[Distinctive features of the os naviculare pseudarthrosis vs the os naviculare accessorius]

We report on two cases in which the differential diagnosis between an os tibiale externum (os naviculare accessorius) and a post-traumatic pseudarthrosis of the os naviculare was subject to discussion.Both patients had suffered an acute trauma in the region of the middle foot and showed identical clinical symptoms. Conventional X-ray did not allow a definite classification of the diagnosis either.However, this was possible in both cases by virtue of typical signs evidenced by computed tomography and magnetic resonance imaging.

[Cemented versus uncemented hip replacement--rational decision making using the BiCONTACT total hip system]

The BiCONTACT femoral stem has been developed as a modular system which is suitable for both cemented and uncemented implantation. A highly standardized procedure using an identical set of instruments for both modes of fixation ensures bone preservation. Primary stability is achieved by special design parameters. The cementless implants are coated proximally, thus facilitating osteointegration and proximal load transfer. Cemented stems provide an identical design but a smooth surface and are anchored by a homogenous cement mantle. The BiCONTACT stem is in use in the BG Trauma Center Tuebingen since 14 years and a consecutive series of 250 cases (series A) with uncemented implantation and of 250 cases (series B) with cemented implantation has been analyzed in two different prospective follow-up studies. Long-term survival after 11 years was 97.1 % (95 % confidence limits: 93.8 %-98.7 %) for series A, the follow-up rate was 99.2 %. For series B, the follow up-rate was also 99.2 %, survival estimate after 11 years was 97.5 % (95 % CI: 94.2 %-99.0 %).

Long-term results with the BiCONTACT system--aspects to investigate and to learn from

The BiCONTACT femoral stem for cementless fixation is being used without any technical modification after 15 years. The long-term results should be evaluated in this study. A consecutive series was continuously monitored in a prospective follow-up study. A survival analysis was performed, clinical results were rated according to the Harris score. There were 236 patients with 250 total hip replacements (THR); mean age at time of implantation was 58.2 years. Indications for THR included osteoarthritis (62.4%), dysplasia (16.8%), trauma (8.4%) and femoral-head necrosis (16.8%). Average time of follow-up evaluation was 8.9 years (range 7.4-10.7 years). At follow-up, 27 patients had died and two could not be located. Seven patients were revised--two for infection, one for recurrent dislocation, two for component undersizing with rapid subsidence, and one for aseptic loosening of a varus-malaligned stem; one radiologically well-fixed stem had been revised during acetabular revision. Survival estimate showed an overall survival rate of 97.1% after 11 years (confidence limits: 98.7% upper and 93.6% lower). Radiologically, tiny reactive lines (< 2 mm) were present in the distal zones of the femoral shaft, but no radiolucencies could be found in the proximal anchoring zone. Migration analysis with Ein-Bild-Röntgen-analyse/femoral component analysis (EBRA/FCA) demonstrated a very small amount of migration: in 31.0%, the overall migration was between 0.5 and 1 mm after 120 months; 8.5% had an absolute amount of subsidence exceeding 2 mm after 120 months (one case more than 3 mm). Mean subsidence was 0.2 mm after 3 months and 6 months, 0.3 mm after 12 months, and reached 0.5 mm after 10 years. An initial small amount of subsidence could be detected in 45.1%, and 15.5% had a late onset of subsidence. Continuous sinking could be found in 12.7%, while 26.8% had irregular patterns of migration. Clinical results were somewhat compromised by a higher-than-average rate of cup loosening (uncoated threaded cup). The average Harris hip score at follow-up was 84.3 points. Interestingly, no femoral osteolysis could be detected, even in cases with severe acetabular osteolyses, indicating sealing of the stem interface by tight osseointegration of the proximally-coated stem.

The risks of reuse: legal implications for hospitals of reusing single-use medical devices

There is no doubt that the practice of reuse in hospitals is a reaction to the budgetary constraints under which hospitals are operating. However, the costs of appropriately monitoring and sterilizing reused equipment as well as the significant risk of patient harm and potential liability raise the unavoidable question of whether this practice is an advisable one. These costs and risk should be carefully examined before a decision about whether to reuse single-use devices is made.

