The effect of prosthetic mass properties on the gait of transtibial amputees—a mathematical model

PURPOSE

Present models in the literature, predicting that prostheses should not be too lightweight, are not supported by empirical evidence. Recent studies suggest that these models are incorrectly based on the assumption that the swing phase is uninfluenced by muscle activity. The purpose of the present study was to introduce a new mathematical model to predict the effect of mass properties on the gait of transtibial amputees, based on experimental findings that subjects adapt to mass perturbations by maintaining the same joint kinematics.

METHOD

Effect of mass perturbations on the lower leg was evaluated in terms of muscular cost and forces between stump and socket, using a linked-segment model of the swing phase. Gait analysis and anthropometric data from 10 transtibial amputees were used as model input.

RESULTS

Location of perturbation strongly influenced the muscular cost. Cost generally increased after distally adding mass but decreased after proximally adding mass to the lower leg. Stump-socket interface forces always increased after mass addition.

CONCLUSIONS

A new model was introduced, predicting that the weight of distally located components (e.g. foot, ankle, shoe) strongly influence the estimated muscular cost, in contrast to proximal components. A comparison with experimental literature suggests this new model better describes the experimental data than existing models.

Beta-blockers and health-related quality of life in patients with peripheral arterial disease and COPD

Background:

Beta-blockers are frequently withheld in patients with cardiovascular disease who also have chronic obstructive pulmonary disease (COPD) because of concerns that they might provoke bronchospasm and cause deterioration in health status. Although beta1-selective beta-blockers are associated with reduced mortality in COPD patients, their effects on health status are unknown. The aim of this study was to investigate the relationship between beta-blockers and health-related quality of life (HRQOL) in patients with peripheral arterial disease and COPD.

Methods:

Of the original cohort of 3371 vascular surgery patients, 1310 had COPD of whom 469 survived during long-term follow-up. These COPD patients were sent the Short Form-36 (SF-36) health-related quality of life questionnaire, which was completed and returned by 326 (70%) patients.

Results:

No significant differences in any of the SF-36 domains were observed between COPD patients who did and did not use beta-blockers (p > 0.05 for all). Furthermore, beta-blockers were not associated with any impairment in HRQOL among patients with COPD.

Conclusion:

Beta-blockers had no material impact on the HRQOL of patients with peripheral arterial disease who also had COPD. This suggests that beta-blockers can, in most circumstances, be administered to patients with COPD without impairment in HRQOL.

Association between chronic obstructive pulmonary disease and chronic kidney disease in vascular surgery patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is recognized as a source of systemic inflammation and is associated with the development of cardiovascular disease. However, little is known about the association between COPD and chronic kidney disease (CKD). Therefore, we investigated the relationship between COPD and CKD and the association between COPD and mortality in patients with CKD.

METHODS

We conducted a cohort study of 3358 vascular surgery patients between 1990 and 2006. CKD was defined according to the Modification of Diet in Renal Disease equation as an estimated glomerular filtration rate (GFR) <60 mL/min/1.73 m(2). In addition, the patients were divided into three categories based on the baseline estimated GFR: > or =90 mL/min/1.73 m(2); 60-89 mL/min/1.73 m(2) and <60 mL/min/1.73 m(2). Multivariable logistic regression analysis was used to evaluate the independent association between prevalent COPD and CKD.

RESULTS

The prevalence of COPD was inversely related to kidney function. COPD was present in 47, 38 and 32% of patients with an estimated GFR <60, 60-89 and > or =90 mL/min/1.73 m(2), respectively. COPD was independently associated with CKD (OR 1.22; 95% CI 1.03-1.44; P = 0.03). This association was strongest in patients with moderate COPD (OR 1.33; 95% CI 1.07-1.65; P = 0.01). Both moderate and severe COPD were associated with increased long-term mortality in patients with CKD (HR 1.27; 95% CI 1.03-1.56; P = 0.03 and HR 1.61; 95% CI 1.10-2.35; P = 0.01, respectively), compared to patients without COPD.

CONCLUSIONS

Our findings indicate that COPD is moderately associated with CKD in a large cohort of vascular surgery patients. In addition, moderate and severe COPD are related to increased long-term mortality in patients with CKD.

Everyday physical activity and adiposity in Prader-Willi syndrome

The aim of this study was to assess the impact of Prader-Willi syndrome (PWS) on the level of everyday physical activity and to explore whether the activity level is related to adiposity. Measurements were performed with an accelerometry-based Activity Monitor during two consecutive schooldays in 12 children with PWS (7-16 years of age) and in 12 age- and gender-matched, healthy children. Adiposity was assessed by body mass index standard deviation scores and by percentage body fat (dual energy X-ray absorptiometry). Mean duration of dynamic activities (expressed as percentage of 24 h) was lower in children with PWS than in the comparison group (8.7 [2.5]% and 12.0 [3.1]%, respectively; p = 0.01). Six children with PWS had normal activity levels. Physical activity level was not related to adiposity. The results indicate that, as a group, children with PWS have an inactive lifestyle. However, children with PWS cannot be stereotyped as inactive since half of them had normal activity levels.

Barriers to and facilitators of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre

OBJECTIVE

To determine the most important barriers to and facilitators of the level of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre.

DESIGN

Qualitative study with both cross-sectional and retrospective questions.

SUBJECTS

Thirty-two persons with a spinal cord injury.

METHODS

Semi-structured interview with questions concerning the current situation (>9 months after discharge) and retrospective questions concerning the period shortly after discharge (=3 months). The interview consisted of 10 topic categories assumed to have an impact on the level of everyday physical activity and covering the main parts of the International Classification of Functioning, Disability and Health (ICF) model.

RESULTS

In the current situation, the most important barriers were problems with accessibility of stores and buildings, physical health problems and mental health problems. Shortly after discharge, the most important barriers were emotional distress, problems with self-care, and mental health problems. The most frequently mentioned facilitators were preparation in the rehabilitation centre with respect to daily activities and social activities and stimulation to be physically active.

CONCLUSION

Persons with a spinal cord injury experience important barriers to physical activity, particularly on the ICF component Body Functions and Structure.

Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis

RATIONALE

beta-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms.

OBJECTIVES

We investigated the relationship between cardioselective beta-blockers and mortality in patients with COPD undergoing major vascular surgery.

