Lysozym und IL-8 in der Sarkoidose-Diagnostik zu liefern. Bevorzugt sollten mittels ROC-Analysen Cut-off-Werte erstellt werden. METHODIK: Bei 66 Sarkoidosepatienten und 46 Patienten mit fibrosierender interstiteller Lungenerkrankung und einer aus 49 Gesunden bestehenden Kontrollgruppe wurden die genannten Parameter gemessen. Dies geschah für ACE mittels eines kinetischen Tests, für sIL-2R mittels eines Enzymimmunoassays, für Lysozym mittels einer photometrischen Trübemessung und für IL-8 mittels eines ELISAs. ERGEBNISSE: Ein neuer Normbereich des Medians von ACE konnte mit 2.5 bis 80.7 Units/l, ein Median mit 31.4 Units/l und eine Cut-off-Wert von 36.3 Units/l angegeben werden. Für sIL-2R ergaben sich ein Mittelwert von 302.4 U/ml bei einem Normbereich von 133.9 bis 682.8 U/ml und ein Cut-off-Wert von 382.00 U/ml. Ein neuer Mittelwert von Lysozym lag bei 1200.1 U/ml mit einem Normbereich von 836.5 bis 1563.6 U/ml. Der Cut-off-Wert betrug 1210.00 U/ml. Der Mittelwert von IL-8 lag bei 17.3 pg/ml mit einem Normbereich von 3.12 bis 43.02 pg/ml und einem Cut-off-Wert von 20.3 pg/ml. ZUSAMMENFASSUNG: Die ermittelten Werte ließen sich nur schwer mit anderen Arbeiten vergleichen. Vor allem beim Serum-ACE wurden verschiedene Einheiten, die nicht immer linear umrechenbar waren verwendet. Insbesondere sIL-2R wies neue Serumwerte auf. Außerdem ließ sich eine Altersabhängigkeit für sIL-2R nachweisen. N2 - BACKGROUND: The main goal of this study was to achieve new normal values for ACE, sIL-2R, Lysozyme and IL-8 in the diagnostic of sarcoidosis. Those should have been prepared in particullar by means of ROC-analyses. METHODS: Within a group of 66 patients with sarcoidosis, 46 patients with fibrosing interstitial lungdisease and 49 healthy individuals we mesaured the ACE, sIL-2R, Lysozyme and IL-8. A kinetic test, an enzymeimmunoassay, the measure of the absorption and an ELISA were used. RESULTS: We found a new median for ACE at 31.4 Units/l within a range from 2.5 to 80.7 Units/l and a cut-off value at 36.3 Units/l. The mean value for sIL-2R was 302.4 U/ml within a range from 133.9 to 682.8 U/ml and a cut-off value at 382.00 U/ml. For Lysozyme a new normal value was found at 1200.1 U/ml with a range from 836.5 to 1563.6 U/ml and a cut-off value at 1210.00 U/ml. The mean value for IL-8 was at 17.3 pg/ml within a range from 3.12 to 43.02 pg/ml and a cut-off value at 20.3 pg/ml. CONCLUSION: It was difficult to compare the new found values to other studies, because different units were used, in particular for ACE. New normal values were found especially for sIL-2R. Besides, we detected a dependence of sIL-2R on the age. KW - ACE KW - sIL-2R KW - Lysozym KW - ROC KW - Sarkoidose KW - ACE KW - sIL-2R KW - Lysozyme KW - ROC KW - Sarcoidosis Y1 - 2005 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-15414 ER - TY - THES A1 - Sieber, Dirk Karl Christian T1 - Osteoporoseerkennung bei Schenkelhalsfrakturen - eine vernachlässigte Diagnose - Diagnosestellung und resultierende Therapie T1 - Recognition of osteoporosis in hip fracture - a neglected diagnosis - N2 - In dieser Arbeit wurden die Diagnostik- und Behandlungsabläufe von 250 Patienten nach erlittener proximaler Femurfraktur in der Region Würzburg (Deutschland) untersucht. Auswertungsschwerpunkte waren die durchgeführte Diagnostik zur Abklärung einer Osteoporose, die Einleitung einer Pharmakotherapie und die Informationsübermittlung an den weiterbehandelnden Arzt. Aus den erhobenen Daten konnte eine Inzidenz für die Jahre 1993 und 1994 von 180 und eine Inzidenzdichte auf 100.000 Einwohner von 138,5 pro Jahr gemeinsam für Frauen und Männer hochgerechnet werden. Das mittlere Alter der untersuchten Patienten lag bei 76,3 Jahren, die 10%-Perzentile bei 59, die 90%-Perzentile bei 89 Jahren und der Median war 80 Jahre, und damit vergleichbar mit den anderen internationalen Studien. Die geschlechtsspezifischen Verteilung der Frakturen zeigte ein deutliches Übergewicht der Frauen (194 vs. 56 bei Männern). Bei allen Patienten unterblieb eine weitere Abklärung der Frakturursache während des stationären Aufenthaltes, obwohl die Diagnose Osteoporose zumindest hoch wahrscheinlich (241 Fälle) oder stationär festgestellt worden war (147 Fälle, radiologisch oder histologisch). - In keinem Fall wurde die zur Differenzialdiagnose erforderliche Laborroutine vollständig durchgeführt. - In 147 Fällen wurde die Diagnose einer Osteoporose durch den Radiologen (konventionelle Röntgenaufnahme) oder durch den Pathologen (Untersuchung des Femurkopfes) gestellt (in 127 Fällen radiologisch, in 58 Fällen histopathologisch). - Bei nur 20 der so festgestellten 147 Fälle (13,6 %) wurde eine Osteoporose-Therapie stationär eingeleitet und in nur 13 Fällen als Therapieempfehlung für