Testicular germ cell cancer despite previous local radiotherapy to the testis

BACKGROUND

Testicular intraepithelial neoplasia (TIN, also carcinoma in situ of the testis) is the uniform precursor of testicular germ cell cancer. Local radiotherapy to the testis with dosages of 18-20 Gy has been found to safely eradicate TIN and germ cells, too. Thus, the general assumption is that the development of invasive germ cell tumours can be prevented by this radiotherapy.

PATIENTS AND METHODS

Herein, we report two patients with one-sided testicular tumour and biopsy-proven contralateral TIN. Both of them developed germ cell neoplasms in the remaining testis although local radiotherapy with 20 Gy had been applied to the testis.

RESULTS

One patient developed pure seminoma 7 years after completion of radiotherapy, the other developed a combined tumour consisting of embryonal carcinoma and seminoma after 5 years. Treatment consisted of orchiectomy in each of the cases. Histologically, both had TIN in the testicular tissue surrounding the new growths.

CONCLUSIONS

Pathogenetically, a small fraction of radioresistent TIN cells overcoming irradiation and progressing to full-blown germ cell cancer in the later course may be the histogenetic clue to explain these unexpected events. Other explanations, though less probable, could be technical radiotherapeutic failure due to targeting problems and a pre-existing radioresistent germ cell tumour in the irradiated testicle.

Novel chemokine functions in lymphocyte migration through vascular endothelium under shear flow

The recruitment of circulating leukocytes at vascular sites in target tissue has been linked to activation of Gi-protein signaling in leukocytes by endothelial chemokines. The mechanisms by which apical and subendothelial chemokines regulate leukocyte adhesion to and migration across endothelial barriers have been elusive. We recently found that endothelial chemokines not only stimulate integrin-mediated arrest on vascular endothelial ligands but also trigger earlier very late antigen (VLA)-4 integrin-mediated capture (tethering) of lymphocytes to vascular cell adhesion molecule 1 (VCAM-1)-bearing surfaces by extremely rapid modulation of integrin clustering at adhesive contact zones. This rapid modulation of integrin avidity requires chemokine immobilization in juxtaposition with the VLA-4 ligand VCAM-1. We also observed that endothelial-bound chemokines promote massive lymphocyte transendothelial migration (TEM). It is interesting that chemokine-promoted lymphocyte TEM requires continuous exposure of lymphocytes but not of the endothelial barrier to fluid shear. It is noteworthy that lymphocyte stimulation by soluble chemokines did not promote lymphocyte TEM. Our results suggest new roles for apical endothelial chemokines both in triggering lymphocyte capture to the endothelial surface and in driving post-arrest events that promote lymphocyte transmigration across endothelial barriers under shear flow.

Allogeneic cancellous bone graft and a Burch-Schneider ring for acetabular reconstruction in revision hip arthroplasty

BACKGROUND

There is an ever-increasing number of failed hip arthroplasties associated with massive deficiency of acetabular bone stock consisting of a segmental or cavitary defect. This study was undertaken to evaluate the long-term results after use of morselized cryopreserved allogeneic bone graft and an antiprotrusio cage to treat such a deficiency.

METHODS

From January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with an acetabular defect classified as type IIl or IV according to the American Academy of Orthopaedic Surgeons system were operated on with use of a Burch-Schneider ring and morselized cryopreserved allogeneic cancellous bone graft. Thirty-eight patients (thirty-eight hips) were available for clinical and radiographic follow-up examinations at an average of 7.3 years (range, 4.2 to 9.4 years) after surgery.

RESULTS

All measured clinical parameters had improved significantly by the time of the follow-up examination (p < 0.0001). Radiographs confirmed that none of the thirty-eight hips had any measurable migration or displacement of the acetabular component and that osseous consolidation occurred only within the grafted area in all patients.

CONCLUSION

Acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone graft and the Burch-Schneider ring can be highly successful in managing massive acetabular deficiencies in revision hip arthroplasty.