METHODS

We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose.

MEASUREMENTS AND MAIN RESULTS

There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardioselective beta-blocking agents. beta-Blocker use was associated independently with lower 30-day (odds ratio, 0.37; 95% confidence interval, 0.19-0.72) and long-term mortality in patients with COPD (hazards ratio, 0.73; 95% confidence interval, 0.60-0.88). Intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas low dose was not.

CONCLUSIONS

Cardioselective beta-blockers were associated with reduced mortality in patients with COPD undergoing vascular surgery. In carefully selected patients with COPD, the use of cardioselective beta-blockers appears to be safe and associated with reduced mortality.

Determinants of functioning of adolescents and young adults with cerebral palsy

PURPOSE

To describe the level of functioning of adolescents and young adults with cerebral palsy (CP) and study determinants of their level of functioning.

METHOD

In the CP Transition study, adolescents and young adults aged 16-20 years, diagnosed with CP without severe learning disabilities (n =103) participated. In this group we assessed subject characteristics, i.e., age, type of CP, gross motor function (GMFCS), level of education as well as outcome measures on functioning in daily activities and social participation (Life Habits questionnaire, Vineland Adaptive Behavior Scale, Functional Independence Measure). Multivariate regression analyses were performed.

RESULTS

About 20-30% of the participants encountered restrictions in daily activities (mobility, self-care, nutrition) and social participation (taking responsibility, community living, leisure activities and employment). The GMFCS level, level of education, and age proved to be important determinants of functioning in daily activities and social participation, explaining 70% and 66% of the variance in outcome respectively.

CONCLUSION

A significant number of adolescents and young adults with CP without severe learning disabilities are restricted in daily activities and social participation. These problems are mainly attributable to restricted gross motor functioning, a low level of education and younger age.

Comparison of Total-Breath and Single-Breath Diffusing Capacity in Healthy Volunteers and COPD Patients

BACKGROUND

The measurement of single-breath diffusing capacity (Dlco(SB)) assumes that diffusing capacity per liter of alveolar volume (Dlco/VA) determined in a 750-mL gas sample represents the diffusing capacity (Dlco) of the entire lung. Fast-responding gas analyzers provide the opportunity to verify this assumption because of the possibility to measure CO and CH(4) fractions continuously throughout the entire expiration. Continuous gas sampling provides more information per measurement, but this information cannot be expressed in the traditional parameters. Our goals were to find new parameters to express the extra information of the continuous gas sampling, and to compare these new parameters with the traditional parameters.

METHODS

We compared a new method to determine Dlco with the traditional method in 62 healthy volunteers and 26 COPD patients. Traditionally, Dlco(SB) is determined by multiplying Dlco/VA with alveolar volume, both calculated from gas concentrations in a 750-mL gas sample. The new method calculates total-breath Dlco (Dlco(TB)) by integration of Dlco/VA against exhaled volume.

RESULTS

In healthy volunteers, Dlco/VA shows a slight upward slope during exhalation, while in COPD patients Dlco/VA shows a horizontal line. Total-breath total lung capacity (TLC) is larger than single-breath TLC both in healthy volunteers and in COPD patients, leading to a Dlco(TB) that is significantly larger than Dlco(SB) in both groups (p < 0.001).

CONCLUSION

The assumption that a 750-mL gas sample represents the entire lung seems to be correct for Dlco/VA but not for the CH(4) fraction in case of ventilation inhomogeneity.

Fatigue is a major problem after liver transplantation

Fatigue is often experienced after liver transplantation. The aim of this cross-sectional study was to assess the severity of fatigue in liver transplant recipients. In addition, the nature of fatigue and factors that may be associated with severity of fatigue after liver transplantation were explored. Ninety-six patients up to 15 years after liver transplantation were included. Severity of fatigue and nature of fatigue were assessed with the Fatigue Severity Scale (FSS) and the Multidimensional Fatigue Inventory, respectively. Furthermore, age, gender, indication for transplantation, time since transplantation, immunosuppressive medication, self-experienced disability, and health-related quality of life (HRQoL) were assessed as potential associated factors. Sixty-six percent of all patients was fatigued (FSS > or = 4.0) and 44% of all patients was severely fatigued (FSS > or = 5.1). Patients experienced physical fatigue and had reduced activity rather than mental fatigue and reduced motivation. Age, gender, self-experienced disabilities, and HRQoL were correlated with severity of fatigue. Results of the study indicate that fatigue is a major problem in patients after liver transplantation and no indications were found that complaints of fatigue improve over time. Liver transplant recipients experience physical fatigue and reduced activity rather than mental fatigue and reduced motivation. These findings have implications for the development of interventions needed to rehabilitate persons after liver transplantation.

Quality of life and current coping in young adult survivors of childhood cancer: positive expectations about the further course of the disease were correlated with better quality of life

OBJECTIVES

As a result of advances in the treatment of childhood cancer many patients who may previously have had a limited life expectancy, are now surviving into adulthood. More insight is needed into the long-term adjustment of young adult survivors of childhood cancer. The purpose of this study was to (1) assess health-related quality of life (HRQoL), and (2) to explore the role of cognitive coping in relation to HRQoL.

METHODS

HRQoL of 353 Dutch young adult survivors of childhood cancer was compared with HRQoL of 507 peers. Linear regression analyses predicted survivors' HRQoL by cognitive coping, independent of the impact of demographics and medical variables.

RESULTS

Survivors reported a lower HRQoL than their peers. Health status was the best predictor of the Physical Component Scale of the RAND-36; health status and cognitive coping contributed almost equally well to the Mental Component Scale. The explanatory value of cognitive coping could mainly be attributed to the use of predictive control strategies.

CONCLUSIONS

Because current coping seemed to be an important predictor of HRQoL, interventions directed at the coping strategies of survivors should be useful. The strong association between predictive coping and HRQoL stresses the importance of focusing at having positive expectations about the further course of the disease.

FATIGUE, LEVEL OF EVERYDAY PHYSICAL ACTIVITY AND QUALITY OF LIFE AFTER LIVER TRANSPLANTATION

OBJECTIVE

To assess whether liver transplant recipients have a hypoactive (sedentary) lifestyle and whether the level of everyday physical activity is related to complaints of fatigue. In addition, we explored the relationship between activity level and health-related quality of life.