den Entlassungsbericht übernommen. - Wurde die Diagnose durch den Radiologen oder Pathologen gestellt, so unterblieb in 2 von 3 Fällen jegliche Erwähnung im Entlassungsbericht. Wurde sie erwähnt, dann häufig nur in der Form des Röntgen- oder Histologiebefunds. - Die Diagnose Osteoporose wurde in 19,6 % der Entlassungsbriefe übermittelt und lag damit um ca. 5 % höher als der internationale Vergleich. - Wäre die stationär in 147 Fällen bereits festgestellte Diagnose jedes Mal übermittelt worden, hätte sich statt 19,6 % eine Quote von 58,8 % erreichen lassen. Eine Schenkelhalsfraktur steigert die Morbidität und Mortalität der betroffenen Patienten erheblich. Lediglich 23 von zuvor 195 Patienten konnten bei Entlassung aus der Akutklinik ohne Hilfe gehen, während die Zahl der vollständig immobilen Patienten von 2 auf 23 Patienten zum Zeitpunkt der Entlassung zunahm. 14 Patienten (5,6 %) starben im Krankenhaus oder im dokumentierten Beobachtungszeitraum. 26 Patienten (10,4 %) erlitten bereits ihre zweite proximale Femurfraktur, 12 (4,8 %) davon innerhalb nur eines Jahres und zwei sogar ihre dritte proximale Femurfraktur (0,8%). Die für den Patienten wirkungsvollen und das Gesundheitssystem kosteneffektiven Behandlungsmöglichkeiten machen eine weiterführende diagnostische Abklärung und Behandlung der proximalen Femurfraktur aus ethischen und sozioökonomischen Gründen erforderlich. Dies betrifft den Arzt der Akutversorgung und den weiterbehandelnden Arzt gleichermaßen. Die Behandlung sollte multimodal unter Einschluss einer adäquaten Pharmakotherapie erfolgen. Die aktuellen Therapieempfehlungen lassen sich auch für den nicht Osteologen verständlich und praktikabel aus den aktuellen Leitlinien z.B. der Deutschen Gesellschaft für Osteologie entnehmen und anwenden. Zu möglichen nicht medikamentösen Maßnahmen gehören Behandlungskonzepte mit Mobilisationstraining (Fallverhütung), Hüftprotektoren und Reduktion/Vermeidung von Sedativa (v. a. Benzodiazepine). Das Bewusstsein von Ärzten und Patienten muss für den Zusammenhang „Fraktur mit inadäquatem Trauma“ und „Osteoporose“ geschärft werden. Fortbildungen und Öffentlichkeitsarbeit können hier wertvolle Dienste leisten. Jede erlittene Fraktur mit inadäquatem Trauma sollte bei Arzt und Patient die Frage nach einer Osteoporose aufwerfen. Eine weiterführende Abklärung sollte gegebenenfalls eingeleitet und die Notwendigkeit einer Behandlung überprüft werden. - Diese Studie belegt, dass die Versorgung für den untersuchten Zeitraum völlig ungenügend ist. - Sie kann als Basis dienen, um Verbesserungen in diesem Bereich zu dokumentieren. - Sie zeigt, dass umfassende Anstrengungen erforderlich sind, das Bewusstsein für den Zusammenhang proximale Femurfraktur und Osteoporose zu schärfen und effektive Präventionsmaßnahmen (z.B. Verhinderung einer zweiten Schenkelhalsfraktur) einzuleiten. N2 - Study Objective: To determine to what degree men and women admitted for a hip fracture to 3 university teaching hospitals in Wuerzburg (Germany) were diagnosed, evaluated, or treated for osteoporosis during admission and whether information was passed on to the primary care physician for further treatment. Design: Retrospective chart review. Setting: Three of four university teaching hospitals that cover all primary care treatment of newly acquired hip fractures in the region of Wuerzburg (Germany). Patients: 536 patients with diagnosis fracture of femur from January 1993-December 1994 were evaluated. 194 women and 56 men fulfilled the study’s preset criteria. Measurements and Main Results: All medical records of men and women with newly acquired hip fracture in 1993 or 1994 and admission to one of the three participating university teaching hospitals were evaluated. Available data from outpatient follow-ups and reports from rehabilitation facilities were also included. Emphasized was the evaluation of diagnosis, treatment and reports passed on to the patient´s primary care physician at or after discharge. The mean age in patients was 76.3 years, the 10% percentile at 59, the 90% percentile at 89 and the median was 80 years. Distribution of the fractures showed a clear overweight of women (194 vs. 56 with men). These results were comparable with other international studies. With all patients further clarification of the fracture cause was neglected during hospitalization, although osteoporosis was highly probable in 241 cases and 147 cases of osteoporosis had already been stationary established by conventional x-ray or histological examination. Just one third of the such established cases of osteoporosis were reported in the dismissal letters and if mostly by indirect referral due to x-ray or histological reports. Only in 20 of these 147 cases (13.6%) a stationary pharmacotherapy resulted and just 13 of those were passed on in the dismissal letter. Suffering from a hip fracture increased the morbidity and mortality of the concerned Patients considerable. Of 195 patients walking independently before admission merely 23 could do so at discharge. The number of immobilized patients elevated from 2 to 23. 