The management of infection in arthroplasty of the shoulder

The management and outcome of treatment in 42 patients (49 shoulders) with an infected shoulder prosthesis was reviewed in a retrospective multicentre study of 2343 prostheses. The factors which were analysed included the primary diagnosis, the delay between the diagnosis of infection and treatment and the type of treatment. Treatment was considered to be successful in 30 patients (71%). Previous surgery and radiotherapy were identified as risk factors for the development of infection. All patients with an infected prosthesis had pain and limitation of movement and 88% showed radiological loosening. In 50% of the shoulders, the antibiotics chosen and the length of treatment were considered not to be optimal. The mean follow-up was 34 months. Antibiotics or debridement alone were ineffective. In acute infection, immediate revision with excision of all infected tissue and exchange of the prosthesis with appropriate antibiotic therapy gave the best results. Multidisciplinary collaboration is recommended.

The management of infection in arthroplasty of the shoulder

The management and outcome of treatment in 42 patients (49 shoulders) with an infected shoulder prosthesis was reviewed in a retrospective multicentre study of 2343 prostheses. The factors which were analysed included the primary diagnosis, the delay between the diagnosis of infection and treatment and the type of treatment. Treatment was considered to be successful in 30 patients (71%). Previous surgery and radiotherapy were identified as risk factors for the development of infection. All patients with an infected prosthesis had pain and limitation of movement and 88% showed radiological loosening. In 50% of the shoulders, the antibiotics chosen and the length of treatment were considered not to be optimal. The mean follow-up was 34 months. Antibiotics or debridement alone were ineffective. In acute infection, immediate revision with excision of all infected tissue and exchange of the prosthesis with appropriate antibiotic therapy gave the best results. Multidisciplinary collaboration is recommended.

Reliability of the Pediatric Evaluation of Disability Inventory (PEDI)

Pediatric Evaluation of Disability Inventory (PEDI) is an instrument for evaluating function in children with disabilities aged 6 months to 7.5 years. The PEDI measures both functional performance and capability in three domains: (1) self-care, (2) mobility, and (3) social function. The PEDI has recently been translated into Norwegian. The purpose of this study was to investigate the inter-rater, inter-respondent and intra-rater reliability of the Norwegian version of the PEDI. Reliability was investigated in a sample of 30 Norwegian children without disabilities between 1.0 and 5.0 years. Interviews with parents were conducted twice by the same occupational therapist, and once by a physiotherapist. Kindergarten teachers were also interviewed by the occupational therapist. Using children without disabilities allows us to set up a standard for functional ability. Deviation from the point may indicate improvement or worsening of the state. The inter-rater and intra-rater part of the study showed excellent agreement of the observations, indicated both by small differences and high Intraclass Correlation Coefficients (ICC) (0.95-0.99). The discrepancy between the different interviews was highest between the reports from the parents and the kindergarten teachers (inter-respondent reliability), indicated by ICC from 0.64-0.74. Results of this study indicate that improved reliability is secured when the same interviewer interviews the same respondent, as well as when two trained interviewers interview the same respondent. The consistency of scores should be reviewed when different respondents are interviewed. Professionals administering the PEDI needs to be trained following a required procedure in order to secure consistency in their rating.

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands

OBJECTIVES

To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations.

DESIGN

Analysis of the primary care sections of clinical practice guidelines.

SETTING

Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands.

MAIN OUTCOME MEASURES

Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence.

RESULTS

Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews.

CONCLUSION

The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.

Is the childbirth experience improved by a birth plan?

From antenatal clinics in Sweden, 271 women were recruited after week 33 of pregnancy and given a questionnaire designed to assess their attitudes and feelings about the coming childbirth. Thereafter, they formulated a birth plan. The midwife in attendance at the birth was able to refer to this plan. Women who followed this program were compared with women from the same clinics who were asked to complete a questionnaire during the first postpartum week to assess their birth experience. A questionnaire at the end of pregnancy, followed by a birth plan, was not effective in improving women's experiences of childbirth. In the birth plan group, women gave significantly lower scores for the relationship to the first midwife they met during delivery, with respect to listening and paying attention to needs and desires, support, guiding, and respect. Although a birth plan did not improve the experience of childbirth in the overall group, there may be beneficial effects with regard to fear, pain, and concerns about the newborn for certain subgroups of women.