DESIGN

Case comparison.

SUBJECTS

Eight persons 6-36 months after liver transplantation with varying severity of fatigue and 8 persons without known impairments (matched for gender, age, social situation and employment).

METHODS

Activity levels were assessed during 2 randomly selected consecutive weekdays with an accelerometry-based Activity Monitor. In the transplantation group, severity of fatigue (Fatigue Severity Scale) and health-related quality of life (RAND-36) were also assessed.

RESULTS

Five liver transplant recipients had a hypoactive lifestyle, but there was no significant difference in activity level between the transplantation group and comparison group. Severity of fatigue was correlated (p=0.01) with both duration of dynamic activities and intensity of everyday activity (r(s)=-0.81 and -0.84, respectively). Activity level was correlated (p< or =0.05) with several domains of health-related quality of life (r(s)=0.72-0.78).

CONCLUSION

As a group, liver transplant recipients were not significantly less active than comparison subjects. Activity level was related with severity of fatigue and health-related quality of life. These findings have implications for the development of interventions needed to rehabilitate persons after liver transplantation.

Possible harmful effects of high intra-abdominal pressure on the pelvic girdle

The present study explores the hypothesis that a high intra-abdominal pressure (IAP) loads the ligaments of the pelvic girdle to such an extent that frequent periods of high IAP might cause pain and/or interfere with recovery of patients with pelvic girdle pain (PGP). In a theoretical model the size of the load of IAP on the pelvic girdle was computed. The diameters of abdomen and pelvis needed for the calculations were measured on MRI scans; the IAP values during activities were gained from literature. In slim, healthy subjects the calculated load on the pelvic ring during activities of daily living was 26.0-52.0 N with peaks to 135 N. During straining, vigorous work or heavy exercises the load could increase to values ranging from 104 to 520 N. The load is higher in subjects with pain or fatigue, or in case of a distended abdomen. When the load on the pelvic ring induced by IAP is larger than 100 N, the force exceeds the force at which a pelvic belt relieves complaints in PGP; at 90 N, the force is larger than the force at which isometric hip adduction provokes pain in PGP. We conclude that the size of the load induced by IAP on the pelvic girdle seems to be sufficient to cause pain in patients with PGP and might interfere with recovery. It seems worthwhile to give patients with PGP instructions to reduce IAP as much as possible during activities.

Four-dimensional multislice computed tomography for determination of respiratory lung tumor motion in conformal radiotherapy

PURPOSE

We used four-dimensional multislice spiral computed tomography (MSCT) to determine respiratory lung-tumor motion and compared this strategy to common clinical practice in conformal radiotherapy treatment-planning imaging.

METHODS AND MATERIALS

The entire lung volume of 10 consecutive patients with 14 lung metastases were scanned by a 16-slice MSCT. During the scans, patients were instructed to breathe through a spirometer that was connected to a laptop computer. For each patient, 10 stacks of 1.5-mm slices, equally distributed throughout the respiratory cycle, were reconstructed from the acquired MSCT data. The lung tumors were manually contoured in each data set. For each patient, the tumor-volume contours of all data sets were copied to 1 data set, which allowed determination of the volume that encompassed all 10 lung-tumor positions (i.e., the tumor-traversed volume [TTV]) during the respiratory cycle. The TTV was compared with the 10 tumor volumes contoured for each patient, to which an empiric respiratory-motion margin was added. The latter target volumes were designated internal-motion included tumor volume (IMITV).

RESULTS

The TTV measurements were significantly smaller than the reference IMITV measurements (5.2 +/- 10.2 cm(3) and 10.1 +/- 13.7 cm(3), respectively). All 10 IMITVs for 2 of the 4 tumors in 1 subject completely encompassed the TTV. All 10 IMITVs for 3 tumors in 2 patients did not show overlap with up to 35% of the corresponding TTV. The 10 IMITVs for the remaining tumors either completely encompassed the corresponding TTV or did not show overlap with up to 26% of the corresponding TTV.

CONCLUSIONS

We found that individualized determination of respiratory lung-tumor motion by four-dimensional respiratory-gated MSCT represents a better and simple strategy to incorporate periodic physiologic motion compared with a generalized approach. The former strategy can, therefore, improve common and state-of-the-art clinical practice in conformal radiotherapy.

The course of life of survivors of childhood cancer

The developmental consequences in adulthood of growing up with childhood cancer are not well understood. The Course of life questionnaire was developed to assess the attainment of developmental milestones retrospectively and socio-demographic outcomes in young adulthood. The aim of this study was to assess the course of life and socio-demographic outcomes in young adult survivors of childhood cancer. Knowledge about possible gaps in the course of life could enable health care providers to aim for the most favourable course of life. A total of 353 Dutch survivors and a comparison group of 508 peers without a history of cancer, all aged between 18 and 30, filled in the Course of life questionnaire. The course of life of the survivors was found to be hampered. The young adult survivors of childhood cancer in the Netherlands turned out to have achieved fewer milestones than their peers with respect to autonomy development, social development, and psycho-sexual development, or to have achieved the milestones when they were older than their peers. In addition, survivors displayed less risk behaviour than the comparison group. The survivors and the comparison group also differed on some socio-demographic issues. A considerably lower percentage of survivors than peers in the comparison group were married or living together, and/or employed. Their educational level, on the other hand, was as high as that of their peers.

Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure?

BACKGROUND

Due to dyspnea and fatigue, patients with chronic heart failure (CHF) are often restricted in the performance of everyday activities, which gradually may lead to hypoactivity.

AIMS

To assess whether aerobic training leads to a more active lifestyle and improved quality of life (QoL) in patients with CHF.

METHODS

Patients with stable CHF (NYHA II/III; 59 (11) years) were randomly assigned to a training group (n=18; 3-month aerobic program above standard treatment) or control group (n=16; standard treatment without special advice for exercise). Measurements were performed on level of everyday physical activity (PA, novel accelerometry-based activity monitor) and QoL, and on several related parameters.

RESULTS

Training did not result in a more active lifestyle or improved QoL, but improved (P<0.05) peak power (17%), 6-min walk distance (10%), muscle strength (13-15%) and depression (-1.3 unit). Changes in level of everyday PA were related to changes in peak Vo(2) (r=0.58, P=0.01) and knee extension strength (r=0.48, P=0.05).

