[Incidence of hip fracture in Germany--person-related analysis of health insurance population]

BACKGROUND AND PURPOSE

An increasing number of hip fractures were reported world wide during the last decades. Up to now incidence data are rare for Germany. The aim of this study is to determine actual person-related age- and sex-specific rates of hip fractures in Germany.

METHODS

The linkable and person-specific but non-identifying database of a German statutory health insurance company, Gmuender ErsatzKasse (GEK), was used. All subjects who were admitted to hospital with a primary diagnosis of hip fracture (ICD-10: S72.0-S72.2) in 2004 were identified. Incidence rate ratios (IRR), age- and sex-specific rates (per 1000 person-years) were calculated. Annual numbers of hip fractures for all persons covered by statutory health insurances (Gesetzliche Krankenversicherung- GKV) and the German population were estimated.

RESULTS

The incidence of hip fracture increases exponentially with age. Hip fractures occur 129 times more often (IRR: 129.07; 95 % CI: 66.55 - 269.78) in women aged 90 - 94 years and 79 times more often (IRR: 78.97; 95 % CI: 30.02 - 185.87) in men aged 90 - 94 years compared to those aged 50 - 54 years. Approximately 101 037 (95 % CI: 91 779 - 110 294) persons are annually admitted to hospital in Germany due to this event.

CONCLUSION

Hip fractures are common in the elderly and especially in women. Because of demographic changes and a possible secular trend an increasing number of hip fractures are to be expected in the future.

Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of four different techniques

Tears of the anterior cruciate ligament in skeletally immature patients were operated with four different methods and their outcome compared to each other. Sixty-eight patients (33 males, 35 females), mean 12.5 years, were treated in four different centers from 1984 to 2001. Twenty-eight patients underwent the ACL-reconstruction with hamstring grafts, 16 patients with bone-patella-bone autografts, 12 patients with quadriceps grafts and 12 patients with facia lata. The mean follow-up was 32 months. Postoperative evaluation included radiographs, KT-1000/2000 stability measurements, Lysholm score, The Tegner activity scale and IKDC score. Neither leg length discrepancy nor angular deformities were noted. Mean KT-1000 difference was 2.1 mm, mean postoperative Lysholm knee score 93.3, IKDC 87% normal or nearly normal. The Tegner index decreased from 6.6 to 5.7. In total, six patients developed instability due to an adequate trauma 1 year after the index operation. Two patients showed mild arthrotic changes. All but two patients were able to return to the same level of preoperative sports participation. None of the four methods studied showed major differences in outcome compared to the other. No growth disturbance could be noted.

Bendamustine in combination with thalidomide and prednisolone (BPT) in patients with refractory or relapsed multiple myeloma: Results of a phase I clinical trial

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Background: Thalidomide is an active single agent in advanced relapsed or refractory multiple myeloma (MM). Combination of low dose thalidomide with bendamustine and prednisolone might be a way to maintain efficacy of the drug without dose limiting toxicity (DLT). Methods: The treatment consists of a fixed dose of bendamustine (60mg/qm) day 1, 8, and 15 and prednisolone (100 mg) day 1, 8, 15, and 22. At the same time, thalidomide was given in patients cohorts with escalating doses, starting with 50 mg to a maximum of 200 mg daily. 8 patients (4 after conventional chemotherapy and 4 after APBSCT) were enrolled at each dose level. Cycles were repeated every 28 days for a minimum of 2 and a maximum of 10 cycles until a maximal response was achieved, a DLT or a disease progression were observed. 23 patients ( 8 in the first dose level with 50 mg thalidomide, 8 in the second dose level with 100 mg and 7 patients in the third dose level with 200 mg) are enrolled until now. The number of prior treatment regimens was 2 or more in all patients. 6 patients were refractory for the last treatment. Median age was 67 years (range: 40 - 78). Results: All patients completed 2 cycles of BPT-treatment and were hence evaluable. Response was assessed using EBMT criteria modified to include near complete remission (nCR) and very good partial remission (VGPR). 20 of 23 patients responded after at least 2 cycles of chemotherapy with 3 CR, 5 VGPR, 11 PR and 2 MR. 2 patients had stable disease. With a median follow up of ten months, EFS and OS at twelfe months were 36 % and 85 %, respectively. Most common site effects were constipation (10 patients WHO grade 1, 8 patients WHO grade 2), polyneuropathy (14 patients WHO grade 1, 2 patients WHO grade 2) and somnolence (4 patients WHO grade 1). None of the 23 patients developed dose-limiting hematoxicity as defined by an ANC < 1,0 Gpt/l for > 7 days or an ANC < 0,5 Gpt/l for > 3 days or platelet count < 25 Gpt/l. Short neutropenia was reported in 8 patients (WHO grade 3 and 4) but no thrombocytopenia was observed. Conclusions: BPT with a dose between 50 and 200 mg thalidomide daily is well tolerated in patients with relapsed or refractory MM.

No significant financial relationships to disclose.