Identification, Phylogenetic Analysis, and Biological Characterization of Serratia marcescens Strains Causing Cucurbit Yellow Vine Disease

ABSTRACT A serious vine decline of cucurbits known as cucurbit yellow vine disease (CYVD) is caused by rod-shaped bacteria that colonize the phloem elements. Sequence analysis of a CYVD-specific polymerase chain reaction (PCR)-amplified 16S rDNA product showed the microbe to be a gamma-proteobacterium related to the genus Serratia. To identify and characterize the bacteria, one strain each from watermelon and zucchini and several noncucurbit-derived reference strains were subjected to sequence analysis and biological function assays. Taxonomic and phylogenetic placement was investigated by analysis of the groE and 16S rDNA regions, which were amplified by PCR and directly sequenced. For comparison, eight other bacterial strains identified by others as Serratia spp. also were sequenced. These sequences clearly identified the CYVD strains as Serratia marcescens. However, evaluation of metabolic and biochemical features revealed that cucurbit-derived strains of S. marcescens differ substantially from strains of the same species isolated from other environmental niches. Cucurbit strains formed a distinct cluster, separate from other strains, when their fatty acid methyl ester profiles were analyzed. In substrate utilization assays (BIOLOG, Vitek, and API 20E), the CYVD strains lacked a number of metabolic functions characteristic for S. marcescens, failing to catabolize 25 to 30 compounds that were utilized by S. marcescens reference strains. These biological differences may reflect gene loss or repression that occurred as the bacterium adapted to life as an intracellular parasite and plant pathogen.

[Less ethnic knowledge in the Dutch College of General Practitioner's practice guidelines on type 2 diabetes mellitus, hypertension and asthma in adults than in the supporting literature]

OBJECTIVE

To assess whether ethnic differences present in the scientific literature used as the basis for the Dutch College of General Practitioner's (NHG) practice guidelines were reflected in the ethnic-specific information the guidelines contained.

DESIGN

Analysis of published information.

METHOD

The scientific literature used as the basis for the guidelines about type 2 diabetes mellitus, hypertension and asthma in adults was collected and carefully screened. Relevant ethnic-specific information was compared to the content of the guidelines.

RESULTS

Several relevant ethnic differences were stated in the scientific literature used as the basis for the guidelines. Differences in prevalence and clinical progress were stated for type 2 diabetes mellitus, differences in lung-volume were stated for asthma and differences in prevalence, onset, complications, response to pharmacological treatment and dietary salt restriction were stated for hypertension. The type 2 diabetes mellitus guideline stated a higher prevalence of diabetes in Hindustani people and recommended earlier screening in this group. The asthma guideline stated that the lung volume is dependent of ethnicity. The hypertension guideline did not state any ethnic-specific information.

CONCLUSION

The guidelines on type 2 diabetes mellitus, hypertension and asthma in adults only adopted a limited number of the ethnic differences contained in the scientific literature on which they were based. Possible explanations are that information was only included if there was a clear scientific basis, and that ethnic distinctions were found to be politically and socially undesirable. However, this lack of information might lead to ineffective or sub-optimal care for ethnic minorities.

Health Information Management Education at the Institute of Health Policy and Management of the Erasmus University Medical Center

This paper presents a review of the philosophy and content of the Master course of Health Information Management that is being taught at the Institute of Health Policy and Management of the Erasmus University Medical Center in Rotterdam, the Netherlands. We present our experiences of teaching this master course, including its predecessor. Our work, both teaching and researching, can be characterized by the sociotechnical approach of health informatics, which means that we focus on the interrelation of technology and its social environment.

Predicting verbal memory decline following anterior temporal lobectomy (ATL)

OBJECTIVE

To develop a multivariate risk factor model for predicting postoperative verbal memory decline in an individual patient following dominant or nondominant anterior temporal lobectomy (ATL).

METHODS

The authors studied 132 consecutive ATL patients who 1). were older than 16 years at surgery, 2). had estimated preoperative Full Scale IQ score of >69, 3) had unilateral language dominance based on the intracarotid amobarbital procedure (IAP), and 4) underwent neuropsychological testing at baseline and >or=6 months postoperatively (mean 1.2 years). Five potential risk factors for postoperative verbal memory decline were selected a priori that reflect the functional adequacy of the to-be-resected temporal lobe. These were 1). resection in the dominant hemisphere, 2). MRI findings other than exclusively unilateral mesial temporal sclerosis, intact preoperative 3). immediate and 4). delayed verbal memory function, and 5). intact IAP memory performance following injection contralateral to the seizure focus. Verbal memory decline was defined using two verbal memory tests and published reliable change indices.