CONCLUSIONS

At group level training did not result in a more active lifestyle or improved QoL. However, correlations between training-related changes in parameters suggest that aerobic training has the potential to increase levels of everyday PA in CHF.

Preserved diffusion capacity in children with cystic fibrosis

Early detection of progressive lung disease in cystic fibrosis (CF) may lead to better treatment and prognosis. Routine lung function indices may be relatively insensitive markers of peripheral airway obstruction and alveolar collapse. We hypothesized that the single-breath diffusion capacity of the lung for carbon monoxide (DLCO) would change before tests of airway function in patients with CF. We assessed lung function longitudinally in 53 children with CF during a mean period of 3.8 years to determine whether the diffusion capacity of the lung becomes abnormal before more conventional indices of lung function do. Within patients, DLCO was slightly elevated and remained stable, while forced expired volume in 1 sec (FEV1) and forced vital capacity (FVC) declined progressively (mean individual decline, -1.8% and -0.8% of predicted). Cross-sectionally, this decline was faster (mean group decline -3.8% and -2.8% of predicted), indicating an additional cohort effect. Normalized diffusion capacity at an early stage of CF is slightly elevated and is preserved in spite of progressive obstructive lung disease. This can be attributed to alterations in pulmonary and bronchial circulation due to loss of function and/or number of alveolar units. Diffusion capacity at rest does not appear to be a suitable early marker of progressive deterioration of CF lung disease.

Quality of life in young adult survivors of childhood cancer

In recent years the necessity of measuring quality of life in childhood cancer survivors has been stressed. This paper gives an overview of the results of studies into the quality of life (QL) of young adult survivors of childhood cancer and suggest areas for future research. The review located 30 empirical studies published up to 2001. The results are described in terms of the following QL dimensions: physical functioning (QL, general health), psychological functioning (overall emotional functioning, depression and anxiety, self-esteem), social functioning (education, employment, insurance, living situation, marital status and family), and sexual functioning. Factors related to survivors' QL are reported: demographics and illness- and treatment related variables. Although the literature yields some inconsistent findings, a number of clear trends can be identified: (a) most survivors reported being in good health, with the exception of some bone tumour survivors; (b) most survivors function well psychologically; (c) survivors of CNS tumours and survivors of acute lymphoblastic leukaemia (ALL) are at risk for educational deficits; (d) job discrimination, difficulties in obtaining work and problems in obtaining health and life insurance were reported; (e) survivors have lower rates of marriage and parenthood; (f) survivors worry about their reproductive capacity and/or about future health problems their children might experience as a result of their cancer history. There is a need for methodological studies that measure QL among survivors of childhood cancer more precisely by taking into account the effects of the severity of the cancer and the long-term impact of different treatments. Additional data are needed to help us understand the needs of survivors and to identify those subgroups of survivors who are at greatest risk for the adverse sequelae of the disease and its treatment.

Social and emotional adjustment in young survivors of childhood cancer

An overview is given of the social and emotional adjustment in young survivors of childhood cancer. The results are described in terms of self-esteem, anxiety, depression and posttraumatic stress (emotional adjustment), and in terms of behavioral functioning, social competence and school performance (socio-behavioral adjustment). Furthermore, factors related to survivors' adjustment are reported: demographics, illness- and treatment-related factors, coping and social support, and family and parental functioning. Limitations of the studies and consequences for future research are discussed. On the whole, the adjustment of young cancer survivors as a group was reasonably good, but the findings with respect to the emotional and social adjustment were inconsistent. This might be attributed to limitations of the study designs and the fact that the studies were not all directly comparable. In order to gain more insight into the predictors of adjustment, longitudinal studies are recommended, which should include control groups or standardized instruments with norm data, and use cancer-specific measures in addition to generic measures.

Level of Activities Associated With Mobility During Everyday Life in Patients With Chronic Congestive Heart Failure as Measured With an "Activity Monitor"

Background and Purpose. Because of dyspnea and fatigue, patients with congestive heart failure (CHF) may be restricted in the performance of normal everyday activities. The aim of this study was to obtain a preliminary indication of the level of activities associated with mobility during everyday life and between-day variance in activities in patients with mild to moderate CHF as measured with an “Activity Monitor.” Subjects and Methods. The “Activity Monitor” is based on long-term (&gt;24 hours) ambulatory monitoring of signals from accelerometers fixed to the subject's body during everyday activities with the aim of assessing the level of activities associated with mobility. Measurements were obtained over 3 days from 5 male subjects with CHF (mean age=64 years, SD=5, range=59–72) and over 2 days from 5 matched comparison subjects (mean age=65 years, SD=4, range=61–71). Results. Mean duration of movement-related activities (walking, cycling, or general movement) (expressed as a percentage of the duration of the measurement day) was lower in the subjects with CHF (X̄=3.9, SD=1.5, range=2.2–6.7) than in the comparison subjects (X̄=11.3, SD=3.0, range=6.6–14.1). In the patients, between-day variance was smaller for different weekdays (eg, Monday versus Tuesday) than for similar weekdays (eg, 2 Mondays) (1.11% and 7.28%, respectively). Discussion and Conclusion. The results show how activities associated with mobility during everyday life may be restricted in people with CHF.

Level of activities associated with mobility during everyday life in patients with chronic congestive heart failure as measured with an "activity monitor"

BACKGROUND AND PURPOSE

Because of dyspnea and fatigue, patients with congestive heart failure (CHF) may be restricted in the performance of normal everyday activities. The aim of this study was to obtain a preliminary indication of the level of activities associated with mobility during everyday life and between-day variance in activities in patients with mild to moderate CHF as measured with an "Activity Monitor."

SUBJECTS AND METHODS

The "Activity Monitor" is based on long-term (>24 hours) ambulatory monitoring of signals from accelerometers fixed to the subject's body during everyday activities with the aim of assessing the level of activities associated with mobility. Measurements were obtained over 3 days from 5 male subjects with CHF (mean age=64 years, SD=5, range=59-72) and over 2 days from 5 matched comparison subjects (mean age=65 years, SD=4, range=61-71).

