Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders.

BACKGROUND: A number of meta-analyses have led to contradictory results regarding the efficacy of the psychological and pharmacological treatment of anxiety disorders. The main reasons for these inconsistent results seem to be the inclusion of heterogeneous studies and influences of selection biases. We performed a meta-analysis, which only included studies using a direct comparison of pharmacological, psychological, or combined treatments. METHOD: Sixteen studies on panic disorder, six studies on social anxiety disorder, and two studies on generalized anxiety disorder have been analyzed. Effect sizes for differences between the different treatment modalities were calculated. Also, the effect sizes of the pre-post differences were calculated. RESULTS: Pharmacological treatment, cognitive-behavioural treatment, and the combination of both treatment modalities all led to substantial improvement between pre- and post-treatment. Combined pharmacological and psychological treatment was superior to the monotherapies for panic disorder. For social anxiety disorder, there is only preliminary support for combined treatment. Due to lack of sufficient data, no final conclusions can be drawn for generalized anxiety disorder. CONCLUSIONS: While drug treatment and CBT showed equal efficacy, only in panic disorder the combination of pharmacological and psychological treatment was superior to either treatment alone. For the other anxiety disorders, the evidence for greater efficacy of combination treatment is still not sufficient due to lack of studies.     

Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results

The purpose of the study was to evaluate the mid-term results of surgical treatment in different groups of patients with multiple knee ligament injuries. Review of our patients’ records revealed that 48 acute and chronic patients were surgically treated for combined knee injury. Due to severe capsular damage in these injuries, open techniques were used. In our treatment protocol, avulsed ligaments and tears of the posterolateral and posteromedial corner were repaired if possible, whereas midsubstance tears of cruciate ligaments and chronic cases were reconstructed with autografts. Postoperatively, an accelerated program of rehabilitation was introduced, aiming to progressively mobilize the joint and improve muscle endurance. For the follow-up evaluation we designed a protocol composed of two parts. In the first part, anatomical lesions were recorded and in the second part, clinical evaluation was performed using the Lysholm score, the Tegner rating system, the IKDC evaluation form, and the KT1000. Student’s t tests and chi-square tests were used for data analysis. Forty-eight patients (mean age 28.6±11.9 years; 41 males) were classified according to the specific anatomical structures involved. Group A included 12 anterior cruciate ligament (ACL) and medial structure injuries, group B included 11 ACL or posterior cruciate ligament (PCL) ruptures combined with posterolateral injuries, and group C consisted of 25 knee dislocations (ACL and PCL ruptures which might be combined with damage of the collateral ligaments). Thirty-eight patients were surgically treated during the acute phase and ten patients were treated chronically. Forty-four patients (91.6%) were followed up at a mean of 51.3±29.9 months. Average Lysholm score was 87±12.3; average Tegner score was 5.09±2.19 before accident and 4.34±2.12 in re-examination; IKDC score was A in 10 cases, B in 22, C in 6, and D in 6. The mean range of motion was 129.9°±12.5°. The average loss of extension and flexion were 1.6°±2.5° and 7.6°±7.9°, respectively. The side-to-side difference in corrected anterior and posterior translation in quadriceps neutral angle and in anterior translation in 30° angle was <3 mm for about 65% of our patients. Surgical treatment of multiple knee ligament injuries, using autografts, provided satisfactory stability, range of motion, and subjective functional results. However, despite the improvement of the quality of life, the preinjury patients’ activity level was not fully obtained in re-examination. Patients underwent surgical treatment during the acute phase had better scores in several points, but finally there was no statistical significance between acute and chronic patients. Moreover, no statistically significant differences were observed among the groups with specific damaged anatomical structures.     

Arthroscopic treatment of synovial chondromatosis of the ankle

A 34-year-old male soccer player with chronic right ankle dysfunction and a history of repeated ankle joint injuries is presented. Imaging studies revealed synovial chondromatosis of the ankle joint. Arthroscopic partial synovectomy was performed and more than 20 loose bodies were excised. Four months postoperatively the patient was asymptomatic and has returned to his previous level of sport activities. At the latest follow-up, 2 years after the initial diagnosis there is no local recurrence of the disease. Arthroscopy is a minimal invasive surgical technique, with satisfactory results in the treatment of synovial chondromatosis of the ankle joint.     

