[Multidisciplinary treatment program for chronic low back pain, part 2. Somatic aspects]

PROBLEM

There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons.

METHODS

Our study group consisted of 90 disabled CLBP patients (44 female, 46 male; average age 42 years) who underwent a multidisciplinary 8-week daily treatment program of functional restoration with behavioral support (instruction, endurance training, strength exercises, behavioral and treatment to facilitate return to work therapy). Initially these patients where compared with 107 asymptomatic persons (44 female, 63 male, average age 41 years). The patients were investigated before and after treatment, and at intervals of 6 and 12 months. The reliability of the functional measurements was evaluated by interrater comparison. Physical assessment included a medical examination (mainly diagnosis of radicular or nonradicular pain), changes in the lumbar spine revealed by X-ray studies according to Herron and Turner, rating of physical impairment according to Waddell, flexibility, length of hamstrings muscles (SLR), test of power and endurance of trunk movement by standardized exercises according to the Swiss group of Spring and isokinetic measurements (LIDO Back), tests of lifting capacity (LIDO Lift), and (in part) of general endurance on a cycle ergometer (CASE 15 Marquette).

RESULTS

Physical findings showed that mobility was reduced substantially in patients suffering from back pain due to reduced SLR (shortened hamstrings) and decreased spinal mobility. Patients also demonstrated significant reductions in their ability to perform lifting tasks in comparison to healthy individuals. The results of trunk flexion showed no significant differences between patients and the control group, whereas the ability to perform trunk extension was much better in the control group. In principle we found the same results with isokinetic measurements as in the exercises without machines. Cardiovascular endurance was also much better in the control group than it was in the back pain patients. At the end of the treatment program all physical deficits were improved significantly. In many cases performance was comparable with that of the control group. With time, however, training effects gradually decreased. The success of treatment (return to work, absence from work, pain reduction, use of medical care) was independent of the functional status of the patients before and after treatment.

CONCLUSION

Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and severe physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of patients and their home training programs is necessary. Overall, treatment of CLBP has to include physical training and psychosocial treatment to achieve satisfactory results.

Single axon IPSPs elicited in pyramidal cells by three classes of interneurones in slices of rat neocortex

1. Using dual intracellular recordings in slices of adult rat neocortex, twenty-four IPSPs activated by single presynaptic interneurones were studied in simultaneously recorded pyramidal cells. Fast spiking interneurones inhibited one in four or five of their close pyramidal neighbours. No reciprocal connections were observed. After recordings neurones were filled with biocytin. 2. Interneurones that elicited IPSPs were classified as classical fast spiking (n = 10), as non-classical fast spiking (n = 3, including one burst-firing interneurone), as unclassified, or slow interneurones (n = 8), or as regular spiking interneurones (n = 3), i.e. interneurones whose electrophysiological characteristics were indistinguishable from those of pyramidal cells. 3. All of the seven classical fast spiking cells anatomically fully recovered had aspiny, beaded dendrites. Their partially myelinated axons ramified extensively, varying widely in shape and extent, but randomly selected labelled axon terminals typically innervated somata and large calibre dendrites on electron microscopic examination. One 'autapse' was demonstrated. One presumptive regular spiking interneurone axon made four somatic and five dendritic connections with unlabelled targets. 4. Full anatomical reconstructions of labelled classical fast spiking interneurones and their postsynaptic pyramids (n = 5) demonstrated one to five boutons per connection. The two recorded IPSPs that were fully reconstructed morphologically (3 and 5 terminals) were, however, amongst the smallest recorded (< 0.4 mV). Some connections may therefore involve larger numbers of contacts. 5. Single axon IPSPs were between 0.2 and 3.5 mV in average amplitude at -55 to -60 mV. Extrapolated reversal potentials were between -70 and -82 mV. IPSP time course correlated with the type of presynaptic interneurone, but not with IPSP latency, amplitude, reversal potential, or sensitivity to current injected at the soma. 6. Classical fast spiking interneurones elicited the fastest IPSPs (width at half-amplitude 14.72 +/- 3.83 ms, n = 10) and unclassified, or slow interneurones the slowest (56.29 +/- 23.44 ms, n = 8). Regular spiking interneurone IPSPs had intermediate half-widths (27.3 +/- 3.68 ms, n = 3). 7. Increasingly brief presynaptic interspike intervals increased the peak amplitude of, but not the area under, the summed IPSP. Only at interspike intervals between 10 and 20 ms did IPSP integrals exhibit paired pulse facilitation. Paired pulse depression was apparent at < 10 and 20-60 ms. During longer spike trains, summing IPSPs decayed to a plateau potential that was relatively independent of firing rate (100-250 Hz). Thereafter, the voltage response could increase again. 8. Summed IPSPs elicited by two to fifteen presynaptic spike trains decayed as, or more rapidly than, single-spike IPSPs. Summed IPSPs elicited by > 20 spikes (> 150 Hz), however, resulted in an additional, more slowly decaying component (latency > 50 ms, duration > 200 ms). The possible involvement of GABAB receptors in this component is discussed. 9. It is suggested that three broad classes of interneurones may activate GABAA receptors on relatively proximal portions of neocortical pyramidal neurones. The different time courses of the IPSPs elicited by the three classes may reflect different types of postsynaptic receptor rather than dendritic location. An additional class, burst firing, spiny interneurones appear to activate GABAA receptors on more distal sites.