RESULTS

Mean duration of movement-related activities (walking, cycling, or general movement) (expressed as a percentage of the duration of the measurement day) was lower in the subjects with CHF (X=3.9, SD=1.5, range=2.2-6.7) than in the comparison subjects (X=11.3, SD=3.0, range=6.6-14.1). In the patients, between-day variance was smaller for different weekdays (eg, Monday versus Tuesday) than for similar weekdays (eg, 2 Mondays) (1.11% and 7.28%, respectively).

DISCUSSION AND CONCLUSION

The results show how activities associated with mobility during everyday life may be restricted in people with CHF.

Microorganisms with a taste for vanilla: microbial ecology of traditional Indonesian vanilla curing

The microbial ecology of traditional postharvesting processing of vanilla beans (curing) was examined using a polyphasic approach consisting of conventional cultivation, substrate utilization-based and molecular identification of isolates, and cultivation-independent community profiling by 16S ribosomal DNA based PCR-denaturing gradient gel electrophoresis. At two different locations, a batch of curing beans was monitored. In both batches a major shift in microbial communities occurred after short-term scalding of the beans in hot water. Fungi and yeast disappeared, although regrowth of fungi occurred in one batch during a period in which process conditions were temporarily not optimal. Conventional plating showed that microbial communities consisting of thermophilic and thermotolerant bacilli (mainly closely related to Bacillus subtilis, B. licheniformis, and B. smithii) developed under the high temperatures (up to 65 degrees C) that were maintained for over a week after scalding. Only small changes in the communities of culturable bacteria occurred after this period. Molecular analysis revealed that a proportion of the microbial communities could not be cultured on conventional agar medium, especially during the high-temperature period. Large differences between both batches were observed in the numbers of microorganisms, in species composition, and in the enzymatic abilities of isolated bacteria. These large differences indicate that the effects of microbial activities on the development of vanilla flavor could be different for each batch of cured vanilla beans.

Effects of family interventions on burden of relatives of psychiatric patients in The Netherlands: a pilot study

In this study, the effects of psychoeducational family support groups in the Netherlands on relatives' burden were investigated, using a quasi-experimental design. The experimental group consisted of 119 participants of 19 family support groups, the control group of 45 relatives of once-only informational meetings. Subjects from both groups filled in a questionnaire before the group started and one year later. While controlling for confounding variables in multiple regression analyses, significant effects of family support groups were found on elements of burnout and burden.

Burnout among relatives of psychiatric patients attending psychoeducational support groups

OBJECTIVE

The effectiveness of family interventions may be improved by concentrating on elements of objective burden that best predict subjective burden. The relationship between subjective burden and objective burden was investigated among caregivers of patients with serious mental illness in the Netherlands who were attending psychoeducational support groups.

METHODS

The study used pretest data from an intervention study in which psychoeducational family support groups in the Netherlands were evaluated. A total of 164 participants from 19 psychoeducational groups organized by nine community mental health centers completed the Dutch translation of the Maslach Burnout Inventory and the Involvement Evaluation Questionnaire. Regression analyses were conducted, with elements of subjective burden as dependent variables and elements of objective burden, demographic characteristics, and characteristics of the patient's disorder as predictors.

RESULTS

Burden in general and emotional exhaustion were the aspects of subjective burden best predicted by objective burden. In two regression models, objective burden together with the other predictors explained 57 percent and 54 percent of the variance in subjective burden. Two aspects of objective burden-strain on the relationship with the patient and ability to cope with the patient's behavior-were related to almost all the investigated aspects of subjective burden.

CONCLUSIONS

Strong evidence was found for the relationship between objective and subjective burden and for the hypothesis that particular elements of objective burden contribute more to subjective burden than others. The findings suggest that psychoeducation should concentrate on helping relatives cope with the strain on the relationship with the patient and on improving their ability to cope with the patient's behavior.

Evaluation of diffusing capacity in patients with a restrictive lung disease

BACKGROUND

In healthy volunteers, the single-breath diffusing capacity of the lung for carbon monoxide (DLCO) decreases and DLCO normalized per liter alveolar volume (VA; DLCO/VA) increases if VA is decreased. We hypothesized that comparison of DLCO/VA with its predicted value at predicted total lung capacity (TLC) will result in an underestimation of the diffusion disorder in patients with a restrictive lung disease, if a similar relationship exists between DLCO/VA and lung volume as found in healthy volunteers.

OBJECTIVE

To test this hypothesis, we studied total gas transfer DLCO and DLCO/VA as functions of VA in patients who developed a restrictive lung disease and a diffusion disorder in a short period of time.

DESIGN

An observational survey.

SETTING

Pulmonary function department.

PATIENTS

Thirteen patients without any initial pulmonary pathology who developed the mentioned pulmonary pathology due to bleomycin treatment.

INTERVENTIONS

Bleomycin treatment.

MEASUREMENTS AND RESULTS

We performed the single-breath test at various VA levels before, during, and after bleomycin treatment. In the majority of the patients, the DLCO vs VA relationship remained parabolic, but shifted downwards during therapy. Therefore, the linear DLCO/VA vs VA relationship shifted downwards, while the negative slope was not changed, indicating the development of a decreased gas transfer. Six patients also developed a volume restriction.

CONCLUSIONS

The agreement of the data with the hypothesis increased its probability. Consequently, to evaluate a diffusion disorder, DLCO/VA at a lower actual TLC of patients with a lung restriction should be compared to a reference DLCO/VA at a lung volume equal to the actual TLC.

ORCA: the versatile CPR

The introduction of computer-based patient records (CPRs) that fully replace paper records proves especially difficult in specialized care, despite the potential advantages of CPRs for patient care and research. Improved data legibility, availability, sharing of records, and decision support may directly benefit patient care. Barriers to the introduction of CPR applications at institutions may be caused by lack of infrastructure, or by financial or organizational issues. To have clinicians interactively enter data at the point of care is still a big challenge. This paper presents an overview of ORCA (Open Record of CAre): a generic CPR, designed for integration with existing systems, presentation of multi-media patient data, and the collection of structured data, directly by clinicians. ORCA can easily be tailored to the needs of a variety of medical specialists without the need for changes to its data model, functionality, or interface. The paper describes the essence of the architecture of ORCA and the user benefits with emphasis on the support of structured data entry.