RESULTS

Thirty-eight percent of the sample declined reliably on one or both verbal memory measures. Logistic regression analysis demonstrated that all five risk factors were significantly and independently associated with outcome, with side of surgery having the strongest association (p < 0.0001) and preoperative immediate verbal memory the weakest (p < 0.05).

CONCLUSIONS

An individual patient's risk for postoperative verbal memory decline following dominant or nondominant ATL can be predicted using clinical data routinely available preoperatively (side of surgery, qualitative MRI, baseline memory testing, IAP performance). This information may be useful for preoperative patient counseling.

Cerebellar ataxia and coenzyme Q10 deficiency

The authors measured coenzyme Q10 (CoQ10) concentration in muscle biopsies from 135 patients with genetically undefined cerebellar ataxia. Thirteen patients with childhood-onset ataxia and cerebellar atrophy had markedly decreased levels of CoQ10. Associated symptoms included seizures, developmental delay, mental retardation, and pyramidal signs. These findings confirm the existence of an ataxic presentation of CoQ10 deficiency, which may be responsive to CoQ10 supplementation.

Characterisation of porcine monocyte-derived dendritic cells according to their cytokine profile

The influence of interferon (IFN)-alpha on the in vitro differentiation of myeloid porcine dendritic cells (DC) was evaluated as the ability of the DC to stimulate to cell proliferation in a mixed leukocyte reaction (MLR), and as their ability to produce cytokines at exposure to bacterial and viral preparations. Porcine monocytes were enriched from purified peripheral blood mononuclear cells (PBMC) by plastic adherence and cultured in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-4 or in GM-CSF, IL-4 and IFN-alpha. After 5 days of culture, the cells developed a dendritic morphology and the proportion of cells expressing MHC class II and B7 molecules was increased as determined by flow cytometry. Dendritic cells, differentiated for 5 days in GM-CSF, IL-4 and IFN-alpha, were able to stimulate both allogeneic and syngeneic PBMC to proliferation in an MLR. The DC produced the Th1 associated cytokines IFN-alpha at Sendai virus stimulation, and IL-12 at stimulation with plasmid DNA (pre-incubated in the presence of lipofectin), heat-inactivated Actinobacillus pleuropneumoniae, UV-inactivated Aujeszky's disease virus and live Sendai virus. The heat-inactivated bacteria and Sendai virus also induced production of the Th2 associated cytokines IL-10 and IL-6. The addition of IFN-alpha during differentiation of DC in GM-CSF and IL-4 enhanced their ability to stimulate allogeneic and syngeneic MLR, but did not alter their ability to produce cytokines.

ICT in health care: sociotechnical approaches

The importance of the social sciences for medical informatics is increasingly recognized. As ICT requires inter-action with people and thereby inevitably affects them, understanding ICT requires a focus on the interrelation between technology and its social environment. Sociotechnical approaches increase our understanding of how ICT applications are developed, introduced and become a part of social practices. Socio-technical approaches share several starting points: 1) they see health care work as a social, 'real life' phenomenon, which may seem 'messy' at first, but which is guided by a practical rationality that can only be overlooked at a high price (i.e. failed systems). 2) They see technological innovation as a social process, in which organizations are deeply affected. 3) Through in-depth, formative evaluation, they can help improve system design and implementation.

Comparison of batch and perfusion culture in combination with pilot-scale expanded bed purification for the production of soluble recombinant beta-secretase

beta-Secretase is one of the prime targets for therapeutic intervention of Alzheimer's disease. For the development of a secretase inhibitor a steady supply of large quantities of a homogeneous and active recombinant beta-secretase is a prerequisite. Therefore various culture modes were investigated using HEK-293 cells stably transfected with soluble recombinant beta-secretase. The coupling of the Fc part of human IgG1 to the ectodomain of beta-secretase (residues 1-460) allowed a fast purification of the protein with rProtA expanded bed chromatography. Batch cultures of 5 to 50 L working volume run for 7 days showed reproducible cell growth and product yields of 3 mg/L purified protein. A 20 L perfusion culture was operated for 21 days, reaching a cell density of 30 x 10(6) cells/mL at a dilution rate of 2/d. The total product yield of the perfusion culture was 1.4 g of purified protein. The effect of different perfusion rates on cell growth, protein yield, and quality was investigated and compared to the results obtained in batch cultures. Protein quality was consistent as analyzed on 1D SDS-PAGE, and the final product contained both the mature and the pro form of beta-secretase. Although the cell specific protein expression was slightly reduced in perfusion culture, a substantial increase in specific activity of over 75% was achieved. Some of the increase in activity can be explained by an increase in the percentage of the mature form of the recombinant protein.