The development of involuntary and voluntary attention from childhood to adulthood: a combined behavioral and event-related potential study.

OBJECTIVE: This study investigated auditory involuntary and voluntary attention in children aged 6-8, 10-12 and young adults. The strength of distracting stimuli (20% and 5% pitch changes) and the amount of allocation of attention were varied. METHODS: In an auditory distraction paradigm event-related potentials (ERPs) and behavioral data were measured from subjects either performing a sound duration discrimination task or watching a silent video. RESULTS: Pitch changed sounds caused prolonged reaction times and decreased hit rates in all age groups. Larger distractors (20%) caused stronger distraction in children, but not in adults. The amplitudes of mismatch negativity (MMN), P3a, and reorienting negativity (RON) were modulated by age and by voluntary attention. P3a was additionally affected by distractor strength. Maturational changes were also observed in the amplitudes of P1 (decreasing with age) and N1 (increasing with age). P2-modulation by voluntary attention was opposite in young children and adults. CONCLUSIONS: Results suggest quantitative and qualitative changes in auditory voluntary and involuntary attention and distraction during development. The processing steps involved in distraction (pre-attentive change detection, attention switch, reorienting) are functional in children aged 6-8 but reveal characteristic differences to those of young adults. In general, distractibility as indicated by behavioral and ERP measures decreases from childhood to adulthood. SIGNIFICANCE: Behavioral and ERP markers for different processing stages involved in voluntary and involuntary attention reveal characteristic developmental changes from childhood to young adulthood.     

Posttraumatisches septisches Abdomen

Abdominal infection has the fifth highest incidence of all posttraumatic infections but has the second highest mortality rate with 25%,pneumonia,with 29%, being the only posttraumatic infection that is more frequently lethal.Posttraumatic abdominal sepsis, on the other hand, has a mortality rate of almost 50%.This rate cannot be reduced except by prompt identification of the correct diagnosis of the underlying injury or complication.This means that delayed laparotomy is strikingly detrimental in these patients, with 46% mortality as opposed to 11% in patients who undergo laparotomy promptly. In parallel with this, the mortality of fresh-onset and localized peritonitis is 14%,whereas that of diffuse purulent peritonitis is up to a devastating 42%.     

Rekonstruktion und Stabilisierung nach fehlverheilten Frakturen und Pseudarthrosen im Femurbereich mit Marknagel und anderen Osteosyntheseverfahren (LISS-System)

Malunion and nonunion after fracture present many difficulties in trauma surgery. Selection of the best therapy and operative techique requires careful analysis of the complications. Hyperthrophic nonunion of the femur shaft is mostly best treated with locking reamed nails. Significant differences in torsions after nailing can be corrected by repositioning of the distal interlocking screws if recognized sufficiently early. After fracture healing an open rotation osteotomy is necessary; stabilization can be achieved by means of medullary nails or a condylar plate. How a malalignment of the bone axis is corrected depends on the position of a malunion, the functional deficit caused, and the biomechanical demands on the joint. Condylar plates can often solve the problems in this region. There are also guidelines for ¶the treatment of atrophic and infected nonunions (recommended procedures are ¶aggressive debridement, autologous cancellous bone graft, and biological osteosynthesis), but the treatment of individual cases requires a exhaustive knowledge of and experience in this special field. It is quite common for even well-established procedures to fail. When the bone is biologically reduced and this is the reason for malunion newly developed techniques of internal fixation can be applied. The less invasive stabilization system (LISS), combined with autologous cancellous bone grafting if necessary, can result in healing even in a worst-case scenario.     