Integration and communication for the continuity of cardiac care (I4C)

The project I4C (Integration and Communication for the Continuity of Cardiac Care) is carried out for the advancement of cardiac care, from prevention to follow-up. The goals of I4C are: (1) integrated access to patient data, wherever they are stored; (2) support of evidence-based care; (3) consistent recording of patient data (eg, patient history, electrocardiograms IECGs] or cine-angios) in a multimedia patient record; and (4) a documented reference data set for research. In several clinics, workstations are being installed to serve the four goals. Integration with other information systems in clinical care is realized by encapsulation. A computer-based patient record (ORCA) has been developed to support the collection, consultation, and sharing of patient data. In I4C, ORCA is intended for use in a research setting as well as routine patient care. The functionality of ORCA covers the collection of patient history data in a highly structured manner, the recording of drug prescriptions, an overview of laboratory test results, and viewers for ECGs and angiographic images. At present, structured data entry and consultation is supported in six European languages.

A rebreathing method to determine carbon monoxide diffusing capacity in children: reference values for 6- to 18-year-olds [corrected] and validation in adult volunteers

The diffusing capacity of carbon monoxide (D(L,CO)) and its value normalized to alveolar volume (D(L,CO)/V(A)) are usually estimated with the single breath method at total lung capacity (TLC). Severely ill patients and small children are not able to deliver a satisfactory vital capacity (VC) or hold their breath for 10 s at TLC. The aim of this study was to develop a rebreathing procedure in which diffusing capacity can be determined during spontaneous tidal breathing. The conventional rebreathing method during hyperventilation was modified so that rebreathing volume and gas concentrations were kept constant by CO2 absorption and O2 supplementation. In adult healthy volunteers and in patients who were able to perform both tests, the diffusion indices obtained with this rebreathing method during resting ventilation were compared with those obtained by the single breath method. Predicted (reference) values for rebreathing D(L,CO) and D(L,CO)/V(A) for children were determined. D(L,CO)/V(A) decreased with alveolar volume (V(A)) and increased with alveolar ventilation (V'(A)). In adults at V'(A) above 35 L x min(-1) rebreathing D(L,CO)/V(A) was similar to single breath D(L,CO)/V(A) at similar alveolar volumes. The D(L,CO)/V(A) relative to their corresponding reference values were the same for both methods in adult patients, irrespective of ventilation distribution disturbances. In children the newly described diffusing capacity obtained by the rebreathing method during resting ventilation can serve as a valuable index to assess and follow a diffusion disorder.

Clinical data entry

Routine capture of patient data for a computer-based patient record system remains a subject of study. Time constraints that require fast data entry and maximal expression power are in favor of free text data entry. However, using patient data directly for decision support systems, for quality assessment, etc. requires structured data entry, which appears to be more tedious and time consuming. In this paper, a prototype clinical data entry application is described that combines free text and structured data entry in one single application and allows clinicians to smoothly switch between these two different input styles. A knowledge base involving a semantic network of clinical data entry terms and their properties and relationships is used by this application to support structured data entry. From structured data, sentences are generated and shown in a text processor together with the free text. This presentation metaphor allows for easy integrated presentation of structured data and free text.

Restructuring routinely collected patient data: ORCA applied to andrology

Hospital information systems do not always cover all required detail per specialty. This may lead to scattering of data over disparate systems and the paper record. The ORCA (Open Record for CAre) CPR offers a generic structure for record sharing, and record keeping tailored to specific needs. We studied whether a semantic integration of existing and new data was possible, using the ORCA structure. Existing andrology data, originating from separate sources, were utilized for this purpose. During normalization, validation and explication steps, latent problems in the source data were exposed and removed, followed by a merge with new data items. By conversion of source data to ORCA, a unique representation of medical concepts in the database was attained, facilitating retrieval of univocal data for multiple purposes. We conclude that the expansion to the andrology domain, including transparent integration of existing data, provides support for the generality of ORCA.

Cloning and characterization of two rhamnogalacturonan hydrolase genes from Aspergillus niger

A rhamnogalacturonan hydrolase gene of Aspergillus aculeatus was used as a probe for the cloning of two rhamnogalacturonan hydrolase genes of Aspergillus niger. The corresponding proteins, rhamnogalacturonan hydrolases A and B, are 78 and 72% identical, respectively, with the A. aculeatus enzyme. In A. niger cultures which were shifted from growth on sucrose to growth on apple pectin as a carbon source, the expression of the rhamnogalacturonan hydrolase A gene (rhgA) was transiently induced after 3 h of growth on apple pectin. The rhamnogalacturonan hydrolase B gene was not induced by apple pectin, but the rhgB gene was derepressed after 18 h of growth on either apple pectin or sucrose. Gene fusions of the A. niger rhgA and rhgB coding regions with the strong and inducible Aspergillus awamori exlA promoter were used to obtain high-producing A. awamori transformants which were then used for the purification of the two A. niger rhamnogalacturonan hydrolases. High-performance anion-exchange chromatography of oligomeric degradation products showed that optimal degradation of an isolated highly branched pectin fraction by A. niger rhamnogalacturonan hydrolases A and B occurred at pH 3.6 and 4.1, respectively. The specific activities of rhamnogalacturonan hydrolases A and B were then 0.9 and 0.4 U/mg, respectively, which is significantly lower than the specific activity of A. aculeatus rhamnogalacturonan hydrolase (2.5 U/mg at an optimal pH of 4.5). Compared to the A enzymes, the A. niger B enzyme appears to have a different substrate specificity, since additional oligomers are formed.

Can data representation and interface demands be reconciled? Approach in ORCA

Research in the domain of computer-based patient records had always faced the conflicting demands of efficiency for the practicing physician and suitability of the record contents for data analysis in view of decision support, research, and quality assessment. Interface and contents pose different demands on the data model underlying the record. The challenge is to combine the most suitable model for data representation with the interface that best fits the clinical setting. ORCA (Open Record for CAre) provides a solution by making the distinction between domain dependent and domain independent data and letting domain dependence be decisive for the choice of model. Interactive definition of custom-views provides interface flexibility for domain dependent data. Views on domain independent data need not cope with the limitations of multiple table views in relational DBMSs. A standard set of single table queries can support recording of domain independent data, irrespective of the clinical setting.