14 patients (5,6%) died in the hospital or in the documented observation period. 26 patients (10.4%) already experienced their second hip fractur, 12 (4,8 %) of these within only one year and two even suffered from their third hip fractur (0,8%). Conclusion: In the region of Wuerzburg (Germany) patients with hip fracture are commonly under diagnosed and treated for osteoporosis. The primary care physician is frequently not informed of the identified diagnosis or treatment started for osteoporosis. Identification of osteoporosis, initiating treatment and passing on of this critical information has to be improved greatly. KW - Osteoporose KW - Schenkelhalsfraktur KW - Würzburg KW - Diagnose KW - Epidemiologie KW - osteoporosis KW - hip fracture KW - Wuerzburg KW - diagnosis KW - epidemiology Y1 - 2005 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-20531 ER - TY - THES A1 - Sieber, Christian T1 - Holistic Evaluation of Novel Adaptation Logics for DASH and SVC T1 - Leistungsbewertung neuartiger Adaptionslogiken für DASH mit SVC N2 - Streaming of videos has become the major traffic generator in today's Internet and the video traffic share is still increasing. According to Cisco's annual Visual Networking Index report, in 2012, 60% of the global Internet IP traffic was generated by video streaming services. Furthermore, the study predicts further increase to 73% by 2017. At the same time, advances in the fields of mobile communications and embedded devices lead to a widespread adoption of Internet video enabled mobile and wireless devices (e.g. Smartphones). The report predicts that by 2017, the traffic originating from mobile and wireless devices will exceed the traffic from wired devices and states that mobile video traffic was the source of roughly half of the mobile IP traffic at the end of 2012. With the increasing importance of Internet video streaming in today's world, video content provider find themselves in a highly competitive market where user expectations are high and customer loyalty depends strongly on the user's satisfaction with the provided service. In particular paying customers expect their viewing experience to be the same across all their viewing devices and independently of their currently utilized Internet access technology. However, providing video streaming services is costly in terms of storage space, required bandwidth and generated traffic. Therefore, content providers face a trade-off between the user perceived Quality of Experience (QoE) and the costs for providing the service. Today, a variety of transport and application protocols exist for providing video streaming services, but the one utilized depends on the scenario in mind. Video streaming services can be divided up in three categories: Video conferencing, IPTV and Video-on-Demand services. IPTV and video-conferencing have severe real-time constraints and thus utilize mostly datagram-based protocols like the RTP/UDP protocol for the video transmission. Video-on-Demand services in contrast can profit from pre-encoded content, buffers at the end user's device, and mostly utilize TCP-based protocols in combination with progressive streaming for the media delivery. In recent years, the HTTP protocol on top of the TCP protocol gained widespread popularity as a cost-efficient way to distribute pre-encoded video content to customers via progressive streaming. This is due to the fact that HTTP-based video streaming profits from a well-established infrastructure which was originally implemented to efficiently satisfy the increasing demand for web browsing and file downloads. Large Content Delivery Networks (CDN) are the key components of that distribution infrastructure. CDNs prevent expensive long-haul data traffic and delays by distributing HTTP content to world-wide locations close to the customers. As of 2012, already 53% of the global video traffic in the Internet originates from Content Delivery Networks and that percentage is expected to increase to 65% by the year 2017. Furthermore, HTTP media streaming profits from existing HTTP caching infrastructure, ease of NAT and proxy traversal and firewall friendliness. Video delivery through heterogeneous wired and wireless communications networks is prone to distortions due to insufficient network resources. This is especially true in wireless scenarios, where user mobility and insufficient signal strength can result in a