Arthrodese des unteren Sprunggelenks

Pain in or symptomatic destruction of any number of the joints of the hindfoot can have several causes. As well as primary osteoarthritis, these include secondary arthrotic changes following fractures (especially of the talus and/or calcaneus), muscular and/or tenoligamentous instability (e.g., rupture of the posterior tibialis tendon, poliomyelitis, Charcot-Marie-Tooth disease), spastic and flaccid paresis of the lower leg and foot, late stages of various inflammatory arthritides (rheumatoid arthritis, seronegative spondarthritis, collagenoses), and neuropathic diseases with impaired depth perception (Charcot disease of the foot in diabetes mellitis, for example). As a general policy, only joints that are causing symptoms, are clearly arthritic, or are involved in a fixed foot deformity should be fused, so that as much of the residual hindfoot motion as possible is preserved. This helps to restrict future osteoarthritis in adjacent joints. The use of screws rather than staples seems to increase the fusion rates because this technique allows compression on the fusion.     

Treatment of post-traumatic limb shortening]

The physiological phenomenon of changes in callus formation during distraction was first described by Codivilla at the beginning of this century. Having investigated and proved the influence of tension stress on callus formation, Ilizarov used this as a method to treat limb shortening and deformities. Because of his remarkable results we introduced this method in our hospital in 1990, using the original Ilizarov ring fixator. From November 1990 to December 1991, we used this technique in 10 cases of combined post-traumatic bone shortening with deformity (the tibia was affected in six patients, the femur in three and the forearm in one). The mean shortening was 3.1 cm, the mean varus or valgus deformity 9.5 degrees, the mean anteflexion or recurvation 8.3 degrees, and the mean rotation deformity 8.5 degrees. Distraction/correction lasted between 8 and 55 days (mean: 37 days). Fixation was necessary for between 60 and 339 days. If corticotomy was performed in the diaphyseal bone, fixation lasted almost twice as long (11.33 days/mm lengthening) as in the metaphyseal area (6.55 days/mm lengthening). There were 14 complications, most of which were considered minor. The latter included pin infections (4), wire breaking (1) and restricted range of motion of the knee or ankle (5). Among the major complications were two nerve irritations, which recovered spontaneously, and two pin-induced local bone infections, which required surgical intervention. Achievement of the goals of treatment-complete correction of shortening and deformity-was not affected by these complications.     

Health promotion and disease prevention in HMOs: a survey of newly established IPAs in New York City

Independent Practice Associations (IPAs) are the fastest growing segment of the Health Maintenance Organization (HMO) industry, but little is known about their provision of health promotion and disease prevention to subscribers. To examine the extent to which IPA policies encourage health promotion and disease prevention, we interviewed medical directors and other senior administrators of six newly developing IPA-HMOs in New York City. We also reviewed promotional literature to assess how extensively health promotion and disease prevention were marketed to the potential subscriber. Although medical protocols for preventive screening exist in most IPAs, compliance with guidelines is left largely to the individual physician's judgment for implementation. IPA respondents suggested that their physician panels are oriented toward prevention, but there is uncertain evidence in this regard, and incentive payments could discourage referrals for screening. Health education programs are sporadic. Health promotion and disease prevention do not appear to be a high priority among six newly established IPAs in New York City. We recommend several steps that would encourage IPA-HMOs to increase their health promotion activities.     

Evaluation of ambulatory care training by graduates of internal medicine residencies

In 1984, 154 physicians who had completed residencies in internal medicine at 15 major teaching hospitals in 1982 evaluated their residency training in ambulatory care. A majority of the physicians would have liked more experience in practical areas related to career planning and office management, more input from subspecialties such as orthopedics and dermatology, greater knowledge about the management of psychosocial problems, and more information about exercise and nutrition. Although many physicians also wanted more time devoted to several other topics, less than 20 percent recommended spending less time on 26 of the 27 topics being evaluated. Since these recommendations are similar to those reported in evaluation studies published over the past 25 years, it appears that training programs in internal medicine have not been successful in restructuring their curricula to meet many of the needs of practicing physicians.     

Predictors of non-spine fracture in elderly men: the MrOS study.

We examined determinants of nonvertebral fracture in elderly men from six U.S. communities followed an average of 4.1 years. Six clinical risk factors predicted fracture risk independent of hip BMD: tricyclic antidepressant use, previous fracture, inability to complete a narrow walk trial, falls in previous year, age > or =80 years, and depressed mood. INTRODUCTION: There are few prospective studies of fracture determinants in men. We examined the associations between a comprehensive set of clinical risk factors and risk of nonspine fracture in older men and whether determinants of fracture risk were independent of total hip BMD. MATERIALS AND METHODS: A total of 5995 men > or =65 years of age were recruited from six communities in the Unites States and followed prospectively for an average of 4.1 years. Baseline assessments of demographic, lifestyle, medical history, functional status, anthropometry, and cognitive, visual, and neuromuscular function were assessed by questionnaire or examination. Triannual mailed questionnaires ascertained incident fracture; reported fractures were adjudicated by physicians using medical records and X-ray reports. Proportional hazards models were used to develop multivariable models, selecting variables and controlling for BMD. RESULTS: Of 5876 men, 4.7% (N = 275) reported an incident nonspine fracture during follow-up (11.46/1000 person-years). Tricyclic antidepressant use (hazard ratio [HR], 2.36; 95% CI, 1.25-4.46), history of fracture at or after age 50 (HR, 2.07; 95% CI, 1.62-2.65), inability to complete a narrow walk trial (HR, 1.70; 95% CI, 1.23-2.34), falls in previous year (HR, 1.59; 95% CI, 1.23-2.05), age > or =80 years (HR, 1.33; 95% CI, 1.01-1.76), depressed mood (HR, 1.72; 95% CI, 1.00-2.95), and decreased total hip BMD (HR, 1.53; 95% CI, 1.34-1.74) were independently related to increased risk. Compared with having none (48.0% of men), having three or more of the clinical risk factors (4.9% of men) increased fracture risk 5-fold, independent of BMD. Having three or more risk factors and being in the lowest tertile of BMD was associated with a 15-fold greater risk than having no risk factors and being in the highest BMD tertile. CONCLUSIONS: Several clinical risk factors were independently associated with nonspine fractures in elderly men. The combination of multiple risk factors and low BMD was a very powerful indicator of fracture risk.     