Video-enhanced visualization of the larynx and intubation with the Bullard laryngoscope — equipment report

PURPOSE: A simple technical solution is presented to provide video transmission from the tip of a Bullard laryngoscope to a bedside video display, while the operator is still able to look through the viewing ocular of the Bullard laryngoscope during tracheal intubation. EQUIPMENT: This is achieved by insertion of an ultrathin fibreoptic video-endoscopic system into the working channel of the Bullard laryngoscope. Thereby the view from the distal blade tip is transmitted to a bedside monitor, without interfering with the use of the Bullards laryngoscope's original eyepiece. The presented technical solution allows video transmission without considerable additional weight normally associated with attaching video endoscopy cameras, light and camera cables to endoscopic devices. Thus, the Bullard laryngoscope remains lightweight and easy to maneuver. A screw-threaded adapter with a side-port is proposed to prevent displacement of the fibreoptic cable while still allowing application of oxygen. CONCLUSION: Experience and skills with tracheal intubation using the presented video-enhanced Bullard laryngoscope can be achieved in the originally intended way, while the supervisor or attending viewers can follow the tracheal intubation procedure on the video display.     

Tissue engineering of bone for mandibular augmentation in immunocompetent minipigs: preliminary study.

Large mandibular defects caused by trauma, infection or resection of a tumour are still a major problem for plastic and maxillofacial surgeons. The modern concept of tissue engineering combines the osteoinductive effects of osteogenic cells with a suitable scaffold structure to promote differentiation of osteoblasts and optimal matrix production. Critical size mandibular bone defects were therefore made to investigate the osteogenic potential of periosteal cells and a bioabsorbable polymer fleece (Ethisorb 510) in minipigs. Periosteal cells were isolated from four minipigs, expanded in vitro and seeded with fibrin glue into Ethisorb 510 fleeces. Tissue constructs were used to repair critical size mandibular defects and compared with two minipigs with untreated bone defects. Bone healing was evaluated after 90 and 180 days by radiographs and a histological scoring system. The radiographs showed increased radiodensity of defects filled with the cell-fibrin-fleece-constructs compared with the untreated control group after 90 and 180 days in vivo. The defects repaired by the cell-fibrin-scaffolds (180 days in vivo) obtained the highest histological mean score 2.9 (range 2-3), while defects filled by cell-fibrin-scaffolds (90 days in vivo) achieved a mean score of 2.1 (range 2-3). In contrast, the control group (n = 2) scored 1 and 2. The results show that a combination of periosteal cells and polymer fleeces may be a promising approach for clinical mandibular augmentation.     

Radiation therapy in proliferative vitreoretinopathy

In a prospective study of the effect of postoperative radiation therapy for the prevention of reproliferation of membranes and recurrent proliferative vitreoretinopathy (PVR) two similar groups of patients with retinal detachment and PVR grade D1 to D3 in one eye were compared. Half the eyes (30) received a total dose of 3000 cGy after surgery; the other half remained untreated. After a followup of 6 months and 14 months or more (maximum 36 months) the anatomical and functional results of each group were compared. After 6 months in the unirradiated group 57% (17/30) remained attached and 43% (13/30) had detached again. In the irradiated group 63% (19/30) were attached and 37% (11/30) had detached. However, there was no statistically significant difference between the two groups (P=0.479, Fisher's Exact Test). After 14 months the number of cured and uncured eyes remained the same in the unirradiated group, while in four of the eyes in the irradiated group a later onset of reproliferation and detachment occurred (after 7, 8, 12 and 14 months, respectively). A final cure rate of 57% (17/30) was achieved in the unirradiated group and a 50% (15/30) cure rate in the irradiated group. Thus the failure rate was 43% (13/30) in the unirradiated group and 50% (15/30) in the irradiated group (P=0.473, Fisher's Exact Test). No side effects from the radiation were observed in any case and no radiation retinopathy occurred during an observation period of up to 3 years. The visual acuity of the cured treated and cured untreated eyes was similar in the two groups. From these results we conclude that immediate radiation treatment does not improve the long-term results and does not reduce the number of reoperations. In a considerable number of treated eyes the onset of reproliferation was delayed from 7 to 14 months, whereas in the untreated group reproliferation was always observed during the first 6 months. A combination of various antiproliferative and antiinflammatory therapies are needed to suppress recurrent PVR after succesful vitreoretinal surgery and to minimize the side effects of these treatments.Presented in part at the XVIIth Meeting of the Club Jules Gonin, 1–6 September 1990, Lausanne