Kinetics of mRNA and protein synthesis of genes controlled by the 1,4-beta-endoxylanase A promoter in controlled fermentations of Aspergillus awamori

In this study, induction and repression kinetics of the expression of the Aspergillus awamori 1,4-beta-endoxylanase A (exlA) gene under defined physiological conditions was analyzed at the mRNA and the protein levels. Induction was analyzed by pulsing D-xylose to a sucrose-limited continuous culture of an A. awamori 1,4-beta-endoxylanase A (EXLA)-overproducing strain. Directly after the D-xylose pulse, exIA mRNA was synthesized, and it reached a constant maximal level after 45 to 60 min. This level was maintained as long as D-xylose was present. The kinetics of mRNA synthesis of the genes encoding Thermomyces lanuginosa lipase (lplA) and Escherichia coli beta-glucuronidase (uidA), which were also under the control of the exlA promoter, were similar to those observed for exlA mRNA. The repression of exlA expression was analyzed by pulsing D-glucose to a D-xylose-limited continuous culture. Immediately after the glucose pulse, the exlA mRNA level declined rapidly, with a half-life of approximately 20 to 30 min, and it reached a minimal level after 60 to 90 min. The time span between mRNA synthesis and the secretion of proteins was determined for EXLA and lipase. In both cases, mRNA became visible after approximately 7.5 min. After 1 h, both proteins became detectable in the medium but the rate of secretion of EXLA was faster than that of lipase.

An expression system based on the promoter region of the Aspergillus awamori 1,4-beta-endoxylanase A gene

A new, highly inducible fungal promoter derived from the Aspergillus awamori 1,4-beta-endoxylanase A (exlA) gene is described. Induction analysis, carried out with the wild-type strain in shake flasks, showed that exlA expression in regulated at the transcriptional level. Using a beta-glucuronidase (uidA) reporter strategy, D-xylose was shown to be an efficient inducer of the exlA promoter, whereas sucrose or maltodextrin were not. Upon D-xylose induction, the exlA promoter was threefold more efficient than the frequently used A. niger glucoamylase (glaA) promoter under maltodextrin induction. Detailed induction analyses demonstrated that induction was dependent on the presence of D-xylose in the medium. Carbon-source-limited chemostat cultures with the uidA reporter strain showed that D-xylose was also a very good inducer in a fermenter, even in the presence of sucrose.

A multi-strategy approach for medical records of specialists

Despite a number of well recognized shortcomings of paper medical records, the use of a Computer Patient Record (CPR) is not widespread among specialists. The complexity of specialized care combined with the diversity of their domains of expertise, make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailored to the specific tasks of each user, and yet general enough to permit exchange and sharing of information. The basic philosophy behind our CPR is a 'mother' record, which is extended with specialized sub-records. Two different types of subrecords are discussed: one to accommodate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR supports the entry of free text and does not impose structured data entry on the physician, but stimulates him to do so by confronting him with the benefits of a structured CPR.

Pulmonary diffusing capacity at reduced alveolar volumes in children

The diffusing capacity, when normalized per liter of alveolar volume (DL,CO/VA) decreases in normal adults, whereas their total diffusing capacity (DL,CO) increases as alveolar volume (VA) increases. We studied these relationships in a group of normal children below 20 years of age. Diffusion variables were determined using the single breath technique. The effects of sex, age, and height on these relationships were estimated. DL,CO increased and DL,CO/VA decreased as alveolar volume increased. DL,CO and DL,CO/VA reference values at total lung capacity (TLC) appeared to be comparable to reference values at TLC in the literature. Reference values of DL,CO and DL,CO/VA derived from measurements at various alveolar volumes also predict similar values at TLC. The advantage of our reference equations is their applicability to patients with restrictive lung disease. Actual DL,CO/VA can be compared with reference DL,CO/VA at actual (restrictive) TLC instead of reference DL,CO/VA at reference TLC. This comparison extends the evaluation of a diffusion disorder.

Cloning, sequence and expression of the gene coding for rhamnogalacturonase of Aspergillus aculeatus; a novel pectinolytic enzyme

Rhamnogalacturonase was purified from culture filtrate of Aspergillus aculeatus after growth in medium with sugar-beet pulp as carbon source. Purified protein was used to raise antibodies in mice and with the antiserum obtained a gene coding for rhamnogalacturonase (rhgA) was isolated from a lambda cDNA expression library. The cloned rhgA gene has an open-reading frame of 1320 base pairs encoding a protein of 440 amino acids with a predicted molecular mass of 45 962 Da. The protein contains a potential signal peptidase cleavage site behind Gly-18 and three potential sites for N-glycosylation. Limited homology with A. niger polygalacturonase amino acid sequences is found. A genomic clone of rhgA was isolated from a recombinant phage lambda genomic library. Comparison of the genomic and cDNA sequences revealed that the coding region of the gene is interrupted by three introns. Furthermore, amino acid sequences of four different peptides, derived from purified A. aculeatus rhamnogalacturonase, were also found in the deduced amino acid sequence of rhgA. A. aculeatus strains overexpressing rhamnogalacturonase were obtained by cotransformation using either the A. niger pyrA gene or the A. aculeatus pyrA gene as selection marker. For expression of rhamnogalacturonase in A. awamori the A. awamori pyrA gene was used as selection marker. Degradation patterns of modified hairy regions, determined by HPLC, show the recombinant rhamnogalacturonase to be active, and the enzyme was found to have a positive effect in the apple hot-mash liquefaction process.

A novel strategy for the isolation of defined pyrG mutants and the development of a site-specific integration system for Aspergillus awamori

A homologous gene transfer system for Aspergillus awamori for site-specific integration is described, based on two components. First, a defined A. awamori pyrG mutant strain constructed by a selection strategy for gene-replacement in fungi. Second, a vector with a homologous pyrG selection marker containing a defined mutation at a site different from that of the mutations in the pyrG gene of the defined mutant strain. Defined mutation in the A. awamori pyrG gene, isolated from a genomic library by heterologous hybridisation with the A. niger pyrG gene as a probe, were introduced by specifically altering sequences at restriction sites in the coding region of the gene. After transformation of the A. awamori wild-type strain with vectors containing these mutated pyrG genes, and selection for 5-fluoro-orotic acid resistance (5-FOAR), on the average 60% of the 5-FOAR colonies originated from replacement of the wild-type pyrG gene by the mutated pyrG allele. After transformation of a mutant strain, carrying a mutation near the 5' end of the pyrG gene with vectors containing a mutation near the 3' end of the pyrG gene, 35% of the resulting transformants contained one copy of the vector at the pyrG locus.