Comparative expression profiling in primary and immortalized endothelial cells: changes in gene expression in response to hydroxy methylglutaryl-coenzyme A reductase inhibition.

Immortalized cell lines offer significant logistical advantages over primary cells when used for in-vitro studies. Immortalized cells may, however, exhibit important differences relative to their primary cell counterparts. In this study, microarrays were used to make a genome-wide comparison between primary human umbilical vein endothelial cells (HUVECs) and EA.hy926, an immortalized HUVEC cell line, in their baseline properties and in their response to inhibition of the mevalonate pathway with an inhibitor of hydroxy methylglutaryl-coenzyme A reductase (statin). HUVECs and EA.hy926 were incubated with control medium, atorvastatin, mevalonate, or a combination of atorvastatin and mevalonate for 24 h. Gene expression profiles were obtained in duplicates using Affymetrix Human Genome U133A 2.0 arrays (Santa Clara, California, USA). Probe-sets were selected according to the following criteria: a twofold or greater increase/decrease in atorvastatin-treated cells compared with untreated cells; a twofold or greater reversal of the effect of atorvastatin by combined treatment with atorvastatin and mevalonate; no significant change in gene expression in cells treated with mevalonate alone compared with untreated cells. Most genes that were expressed by untreated HUVECs, were also expressed by untreated EA.hy926 cells. EA.hy926 cells, however, constitutively expressed a large number of additional genes, many of which were related to cell cycle control and apoptosis. Atorvastatin induced differential expression (> or = twofold) of 103 genes in HUVECs (10 up, 93 down) and 466 genes in EA.hy926 cells (198 up, 268 down). Applying the above selection criteria, thrombomodulin and tissue plasminogen activator were up-regulated in both cell types, whereas, connective tissue growth factor, thrombospondin-1, and cysteine-rich angiogenic inducer 61 were down-regulated. In conclusion, EA.hy926 cells retain most of the characteristics of endothelial cells under baseline conditions as well as after treatment with atorvastatin. It is necessary, however, to carefully select and validate changes in genes that are the focus of studies when using EA.hy926 cells. While this cell line is highly useful in studies on some genes, including genes encoding molecules involved in regulating thrombohemorrhagic homeostasis, they appear to be less suited for studies focused on other genes, particularly those involved in the regulation of cell proliferation and apoptosis.     

Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial.

BACKGROUND: Somatisation is highly prevalent in primary care (present in 25% of visiting patients) but often goes unrecognised. Non-recognition may lead to ineffective treatment, risk of iatrogenic harm, and excessive use of healthcare services. AIM: To examine the effect of training on diagnosis of somatisation in routine clinical practice by general practitioners (GPs). DESIGN OF STUDY: Cluster randomised controlled trial, with practices as the randomisation unit. SETTING: Twenty-seven general practices (with a total of 43 GPs) in Vejle County, Denmark. METHOD: Intervention consisted of a multifaceted training programme (the TERM [The Extended Reattribution and Management] model). Patients were enrolled consecutively over a period of 13 working days. Psychiatric morbidity was assessed by means of a screening questionnaire. GPs categorised their diagnoses in another questionnaire. The primary outcome was GP diagnosis of somatisation and agreement with the screening questionnaire. RESULTS: GPs diagnosed somatisation less frequently than had previously been observed, but there was substantial variation between GPs. The difference between groups in the number of diagnoses of somatisation failed to reach the 5% significance (P = 0.094). However, the rate of diagnoses of medically unexplained physical symptoms was twice as high in the intervention group as in the control group (7.7% and 3.9%, respectively, P = 0.007). Examination of the agreement between GPs' diagnoses and the screening questionnaire revealed no significant difference between groups. CONCLUSION: Brief training increased GPs' awareness of medically unexplained physical symptoms. Diagnostic accuracy according to a screening questionnaire remained unaffected but was difficult to evaluate, as there is no agreement on a gold standard for somatisation in general practice.     

Metaproterenol (Alupent) metered dose inhaler in children 5-12 years of age

This multiclinic study was performed to evaluate the safety and efficacy of metaproterenol sulfate (Alupent) metered dose inhaler in children with asthma ages 5 to 12 years. A total of 268 children completed this study according to the protocol, having received either metaproterenol or placebo for 30 consecutive days. Full spirometric testing was done pre- and postdose on Days 1 and 30 for a total duration of 6 hours on each day. The results showed that metaproterenol was consistently superior to placebo in all pulmonary function parameters measured on Days 1 and 30. This difference was statistically significant for peak values and areas under the curves for both FEV1 and FEF25-75%. There were no significant side effects noted. We conclude that metaproterenol metered dose inhaler is safe and effective in the treatment of asthma in children ages 5 to 12 years.