Gelatinase B [matrix metalloproteinase (MMP)-9] and collagenases (MMP-8/-13) are upregulated in cerebrospinal fluid during aseptic and bacterial meningitis in children

We investigated the protein expression of gelatinases [matrix metalloproteinase (MMP)-2 and -9] and collagenases (MMP-8 and -13) in cerebrospinal fluid (CSF) from patients with bacterial (BM, n = 17) and aseptic (AM, n = 14) meningitis. In both, MMP-8 and -9 were increased in 100% of patients, whereas MMP-13 was detectable in 53% and 82% respectively. Three patients with clinical signs of meningitis, without CSF pleocytosis, scored positive for all three MMPs. MMP-8 appeared in two isoforms, granulocyte-type [polymorphonuclear cell (PMN)] and fibroblast/macrophage (F/M) MMP-8. Analysis of kinetic changes from serial lumbar punctures showed that these MMPs are independently regulated, and correlate only partly with CSF cytosis or levels of the endogenous inhibitor, tissue inhibitor of matrix metalloproteinase-1. In vitro, T cells, peripheral blood mononuclear cells (PBMCs) and granulocytes (PMN) release MMP-8 and -9, whereas MMP-13 could be found only in the former two cell types. Using models of exogenous (n-formyl-Met-Leu-Phe, T cell receptor cross-linking) and host-derived stimuli (interleukin-2), the kinetics and the release of the MMP-8, -9 and -13 showed strong variation between these immune cells and suggest release from preformed stocks. In addition, MMP-9 is also synthesized de novo in PBMCs and T cells. In conclusion, invading immune cells contribute only partially to MMPs in CSF during meningitis, and parenchymal cells are an equally relevant source. In this context, in patients with clinical signs of meningitis, but without CSF pleocytosis, MMPs seem to be a highly sensitive marker for intrathecal inflammation. The present data support the concept that broad-spectrum enzyme inhibition targeting gelatinases and collagenases is a potential strategy for adjunctive therapy in infectious meningitis.

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations

INTRODUCTION

The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability.

MATERIAL AND METHODS

In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%).

RESULTS

In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint.

CONCLUSION

Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.

Neugebrauch von Benzodiazepinen und das Risiko einer proximalen Femurfraktur

Benzodiazepines appear to increase the incidence of hip fractures. Their role as a time-dependent risk factor remains unclear. We therefore conducted a case-crossover study to determine whether the new use of benzodiazepines is associated with a rise in hip fractures. We analysed 49 months of the statutory health insurance Gmünder Ersatzkasse (GEK) and enrolled all first hip fractures. The index date was the day of hospital admission. Exposure to new use of benzodiazepines was compared within the five periods preceding the index date. Out of 1630 subjects, 223 (13.7%) had at least one prescription of benzodiazepines in the preceding 150 days before the index date, 74 (4.5%) of them as a first prescription. The average age of the population was 79.8 years (SD: 7.7). Odds ratio (OR) of hip fracture was highest during the initial 5 days of new use (OR: 3.43; 95% CI 1.15-10.20) and then declined to a non-significant OR of 1.59 (95% CI 0.96-2.63) after 30 days. In conclusion, the start of a new benzodiazepine is associated with an increased risk of hip fractures. However, the population attributable risk (PAR) and, therefore, the percentage of preventable events is small (PAR: 0.55%; 95% CI 0.05-1.06%).

No Indication for a Defect in Toll-Like Receptor Signaling in Patients with Hyper-IgE Syndrome

Hyper-IgE syndrome is a rare primary immunodeficiency of unknown etiology characterized by recurrent infections of the skin and respiratory system, chronic eczema, elevated total serum IgE, and a variety of associated skeletal symptoms. Recent reports about susceptibility to pyogenic bacterial infections and high IgE levels in patients and animals with defects in toll-like receptor (TLR) signaling pathways prompted us to search for TLR signaling defects as an underlying cause of hyper-IgE syndrome. Blood samples from six patients with hyper-IgE syndrome were analyzed for serum cytokine levels, intracellular cytokine production in T cells after stimulation with PMA/ionomycin, and cytokine production from peripheral blood mononuclear cells stimulated by TLR ligands and bacterial products including LPS (TLR4), peptidoglycan (TLR2), PolyIC (TLR3), R848 (TLR7/8), CpG-A, and CpG-B (TLR9), zymosan and heat killed Listeria monocytogenes. All results were compared to data from healthy controls. A reduction in IFN-gamma, IL-2, and TNF-alpha producing T cells after PMA stimulation suggested a reduced inflammatory T cell response in patients with hyper-IgE syndrome. Increased serum levels of IL-5 indicated a concomitant Th2 shift. However, normal production of cytokines (TNF-alpha, IL-6, IL-10, IFN-alpha, IP-10) and upregulation of CD86 on B cells and monocytes after TLR stimulation made a defect in TLR signaling pathways highly unlikely. In summary, our data confirmed an imbalance in T cell responses of patients with hyper-IgE syndrome as previously described but showed no indication for an underlying defect in toll-like receptor signaling.