The Src kinase p56(lck) up-regulates VLA-4 integrin affinity. Implications for rapid spontaneous and chemokine-triggered T cell adhesion to VCAM-1 and fibronectin

In circulating lymphocytes, the VLA-4 integrin preexists in multiple affinity states that mediate spontaneous tethering, rolling, and arrest on its endothelial ligand, vascular cell adhesion molecule-1 (VCAM-1). The regulation and function of VLA-4 affinity in lymphocytes has never been elucidated. We show here that p56(lck), the major Src kinase in T cells, is a key regulator of high affinity VLA-4. This high affinity is essential for the rapid development of firm adhesion of resting T cells to VCAM-1 and to their extracellular matrix ligand, fibronectin. Lck-regulated VLA-4 function does not require intact TCR nor several key components of the TCR signaling pathway, including ZAP-70 and SLP-76. Furthermore, stimulation of p56(lck) by the phosphatase inhibitor, pervanadate, triggers firm VLA-4-dependent adhesion to VCAM-1. Although Lck is not required for chemokine receptor signaling to mitogen-activated protein kinase, the presence of Lck-regulated high affinity VLA-4 also facilitates firm adhesion triggered by the chemokine, SDF-1, at short-lived contacts. Surprisingly, bond formation rates, ability to tether cells to VLA-4 ligand, and VLA-4 tether bond stability under shear flow are not affected by VLA-4 affinity or Lck activity. Thus, the ability of high affinity VLA-4 to arrest cells on VCAM-1 under flow arises from instantaneous post-ligand strengthening rather than from increased kinetic stability of individual VLA-4 bonds. These results suggest that p56(lck) maintains high affinity VLA-4 on circulating lymphocytes, which determines their ability to strengthen VLA-4 adhesion and rapidly respond to proadhesive chemokine signals at endothelial sites.

Results of a cemented titanium alloy straight femoral shaft prosthesis after 10 years of follow-up

Two-hundred fifty implantations of a cemented femoral stem made of titanium alloy in 239 patients were followed for 9.7 years (range 8.7-10.3 years). Eighty-nine patients with 93 hips have died and two could not be located. Five hips have been revised, two for infection, one for aseptic loosening and two during revision of the cup. Three stems showed radiological loosening but have not been revised. The average hip score was 85. The results are encouraging and comparable to other cemented femoral stems.

Arabidopsis eIF3e (INT-6) associates with both eIF3c and the COP9 signalosome subunit CSN7

The Arabidopsis COP9 signalosome is a multisubunit repressor of photomorphogenesis that is conserved among eukaryotes. This complex may have a general role in development. As a step in dissecting the biochemical mode of action of the COP9 signalosome, we determined the sequence of proteins that copurify with this complex. Here we describe the association between components of the COP9 signalosome (CSN1, CSN7, and CSN8) and two subunits of eukaryotic translation initiation factor 3 (eIF3), eIF3e (p48, known also as INT-6) and eIF3c (p105). To obtain a biochemical marker for Arabidopsis eIF3, we cloned the Arabidopsis ortholog of the eIF3 subunit eIF3b (PRT1). eIF3e coimmunoprecipitated with CSN7, and eIF3c coimmunoprecipitated with eIF3e, eIF3b, CSN8, and CSN1. eIF3e directly interacted with CSN7 and eIF3c. However, eIF3e and eIF3b cofractionated by gel filtration chromatography in a complex that was larger than the COP9 signalosome. Whereas eIF3, as detected through eIF3b, localized solely to the cytoplasm, eIF3e, like CSN7, was also found in the nucleus. This suggests that eIF3e and eIF3c are probably components of multiple complexes and that eIF3e and eIF3c associate with subunits of the COP9 signalosome, even though they are not components of the COP9 signalosome core complex. This interaction may allow for translational control by the COP9 signalosome.

The pachytene checkpoint in Saccharomyces cerevisiae requires the Sum1 transcriptional repressor

Saccharomyces cerevisiae mutants that fail to complete meiotic recombination are blocked by the RAD17/RAD24/MEC1 checkpoint signaling pathway in pachytene when early sporulation genes are expressed. Middle genes are not activated in checkpoint-arrested cells because the Ndt80 transcription factor is inhibited. We find that the pachytene checkpoint requires Sum1, a transcriptional repressor that recognizes a subset of Ndt80-binding sites. Mutants lacking Sum1 or Rad17 partially bypass the block to the nuclear divisions but do not form spores, while mutants lacking both Sum1 and Rad17 completely bypass the block and form morphologically normal spores. The level of Sum1 protein decreases as middle genes are expressed, and this decrease is blocked in checkpoint-arrested cells. These data suggest that Sum1 levels are regulated by the checkpoint and that progression of the meiotic divisions and spore differentiation can be differentially controlled by competition of the Sum1 repressor and Ndt80 activator for occupancy at key middle promoters.

