Leitlinien Aortenerkrankungen der European Society of Cardiology

Zeitschrift für Herz-,Thorax- und Gefäßchirurgie - In der Aortenmedizin sind noch viele Fragen offen. Leitlinien helfen uns dabei, die bestmögliche Entscheidung zur Therapie...     

Management of gout in the real world: current practice versus guideline recommendations

Objectives: Gout is a chronic, extremely painful disease that is potentially curable when treated effectively. Unfortunately approximately one-half of patients with gout are inadequately controlled. Methods: We surveyed 315 primary care physicians in the United States and Europe to investigate current practice in the real world, as distinct from recommendations in guidelines. Results: Our survey on 1657 patients found that regular testing of serum uric acid, in conformity with the guidelines, was conducted by approximately 50% of physicians. Advice to patients on diet and lifestyle was less well implemented, and identification of overweight/obese patients was inconsistent. Conclusion: Improvements in practice by physicians would include comprehensive assessment of the patient, adoption of regular monitoring during treatment, and the provision of patient education on adherence and lifestyle.     

Shear strength of the human lumbar spine

Background

Shear loading is recognised as a risk factor for lower back pain. Previous studies of shear loading have either not addressed the influence of age, bone mineral density, axial height loss due to creep or were performed on animal specimens.

Methods

Intact human lumbar motion segments (L2–3) were tested in shear using a modified materials testing machine, while immersed in a Ringer bath at 37 °C. Vertebrae were rigidly embedded in neutral posture (0° flexion) and subjected to a constant axial compression load of 500 N. Shear was applied to three groups: ‘Young-No-Creep’ (20–42 years), ‘Young-Creep’ (22–38 years, creep 1000 N for 1 h) and ‘Old-No-Creep’ (44–64 years). Failure was induced by up to 15 mm of anterior shear displacement at a rate of 0.5 mm/s. The trabecular and apophyseal joint bone mineral densities were evaluated from computed tomography images of the intact lumbar spines.

Findings

Peak shear force correlated positively with trabecular bone mineral density for specimens tested without axial creep. No significant differences were observed with respect to age. During shear overload specimens increased in height in the axial direction.

Interpretation

Trabecular bone mineral density can be used to predict the peak force of lumbar spine in shear in neutral posture.     

Influence of time in-situ and implant type on fixation strength of cemented tibial trays - A post mortem retrieval analysis

Background

Loosening of the tibial tray is cited as the most common cause of failure in total knee arthroplasty but the mechanism remains unclear. Post mortem specimens provide a unique opportunity to investigate the clinical condition.

Methods

Twenty two cemented components were serially retrieved in situ at autopsy from a university clinic. They were investigated for mechanical stability by pull-out, which was related to cement morphology and bone quality from CT scans, and to polyethylene wear by score analysis. Implants were grouped into three types: a particular fixed bearing design (n = 8), a particular rotating platform design (n = 5) and other mixed designs (n = 9).

Findings

Trends were observed for pull-out force to decrease with time in situ and increase with cement penetration but was unrelated to bone density or polyethylene wear. For the fixed bearing implants decreasing pull-out strength was related to an increasing proportion of failure at the bone–cement interface. For the mixed designs the opposite was observed. The rotating platform implants failed at the implant–cement interface.

Interpretation

The analysis demonstrated that interface failure is dependent on the implant design, but that both the stem and the bone interfaces weaken with time in situ. Published findings for laboratory implantations have demonstrated that greater cement penetration improves fixation and this was reflected for clinical samples in this study.     

Influence of press-fit parameters on the primary stability of uncemented femoral resurfacing implants

Primary stability is essential to the success of uncemented prostheses. It is strongly influenced by implantation technique, implant design and bone quality. The goal of this study was to investigate the effect of press-fit parameters on the primary stability of uncemented femoral head resurfacing prostheses. An in vitro study with human specimens and prototype implants (nominal radial interference 170 and 420 microm) was used to investigate the effect of interference on primary stability. A finite element model was used to assess the influence of interference, friction between implant and bone, and bone quality. Primary stability was represented by the torque capacity of the implant. The model predicted increasing stability with actual interference, bone quality and friction coefficient; plastic deformation of the bone began at interferences of less than 100 microm. Experimentally, however, stability was not related to interference. This may be due to abrasion or the collapse of trabecular bone structures at higher interferences, which could not be captured by the model. High nominal interferences as tested experimentally appear unlikely to result in improved stability clinically. An implantation force of about 2,500 N was estimated to be sufficient to achieve a torque capacity of about 30 N m with a small interference (70 microm).     