ARIS: integrating multi-source data for research in andrology

Although the concept of distributed systems for the storage of patient data is more and more commonly accepted, for some considerable time yet most patient data will be stored in centralized rather than departmental systems. An important advantage of storage in a central system is hospital-wide access to much of the patient data. Disadvantages are however that these data cannot be reviewed through one user interface, and that the structure of the data does not lend itself to exploitation for other purposes. We describe the implementation of an Andrology Research Information System in which these data are integrated in a well-structured database facilitating multiple views on the patient data through a graphical user interface, and clinical research, quality control and summary reports. The data can be analyzed directly using the Hermes workstation. In this way the strengths of the centralized system are combined with those of the dedicated ARIS system.

Can one patient record accommodate the diversity of specialized care?

Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.

Diffusing capacity dependent on lung volume and age in normal subjects

In this study we determined reference values of total diffusing capacity of carbon monoxide (DLCO) and DLCO per liter alveolar volume (DLCO/VA) at total lung capacity (TLC) and at lung volumes below TLC in sitting position. In 55 healthy nonsmoking volunteers (20-85 yr old), we determined reference values at TLC level in which age was the only parameter. In a subgroup (n = 16) these references did not change by correction for normal variability in hemoglobin concentration. In all volunteers DLCO decreased and DLCO/VA increased with decreasing VA. The increase in DLCO/VA was linear and less in older subjects. We derived equations to calculate reference values of DLCO/VA for lung volumes at and below TLC with two methods: 1) "random coefficients linear" model, which calculates the reference values directly, and 2) a conversion method, which calculates DLCO/VA for lower VA levels from reference values at TLC. An advantage of the conversion method is the suitability of DLCO/VA reference values at TLC of other populations. A disadvantage is the greater standard deviation of these reference values compared with those obtained by the random coefficients linear method. DLCO can be found by multiplying DLCO/VA with VA.

A powerful macro-model for the computer patient record

Especially in the Netherlands, the introduction of computer patient records (CPRs) in primary care has been relatively successful. Specialists usually maintain more extensive records than general practitioners and it has proven to be a great challenge to design a CPR that is useful and practical for specialized care. In this paper, we present the design of a CPR for use by specialists in an out-patient clinic. The philosophy underlying the design is that specialists may keep record in a relatively conventional way, while, at the same time, the system motivates them to add structure to their data. Data can be presented in various views, each suitable for one or more specific tasks. The potential to benefit from these views depends on the degree of structure in the recorded data. Since a CPR has to be faithful and permanent, explicit representation of observations, insights, and evolution of insight is also supported. The CPR system is in a final stage of implementation and will be evaluated in a clinical setting in summer 1994.

Diclofenac for pain relief after arthroscopy: a comparison of early and delayed treatment

The effect of diclofenac on pain after arthroscopy of the knee joint was investigated in 64 patients. The aim of this double-blind, placebo-controlled, randomised study was to compare administration before surgery with delayed treatment. The effect on postoperative pain was evaluated by means of a Visual Analogue Scale and recording of the need for additional analgesics postoperatively. After surgery, hourly assessments were performed within 6 h after the anaesthetic block (approximately 5 h after start of surgery), and on the morning after surgery. Both treatment with diclofenac before surgery and delayed treatment were superior to placebo concerning pain scores within 6 h after onset of anaesthesia (P < 0.0065 and P < 0.0005, respectively). On the morning after surgery, only delayed treatment was superior to placebo (P < 0.02). No differences in pain scores were evident between the different groups treated with diclofenac. No differences in the need for additional analgesics were found.

Lipid metabolism of myocardial endothelial cells

The vascular endothelium can be regarded as a widely distributed organ, interposed between the intravascular and extravascular spaces, with a pluripotent function in the regulation of capillary diameter, vascular homeostasis, lipoprotein metabolism and the vascular response to injury. In the basal physiological state these processes provide a non-thrombotic, non-inflammatory vascular lining preventing uncontrolled inflammation and coagulation. Endothelial cells respond to potential harmful conditions (mechanical stress, anoxia, ischemia and oxidative stress) and a variety of hormones and vasoactive mediators by inducing coagulation and production of inflammatory mediators through the production of 'bioactive' lipids. Although the number of studies in isolated myocardial endothelial cells is limited, from the presumed metabolic analogy with endothelial cells isolated (and cultured) from other organs, one may conclude that the bioactive lipids include oxygenated arachidonate metabolites (eicosanoids) and the platelet activating factor (1--O-alkyl-2-acetyl-sn-glycerol-3-phosphocholine; PAF). All aspects of lipid metabolism, related to the production of eicosanoids and PAF, are present within myocardial endothelial cells. There is uptake and incorporation of fatty acids by endothelial cells and liberation from endogenous triacylglycerol and (membrane) phospholipid stores by (phospho)lipases. Endothelial cells oxidize fatty acids in a carnitine-dependent, mitochondrial, pathway. Endothelial cells actively interact with high density lipoprotein (HDL) and low density lipoprotein (LDL) leading to uptake of cholesterol(esters) that undergo intracellular hydrolysis, and re-esterification to phospho- and neutral lipids, and leaving the LDL-particle modified in a way that makes them bind to the scavenger receptor on macrophages.(ABSTRACT TRUNCATED AT 250 WORDS)

Interscalene plexus block for arthroscopy of the humero-scapular joint

Interscalene plexus block was performed in nine patients subjected to shoulder arthroscopy. The operating conditions, including muscle relaxation, were fully adequate in all patients (after additional local anaesthesia of the skin in four patients). With the exception of one patient who experienced temporary hoarseness (probably due to a concomitant block of the recurrent laryngeal nerve), no side effects were found and the patients tolerated the surgical procedure well. Interscalene block might be a suitable alternative to general anaesthesia for shoulder arthroscopy. However, additional local anaesthesia at the site where the arthroscope is to be inserted is frequently required.