Dependency of the [18F]fluoromisonidazole uptake on oxygen delivery and tissue oxygenation in the porcine liver

We have previously shown that the accumulation of fluorine-18-labeled fluoromisonidazole ([(18)F]FMISO) is inversely correlated to tissue oxygenation, allowing the quantification of porcine liver tissue hypoxia in vivo. We determined the activity from administered [(18)F]FMISO in relation to the hepatic oxygen availability and the partial pressure of oxygen in tissue (tPO(2)) to define a critical oxygen delivery on a regional basis. [(18)F]FMISO was injected 2 h after onset of regional liver hypoxia due to arterial occlusion of branches of the hepatic artery in 10 domestic pigs. During the experimental procedure the fractional concentration of inspired oxygen (FiO(2)) was set to 0.67 in group A ( N=5) and to 0.21 in group B ( N=5) animals. Immediately before sacrifice, the tPO(2) was determined in normal flow and flow-impaired liver segments. The standardized uptake values (SUV) for [(18)F]FMISO was calculated from 659 single tissue samples obtained 3 h after injection of approximately 10 MBq/kg body weight [(18)F]FMISO and was compared with the regional total hepatic oxygen delivery (DO(2)) calculated from the regional arterial and portal venous flow (based on (141)Ce- and (99m)Tc-microspheres measurements) and the oxygen content of the arterial and portal venous blood. In 121 tPO(2)-measured liver tissue samples, the mean DO(2) was significantly decreased in occluded liver tissue samples [group A: 0.063 (0.044-0.089); group B: 0.046 (0.032-0.066)] compared to normal flow segments [group A: 0.177 (0.124-0.252); group B: 0.179 (0.128-0.25) mL x min(-1) x g(-1); geometric mean (95% confidence limits); p < 0.01 in group A and p < 0.001 in group B]. The tPO(2) of occluded segments [group A: 5.1 (3.2-8.1); group B: 3.9 (2.4-6.2) mm Hg] was significantly decreased compared to normal flow segments [group A: 20.2 (12.6-32.5); group B: 22.4 (14.3-35.2) mm Hg; p < 0.01 in group A and p < 0.001 in group B]. Three hours after [(18)F]FMISO administration, the mean [(18)F]FMISO SUV determined in tPO(2)-measured occluded segments was significantly higher [group A: 4.08 (3.12-5.34), group B: 5.43 (4.14-7.13)] compared to normal liver tissue [group A: 1.57 (1.2-2.06), group B: 1.5 (1.16-1.93); p < 0.001 for both groups]. The [(18)F]FMISO SUV allowed prediction of the tPO(2) with satisfying accuracy in hypoxic regions using the exponential regression curve [[(18)F]FMISO=1.05+6.7((-0.117 tPO(2))); r(2)=0.75; p < 0.001]. In addition, regardless of ventilation conditions, a significant exponential relationship between the DO(2) and the [(18)F]FMISO SUV was found ( r(2)=0.39, p < 0.001). Our results suggest that the reduction of the oxygen delivery below the critical range of 0.1-0.11 mL x min(-1) x g(-1) regularly causes liver tissue hypoxia. The severity of hypoxia is reflected by the [(18)F]FMISO accumulation and allows the in vivo estimation of the tPO(2) in hypoxic regions.

[Functional results after suture repair in ruptures of the long biceps tendon with special consideration of subacromial impingement]

Operative treatment for ruptures of the long biceps tendon still is discussed controversially. In the present literature the keyhole-technique is recommended according to favourable biomechanical conditions. In recent years refixation to the short biceps tendon was preferred. Now it is supposed that this technique may provoke subacromial impingement considering the loss of depression function of the long biceps tendon to the humeral head. Between 1980 to 1991 83 patients with rupture of the long biceps tendon were treated operatively by refixation to the short head. 28 patients were investigated after an average follow-up of 6.5 years. Due to the criteria of the Constant-Score 85% of patients achieved very good, 15% good results. At our patients provocation of a subacromial impingement could not be observed. The subacromial space was not reduced in the postoperative x-ray control. Compared with the non-operated shoulder isokinetic determination of isometric maximal peak torque for elbow-flexion, shoulder-abduction and shoulder-flexion yield to almost identical results for the operated shoulder. Refixation to the short head can be advised for treatment of ruptures of the long biceps tendon due to the certain technique with a low complication rate and very good functional outcome.