very poor transport service performance (e.g. high packet loss, delays and low and varying bandwidth). A poor performance of the transport in turn may degrade the Quality of Experience as perceived by the user, either due to buffer underruns (i.e. playback interruptions) for TCP-based delivery or image distortions for datagram-based real-time video delivery. In order to overcome QoE degradations due to insufficient network resources, content provider have to consider adaptive video streaming. One possibility to implement this for HTTP/TCP streaming is by partitioning the content into small segments, encode the segments into different quality levels and provide access to the segments and the quality level details (e.g. resolution, average bitrate). During the streaming session, a client-centric adaptation algorithm can use the supplied details to adapt the playback to the current environment. However, a lack of a common HTTP adaptive streaming standard led to multiple proprietary solutions developed by major Internet companies like Microsoft (Smooth Streaming), Apple (HTTP Live Streaming) and Adobe (HTTP Dynamic Streaming) loosely based on the aforementioned principle. In 2012, the ISO/IEC published the Dynamic Adaptive Streaming over HTTP (MPEG-DASH) standard. As of today, DASH is becoming widely accepted with major companies announcing their support or having already implemented the standard into their products. MPEG-DASH is typically used with single layer codecs like H.264/AVC, but recent publications show that scalable video coding can use the existing HTTP infrastructure more efficiently. Furthermore, the layered approach of scalable video coding extends the adaptation options for the client, since already downloaded segments can be enhanced at a later time. The influence of distortions on the perceived QoE for non-adaptive video streaming are well reviewed and published. For HTTP streaming, the QoE of the user is influenced by the initial delay (i.e. the time the client pre-buffers video data) and the length and frequency of playback interruptions due to a depleted video playback buffer. Studies highlight that even low stalling times and frequencies have a negative impact on the QoE of the user and should therefore be avoided. The first contribution of this thesis is the identification of QoE influence factors of adaptive video streaming by the means of crowd-sourcing and a laboratory study. MPEG-DASH does not specify how to adapt the playback to the available bandwidth and therefore the design of a download/adaptation algorithm is left to the developer of the client logic. The second contribution of this thesis is the design of a novel user-centric adaption logic for DASH with SVC. Other download algorithms for segmented HTTP streaming with single layer and scalable video coding have been published lately. However, there is little information about the behavior of these algorithms regarding the identified QoE-influence factors. The third contribution is a user-centric performance evaluation of three existing adaptation algorithms and a comparison to the proposed algorithm. In the performance evaluation we also evaluate the fairness of the algorithms. In one fairness scenario, two clients deploy the same adaptation algorithm and share one Internet connection. For a fair adaptation algorithm, we expect the behavior of the two clients to be identical. In a second fairness scenario, one client shares the Internet connection with a large HTTP file download and we expect an even bandwidth distribution between the video streaming and the file download. The forth contribution of this thesis is an evaluation of the behavior of the algorithms in a two-client and HTTP cross traffic scenario. The remainder of this thesis is structured as follows. Chapter II gives a brief introduction to video coding with H.264, the HTTP adaptive streaming standard MPEG-DASH, the investigated adaptation algorithms and metrics of Quality of Experience (QoE) for video streaming. Chapter III presents the methodology and results of the subjective studies conducted in the course of this thesis to identify the QoE influence factors of adaptive video streaming. In Chapter IV, we introduce the proposed adaptation algorithm and the methodology of the performance evaluation. Chapter V highlights the results of the performance evaluation and compares the investigated adaptation algorithms. Section VI summarizes the main findings and gives an outlook towards QoE-centric management of DASH with SVC. KW - DASH KW - DASH KW - SVC KW - crowdsourcing KW - quality of experience KW - qoe KW - progressive download KW - dynamic adaptive streaming over http Y1 - 2013 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-92362 ER -