The opportunity to do better: lessons old and new from Germany's health system

As the U.S. undertakes national health reform, it would do well to consider both the old and new lessons offered by Germany's century-old universal health system. "Old" principles include an explicit national policy, shared financial responsibility, universality of coverage, and structured financing. New lessons, which are more concerned with operational strategies, include societal affordability, budgets, supply side restrictions, and volume controls.     

Bone marrow transplantation for feline mucopolysaccharidosis I

Severe mucopolysaccharidosis type I (MPS I) is a fatal neuropathic lysosomal storage disorder with significant skeletal involvement. Treatment involves bone marrow transplantation (BMT), and although effective, is suboptimal, due to treatment sequelae and residual disease. Improved approaches will need to be tested in animal models and compared to BMT. Herein we report on bone marrow transplantation to treat feline mucopolysaccharidosis I (MPS I). Five MPS I stably engrafted kittens, transplanted with unfractionated bone marrow (6.3x10(7)-1.1x10(9) nucleated bone marrow cells per kilogram) were monitored for 13-37 months post-engraftment. The tissue total glycosaminoglycan (GAG) content was reduced to normal levels in liver, spleen, kidney, heart muscle, lung, and thyroid. Aorta GAG content was between normal and affected levels. Treated cats had a significant decrease in the brain GAG levels relative to untreated MPS I cats and a paradoxical decrease relative to normal cats. The alpha-l-iduronidase (IDUA) activity in the livers and spleens of transplanted MPS I cats approached heterozygote levels. In kidney cortex, aorta, heart muscle, and cerebrum, there were decreases in GAG without significant increases in detectable IDUA activity. Treated animals had improved mobility and decreased radiographic signs of disease. However, significant pathology remained, especially in the cervical spine. Corneal clouding appeared improved in some animals. Immunohistochemical and biochemical analysis documented decreased central nervous system ganglioside storage. This large animal MPS I study will serve as a benchmark of future therapies designed to improve on BMT.     

Modern restorative management of patients with congenitally missing teeth: 3. Conventional restorative options and considerations

Restoration of spaces in hypodontia patients needs to take into account many factors including, the number of missing teeth, the distribution of space, the size of the teeth, and the age of the patient. This paper considers adhesive and conventional bridgework, as well as removal alternatives for the restoration of spaces. The various merits of each are discussed, together with treatment planning considerations for such cases.     

Issues related to children participating in clinical research

Research involving children is necessary to bridge the gap created by years of applying the findings of adult clinical trials to children. Given the mandate from the National Institutes of Health to include children in clinical trials, pediatric nurses will undoubtedly be asked to assist with pediatric research projects. Nurses working with children must consider the unique legal and ethical issues surrounding children as study participants. The purpose of this article is to examine issues related to children participating in clinical research. A review of pertinent literature is summarized, and practical approaches to the recommendations are discussed.     

Dietary supplements for the prevention and treatment of coronary artery disease

PURPOSE: With the recent growth in the use of dietary supplements, it is increasingly important for clinicians to be familiar with the evidence for and against their efficacy. We set out to systematically review the dietary supplements available for the prevention and treatment of coronary artery disease. METHODS: Between May 2004 and May 2006, we searched MEDLINE, the Cochrane Library, and Pro-Quest using the MeSH terms hypertension, hypercholesterolemia, myocardial infarction, dietary supplements, and herb-drug interactions. The MeSH terms of individual supplements identified were then added to the search. Reference lists of pertinent papers were also searched to find appropriate papers for inclusion. We included randomized controlled trials published in English of at least 1 week's duration that studied the efficacy of supplements in the treatment of hypercholesterolemia, or hypertension, or in the prevention of cardiac events. Qualifying papers were identified and assigned a Jadad quality score. In areas of uncertainty, a second investigator independently scored the trial. RESULTS: Fifteen (15) supplements were identified. Of these, most had little data available and most of the data were of poor quality. The supplements with the most supporting data were policosanol and garlic, both for hyperlipidemia. CONCLUSIONS: A growing body of literature exists for numerous supplements in the prevention of coronary artery disease, but much of these data are inconclusive. Clinicians should become familiar with the extent and limitations of this literature so that they may counsel their patients better.     

Evidence that in vivo wear damage alters kinematics and contact stresses in a total knee replacement

Polyethylene wear after a total knee arthroplasty is inevitable. The effects of the wear particles on the surrounding soft tissue causing inflammatory responses and eventual aseptic loosening are well documented, but the biomechanical changes from polyethylene wear have been less understood. This study investigated how wear from a retrieved polyethylene insert from a total knee arthroplasty changed the kinematics and contact stresses. A cruciate-retaining total knee implant (Natural-Knee, Intermedics Orthopedics, Inc., Austin, Texas) was retrieved from a donor program. The polyethylene insert was then scanned and modeled. KneeSIM (LifeMOD/KneeSIM, San Clemente, California) was used to simulate one cycle of gait of three second duration (100% of cycle). A threefold increase in contact stress as well as resulting kinematic changes were seen when the model was used to compare the retrieved versus a modeled off-the-shelf new polyethylene insert. Total knee designs should take into account the wear patterns that result from years of use and how they may affect the biomechanics of the knee long term.