[Interdisciplinary consensus on diagnosis and therapy of testicular tumors. Results of an update conference based on evidence-based medicine. German Testicular Cancer study Group (GTCSG)]

BACKGROUND

An "Interdisciplinary Consensus Statement on the Diagnosis and Therapy of Testicular Tumors" was prepared in 1996 by the "Interdisciplinary Testicular Tumor Working Group" (IAH) with input from representatives from diagnostic and therapeutic disciplines of various working groups of the German Cancer Society (Strahlenther Onkol 1997;173:397-406). In 1998 the IAH met again together with the "Testicular Tumor Working Party" of the Urooncology Working Group (AUO) and formed the "German Testicular Cancer Study Group" (GTCSG). Defined and accepted interdisciplinary standards from the initial meeting were revised based on current scientific developments and clinical results. This cooperating effort increased the quality of the initial recommendations and helped to put the recommendations for diagnosing and treating testicular tumor on a broader scientific basis.

METHODS

According to the principles of "evidence-based medicine" (EBM), the Consensus from 1996 was modified, based on the current level of evidence from the published literature. The methodological process and evaluation criteria used were that of the "Cochrane Collaboration".

RESULTS

An "Interdisciplinary Update Consensus Statement" summarizes and defines the diagnostic and therapeutic standards according to the current scientific practices in testicular cancer. For 21 separate areas scientifically based decision criteria are suggested. For treatment areas where more than one option exist without a consensus being reached for a preferred strategy, such as in seminoma in clinical Stage I or in non-seminoma Stages CS I or CS IIA/B, all acceptable alternative strategies with their respective advantages and disadvantages are presented. This "Interdisciplinary Update Consensus" was presented at the 24th National Congress of the German Cancer Society on March 21st and subsequently evaluated and approved by the various German scientific medical societies.

Results of an uncemented straight femoral shaft prosthesis after 9 years of follow-up

The first consecutive 250 implantations of an uncemented, proximally anchored straight femoral shaft prosthesis (BiCONTACT) in 236 patients are included in this prospective follow-up study. Average time of follow-up evaluation was 8.9 years (range, 7.4-10.7 years). At follow-up, 27 patients had died, and 2 could not be located. Seven patients underwent revision-2 for infection, 1 for recurrent dislocation, 2 for component undersizing with rapid subsidence, and 1 for aseptic loosening of a varus-malaligned stem; 1 radiologically well-fixed stem had been revised during acetabular revision. Overall survival was 97.1% after 11 years (confidence limits, 98.7% [upper] and 93.6% [lower]). The average Harris Hip score at time of follow-up was 84.3 points. Radiologically, tiny reactive lines (<2 mm) were present in the distal zones of the femoral shaft, but no radiolucencies could be found in the proximal anchoring zone. The midterm to long-term follow-up results with the evaluated femoral component are encouraging and are comparable to those of modern techniques of cementing in primary total hip arthroplasty.

cDNA cloning and analysis of tissue-specific expression of mouse peroxisomal straight-chain acyl-CoA oxidase