Intraosseous lymphocytic infiltrates after hip resurfacing arthroplasty

To identify a possible role of lymphocytic infiltrates in failure mechanism of the metal-on-metal hip resurfacing arthroplasty, the extent of lymphocytic infiltration was compared with reasons for prosthesis failure in a series of retrieval specimens. One hundred eighty-one femoral head and neck remnants were subjected to thorough analysis of histological findings and clinical data. Lymphocytic infiltrates were considered weak to moderate in 52 (28.7%) and excessive in ten (5.5%) cases. Six cases with excessive lymphocytic infiltrates belonged to the group of 33 (18.2%) revisions without obvious cause (periprosthetic fracture, component loosening, and infection) for prosthesis failure. Excessive lymphocytic infiltrates were strongly linked to the presence of proliferative desquamative synovitis (p < 0.0001). Both the excessive lymphocytic infiltrates and proliferative desquamative synovitis were associated with female gender (p < 0.05). We hypothesize that a specific cause of groin pain might be related to excessive intraosseous lymphocytic infiltrates and explained possibly by the hypersensitivity reaction of the delayed type after the hip resurfacing arthroplasty. Proliferative desquamative synovitis might constitute another morphologic feature associated with the delayed type hypersensitivity reaction.     

Psychometric evaluation of a visual analog scale for the assessment of anxiety

Background  

Fast-acting medications for the management of anxiety are important to patients and society. Measuring early onset, however, requires a sensitive and clinically responsive tool. This study evaluates the psychometric properties of a patient-reported Global Anxiety - Visual Analog Scale (GA-VAS).     

Patient characteristics and patterns of drug use for sleep complaints in the United States: analysis of National Ambulatory Medical Survey data, 1997-2002

OBJECTIVE: The aims of this work were to characterize ambulatory patients in the United States presenting with primary or secondary insomnia complaints and resultant diagnoses, and to describe the characteristics of patients treated with medications commonly used for sleep complaints. METHODS: Data from the National Ambulatory Medical Care Survey for the years 1997 through 2002 were analyzed. Data were stratified by patient characteristics, physician specialty, resulting diagnosis, and medications prescribed or provided. The unit of analysis was the individual patient visit; statistical comparisons were made using the chi(2) test for categorical variables and the Rao-Scott design-adjusted chi(2) test for comparisons of patient age groups. P<0.05 was the criterion for statistical significance. Cells containing < 30 observations were not included in the statistical analysis. RESULTS: The data included 147,945 patient visit records; rates of physician response to the survey ranged from 62.9% in 1999 to 70.4% in 2002. Based on this sample, it was projected that 30 million office visits involved insomnia complaints over the 6-year period from 1997 to 2002 throughout the United States. With a total of 4.9 billion physician visits projected for that time period, 0.6% of visits were insomnia related. Women were 1.5 times more likely to have insomnia-related visits (P<0.001). Overall, the greatest proportion of insomnia patients of both sexes was between the ages of 18 and 64 years (P<0.001). Sleep difficulties were most frequently attributed to organic disorders, depression and/or anxiety, and primary insomnia (55.8%, 27.3%, and 9.8%, respectively; P<0.001). The most frequently prescribed or recommended medications were zaleplon/zolpidem and trazodone (28.5% and 32.0%, respectively; P<0.001). Zaleplon and zolpidem were most frequently used for patients with organic diagnoses and those aged < or =65 years (33.2% and 29.8%; P<0.001). CONCLUSIONS: Demographics of patients with insomnia and their diagnoses from 1999 to 2002 remained stable, but the use of medications changed predictably as newer agents became available.     

Psychometric evaluation of the medical outcomes study-sleep scale in persons with overactive bladder

BACKGROUND: The Medical Outcomes Study-Sleep Scale (MOS-SS) is a commonly used self-reported instrument for assessing key constructs of sleep quality and quantity. Even though the MOS-SS has successfully undergone previous validation studies in the general population, it has not been evaluated in patients with overactive bladder (OAB). OBJECTIVE: The aim of this study is to evaluate the applicability of the MOS-SS to persons with a diagnosis of OAB. METHODS: This study was a follow-up to a national nested case-control survey designed to provide estimates of the prevalence of OAB in the United States. OAB patients (N = 363) who consented to participate were mailed a postal survey to assess OAB symptoms and health-related quality of life. Analyses were then undertaken to assess the psychometric properties of the MOS-SS in this OAB sample. Psychometric evaluation of the MOS-SS included construct validity, internal consistency reliability, correlation between domains, floor/ceiling effects, and an examination of the factor structure. Results were compared with the original validation population of the MOS-SS by . RESULTS: Internal consistency, correlations between domains, and floor/ceiling effects were generally consistent with results from the original validation study. Factor loadings of the MOS-SS items, as well as tests of construct validity, were similar between persons with OAB and individuals in the original validation population. CONCLUSION: Psychometric evaluation conducted in this study supports the use of the MOS-SS instrument to assess sleep problems among persons with OAB.