Integrating quantitative and qualitative methods in patient care information system evaluation: guidance for the organizational decision maker

OBJECTIVE

The aim of this paper is twofold. First, we describe two important dimensions of patient care information systems (PCIS) evaluation: the domain of evaluation and the different phases of the PCIS implementation. Second, we claim that, though Randomized Controlled Trials (RCTs) are often still seen as the standard approach, this type of design hardly generates relevant information for the organizational decision maker.

METHOD

Interpretive study of evaluation literature.

RESULTS AND CONCLUSIONS

The field of evaluation is scattered and the types of questions that can be asked and methods that can be used seem infinite and badly demarcated. Different stakeholders, moreover, often have different priorities in evaluating ICT. The most important reason for the lack of relevance of RCTs is that they are ill suited for investigating why and how a PCIS is being used, or not, and what the (often unplanned) effects and consequences are. Subsequently, our aim is to contribute to the discussion about the viability of qualitative versus quantitative methods in PCIS evaluation, by arguing for a specific integration of quantitative and qualitative research methods. The joint utilization of these methods, we claim, yields the richest results.

The search for synergy: interrelating medical work and patient care information systems

OBJECTIVES

This article aims to search for the way patient care information systems can be most fruitfully put to work in health care.

METHODS

Given the calls for improved health care quality, there is a need for IT's coordination capacities in health care. Yet IT's track record in this area is less than many expected. Moreover, many argue that the nature of health care work sets natural limits to the possibilities of IT to revolutionize this work. Starting with an analysis of the paper record, this article explores the way IT and professional work can be interrelated synergistically.

RESULTS

Two principles are discussed: 1) The key to a fruitful operation of IT in health care work lies in the unraveling of the care process, and the redistribution of tasks between professionals and the IT application. 2) Professionals should be given the skills and resources to adapt the IT application's demands to the needs of their work practices.

CONCLUSION

IT can bring true process support to health care when taking the two principles discussed here into account.

Childbirth experience in women at high risk: is it improved by use of a birth plan?

Women at obstetric high risk more often experience negative feelings related to childbirth than women with normal outcomes. For these high-risk women, an individual birth plan does not appear to improve the overall experience of childbirth; rather, it seems to intensify the negative feelings in several aspects. The increased vulnerability in women at high risk warrants special attention to the possibility that types of care routinely offered to all women may negatively influence the experiences of high-risk women.

Humoral immune response against Borna disease virus (BDV) in experimentally and naturally infected cats

In order to investigate the peripheral and intracerebral humoral immune response against Borna disease virus (BDV) in cats, serum and cerebrospinal fluid (CSF) samples from experimentally and naturally BDV-infected cats were analysed in two different test systems (indirect enzyme-linked immunosorbent assay and indirect immunofluorescent test). The experimentally infected cats developed high antibody titres against the major immunogenic BDV-proteins, p24 and p40. In contrast, the naturally infected cats showed a comparatively weak humoral immune response. The experimentally infected cats were inoculated with either BDV laboratory strain V or a feline BDV-isolate. Some differences existed between the two groups of cats. The former group developed a higher response against p40, whereas the latter group showed, beside the p40-response, a more pronounced p24-response, similar to the situation in the naturally infected cats.

Porcine interleukin-12 fusion protein and interleukin-18 in combination induce interferon-gamma production in porcine natural killer and T cells

A pcDNA3 vector containing a gene encoding a porcine interleukin-12 (poIL-12) fusion protein was constructed, with the p40 chain and its signal peptide positioned first, followed by a linker and the p35 domain. When expressed in COS cells, secreted poIL-12 fusion protein showed high activity in terms of ability to induce interferon-gamma (IFN-gamma) production in porcine peripheral blood mononuclear cells (PBMCs) in vitro. The IFN-gamma production induced by poIL-12 fusion protein, as well as heterodimeric poIL-12 and human IL-12, was markedly dependent on the presence of human IL-18 (huIL-18). Furthermore, huIL-18 showed a dose-dependent induction of IFN-gamma production in PBMC in the presence of a constant concentration of huIL-12. A marked synergism between poIL-12 and IL-18 was consequently observed in poPBMC. The actual IFN-gamma producing cells were identified as probable NK cells (about 30%) and T lymphocytes (about 70%), using flow cytometry. Furthermore, a histidine-tagged poIL-12 fusion protein was expressed in Drosophila melanogaster Schneider 2 cells, using a modified pMT/V5-His vector lacking the V5 epitope. Such poIL-12 fusion protein was easily purified using Ni-NTA agarose and retained high biological activity.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.