Straight-chain acyl-CoA oxidase is the first and rate limiting enzyme in the peroxisomal beta-oxidation pathway catalysing the desaturation of acyl-CoAs to 2-trans-enoyl-CoAs, thereby producing H2O2. To study peroxisomal beta-oxidation we cloned and characterized the cDNA of mouse peroxisomal acyl-CoA oxidase. It consists of 3778 bp, including a 1983-bp ORF encoding a polypeptide of 661 amino-acid residues. Like the rat and human homologue the C-terminus contains an SKL motif, an import signal present in several peroxisomal matrix proteins. Sequence analysis revealed high amino-acid homology with rat (96%) and human (87%) acyl-CoA oxidase in addition to minor homology ( approximately 40%) with other related proteins, such as rabbit trihydroxy-cholestanoyl-CoA oxidase, human branched chain acyl-CoA oxidase and rat trihydroxycoprostanoyl-CoA oxidase. Acyl-CoA oxidase mRNA and protein expression were most abundant in liver followed by kidney, brain and adipose tissue. During mouse brain development acyl-CoA oxidase mRNA expression was highest during the suckling period indicating that peroxisomal beta-oxidation is most critical during this developmental stage. Comparing tissue mRNA levels of peroxisome proliferator-activated receptor alpha and acyl-CoA oxidase, we noticed a constant relationship in all tissues investigated, except heart and adipose tissue in which much more, and respectively, much less, peroxisome proliferator-activated receptor alpha mRNA in proportion to acyl-CoA oxidase mRNA was found. Our data show that acyl-CoA oxidase is an evolutionary highly conserved enzyme with a distinct pattern of expression and indicate an important role in lipid metabolism.

A Long Straight Stem with Distal Interlocking for Uncemented Stem Revision in THR

Femoral revision in total hip replacement (THR) is often demanding due to severe bone defects of the proximal femur. The surgical technique must provide sufficient stability in the distal femur. However, long-term stability depends on preserving or even rebuilding proximal bone stock.

[Muscle strength after surgical treatment of ruptures of the long biceps tendon by refixation to the short head]

Operative treatment for ruptures of the long biceps tendon still is discussed controversially. In the present literature surgical repair is advised for sporting and high demand patients due to favourable functional results and low loss of strength. Until now only few objective and reproducible results were published. In the present literature the keyhole-technique is recommended due to favourable bio-mechanical conditions. To evaluate postoperative strength 19 patients were investigated after an average follow-up of 6.5 years, by clinical examination and isokinetic measurement. Compared with the non-operated shoulder isokinetic determination of isometric maximal peak torque and strength during concentric stress for elbow-flexion, shoulder-abduction and shoulder-flexion yield to almost identical results for the operated shoulder. According to the criteria of the Constant-Score all patients achieved very good and good results. Refixation to the short head can be advised for treatment of ruptures of the long biceps tendon due to the certain technique with a low complication rate and very good functional outcome.

Sum1 and Hst1 repress middle sporulation-specific gene expression during mitosis in Saccharomyces cerevisiae

Meiotic development in yeast is characterized by the sequential induction of temporally distinct classes of genes. Genes that are induced at the middle stages of the pathway share a promoter element, termed the middle sporulation element (MSE), which interacts with the Ndt80 transcriptional activator. We have found that a subclass of MSEs are strong repressor sites during mitosis. SUM1 and HST1, genes previously associated with transcriptional silencing, are required for MSE-mediated repression. Sum1 binds specifically in vitro to MSEs that function as strong repressor sites in vivo. Repression by Sum1 is gene specific and does not extend to neighboring genes. These results suggest that mechanisms used to silence large regions of chromatin may also be used to regulate the expression of specific genes during development. NDT80 is regulated during mitosis by both the Sum1 and Ume6 repressors. These results suggest that progression through sporulation may be controlled by the regulated competition between the Sum1 repressor and Ndt80 activator at key MSEs.

Allogenic bone graft viability after hip revision arthroplasty assessed by dynamic [18F]fluoride ion positron emission tomography

The biological fate of allogenic bone grafts in the acetabular cavity and their metabolic activity after acetabular augmentation is uncertain but is most important for the stability of hip implants after hip revision arthroplasty. The aim of this study was to quantify regional bone metabolism after hip replacement operations. Dynamic [18F]fluoride ion positron emission tomography (PET) was used to investigate the metabolic activity of acetabular allogenic bone grafts and genuine bone, either 3-6 weeks (short-term group, n = 9) or 5 months to 9 years (long-term group, n = 10) after hip revision arthroplasty. Applying a three-compartment model, the fluoride influx constant was calculated from individually fitted rate constants (Knlf) and by Patlak graphical analysis (Kpat). The results were compared with genuine cancellous and cortical acetabular bone of contralateral hips without surgical trauma (n = 7). In genuine cortical bone, Knlf was significantly increased in short- (+140.9%) and long-term (+100.0%) groups compared with contralateral hips. Allogenic bone grafts were characterised by a significantly increased Knlf in the short-term group (+190.9%) compared with contralateral hips, but decreased almost to the baseline levels of contralateral hips (+45.5%) in the long-term. Values of Knlf cor-related with the rate constant K1 in genuine (r = 0.89, P<0.001) and allogenic bone regions (r = 0.79, P<0.001), indicating a coupling between bone blood flow and bone metabolism in genuine bone as well as allogenic bone grafts. Kpat values were highly correlated with Knlf measurements in all regions. In conclusion, [18F]fluoride ion PET revealed the presence of an increased host bone formation in allogenic bone grafts early after hip revision arthroplasty. In contrast to genuine cortical bone, allogenic bone graft metabolism decreased over time, possibly due to a reduced ability to respond to the same extent as genuine bone to elevated metabolic demands after surgery.

[Structure quality in outpatient care of chronic pain patients]

BACKGROUND

Outcome quality of medical treatment depends on structure quality of the treatment facility. In the present study we tried evaluate structural parameters of outpatient treatment facilities relating to management of headache, low back pain and cancer pain.

METHODS

109 outpatient treatment facilities (104 offices, 3 outpatient departments of hospitals, 2 pain ambulances of hospitals) in middle franconia, one of the larger Bavarian administrative division (population: 1,6 Mio.), have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung").

RESULTS

Only one treatment facility worked within an interdisciplinary setting. Less than 25% (median) of total patients of an outpatient treatment facility suffered from acute or chronic headache, low back pain or cancer pain. 38% of physicians participated regularly on pain conferences. Established methods for diagnosis and documentation of patients suffering from chronic headache, chronic back pain and cancer pain were regularly used by 16%, 12% and 10% of physicians, respectively. Regular interdisciplinary cooperation in the management of patients with chronic headache, chronic back pain and cancer pain was indicated by 28%, 24% and 41% of physicians, respectively. However, personal discussion of patient related problems took place in less than 5% of physicians. Although a considerable number of different therapies (included as standard therapy for outpatient management of chronic pain in the "Schmerztherapievereinbarung") can be applied in each outpatient treatment facility (median:5), psychological therapy for management of chronic headache, chronic back pain and cancer pain was used regularly by 5%, 2% and 7% of physicians, respectively. Scoring of all examined structural parameters provides a measure for the quality of the parameters of a certain outpatient treatment facility as compared to that of an optimal outpatient facility for pain treatment (quality score=100%). However, 75% of examined outpatient treatment facilities reached quality scores only up to 43%.

CONCLUSIONS

There are considerable structural deficits in outpatient treatment facilities involved in management of patients suffering from chronic headache, chronic back pain and cancer pain. Realisation of standards according to the "Schmerztherapievereinbarung" needs organisation of an interdisciplinary network between the different specialties necessary for pain management. Interdisciplinary cooperation should be supported by the official organization of the medical self-government in Germany--the Kassenärztliche Vereinigung--which has to assure optimal conditions for outpatient treatments.

Distinct steps in yeast spore morphogenesis require distinct SMK1 MAP kinase thresholds

The SMK1 mitogen-activated protein kinase is required for spore morphogenesis in Saccharomyces cerevisiae. In contrast to the multiple aberrant spore wall assembly patterns seen even within a single smk1 null ascus, different smk1 missense mutants block in a coordinated fashion at intermediate stages. One smk1 mutant forms asci in which the four spores are surrounded only by prospore wall-like structures, while another smk1 mutant forms asci in which the spores are surrounded by inner but not outer spore wall layers. Stepwise increases in gene dosage of a hypomorphic smk1 allele allow for the completion of progressively later morphological and biochemical events and for the acquisition of distinct spore-resistance phenotypes. Furthermore, smk1 allelic spore phenotypes can be recapitulated by reducing wild-type SMK1 expression. The data demonstrate that SMK1 is required for the execution of multiple steps in spore morphogenesis that require increasing thresholds of SMK1 activity. These results suggest that quantitative changes in mitogen-activated protein kinase signaling play a role in coordinating multiple events of a single cellular differentiation program.