[Optimization of embryo production in cattle by aspiration of the fluid from large follicles before induction of superovulation with the assistance of an ovary puncture cannula]

During a field study at the Besamungsverein Neustadt a.d. Aisch rectal palpable large follicles were eliminated in 167 selected donor cows prior to superovulation induction. For this purpose a so-called "Ovarpunktionskanüle" was used, which allows after vaginal introduction the aspiration of follicle fluid from a rectal fixed ovary. From 152 flushed donor cows an average of 11.0 viable embryos was recovered. Using fresh semen from one problem bull for insemination of donors 13.2 viable embryos per flushing were collected in relation to 4.1 using frozen semen. At the same time the rate of unfertilized ova dropped from 9.8 to 3.5. The follicle aspiration with a so-called "Ovarpunktionskanüle" prior to superovulation induction is-from a practical viewpoint-superior to the dominant follicle removing with the help of transrectal ultrasonography.

Regulatory inputs for the synthesis of ComK, the competence transcription factor of Bacillus subtilis

Competence in Bacillus subtilis is expressed post-exponentially in response to signals which are interpreted by a complex network of regulatory proteins. This network culminates in the transcriptional activation of a set of late-competence proteins that mediate DNA binding and uptake during transformation. ComK, a protein that binds to competence promoters and appears to activate their transcription, is itself synthesized in response to the signal-transduction network. ComK is known to be required for the transcription of its own gene. We have placed comK under control of the xylose-inducible PxylA promoter and used this construct to show that ComK synthesis is sufficient as well as necessary to induce competence. We have also confirmed that the Mec proteins act post-transcriptionally to inactivate ComK, probably by protein-protein interaction. We have further demonstrated that ComS is required to generate an upstream signal that causes reversal of Mec-induced inactivation of ComK. In addition to ComK itself, DegU, AbrB, and SinR are required for comK transcription; mutations in their genes are bypassed by PxylA-comK induction, and therefore their products appear not to act via the Mec proteins. Overproduction of ComK, in a loss-of-function mec mutant, is also known to bypass the need for DegU, SinR and AbrB. We propose that these proteins enhance the activity of ComK as a positive autoregulatory transcription factor, acting as coactivator proteins when ComK is present at low concentrations. Finally, we demonstrate that when ComK is synthesized from the PxylA promoter and mecA is inactivated by mutation, no additional growth-stage-regulated control of competence can be detected.

Histomorphological examination of endoluminal stent grafting in the descending aorta in a sheep model

Experiments were designed to examine the wound healing characteristics at the aorta-endograft interface. Thoracic aneurysms were induced in sheep and excluded by endovascular placement of a selfexpanding stent graft (Corvita Endovascular Graft). After a follow-up of 1, 4, or 12 weeks sheep were sacrificed and the corresponding segments of the aorta were subjected to histological examinations. Histomorphological evaluation of all groups underlined sufficient exclusion of lesions of the aortic wall by endovascular grafting. There was no evidence of proximal or distal leakage, graft dislocation or migration. The results appeared to be evidence that the endoluminal stent graft may be incorporated by the host aortic tissue.

Efficacy of threaded hydroxyapatite-coated implants placed in the posterior mandible in support of fixed prostheses

A data subset from an ongoing prospective multicenter clinical study of threaded hydroxyapatite-coated implants was evaluated to assess safety and efficacy of the implants when used to support fixed prostheses in the posterior mandible. Observations were recorded before surgery, at first-stage surgery, at second-stage surgery, at loading, and at quarterly postrestoration prophylactic exams and annual comprehensive patient visits. Implant failure criteria included mobility, radiographic evidence of bone loss greater than one-third the length of the implant or peri-implant radiolucency, fracture, exfoliation, removal for any reason, and patient reported pain upon palpation. Soft tissue indices were monitored as part of the study. Postrestoration implant performance was analyzed using life-table methodology. From the 2,062 implants restored in 720 patients in the parent study, a total of 423 implants in 195 patients were included in the posterior mandibular data subset. Thirteen implants failed at or before second-stage surgery for a surgical success rate of 96.9 percent. Prosthodontics was completed, and one or more postrestoration annual follow-up visits occurred for 314 implants as of the interim analysis cutoff date. Fourteen implants failed during an observation period extending up to 62 months after completion of prosthodontic treatment. One failed implant was removed, whereas the 13 remaining implants are functional despite having been identified as failures under the protocol criteria. The Cutler-Ederer life table success rate after 5 years was 92.2 percent. Results of this investigation suggest that threaded hydroxyapatite-coated implants are effective when placed in posterior mandibular regions in support of fixed prostheses.

Polynucleotide phosphorylase is necessary for competence development in Bacillus subtilis

comR (pnpA) is a newly identified gene in Bacillus subtilis that is necessary for the expression of late competence genes. Transformability of a comR (pnpA) mutant is 1-5% of that seen in comR+ strains. Cloning and sequencing identified ComR as polynucleotide phosphorylase (PNPase). The PNPase amino acid sequence has 50% identity and 67% similarity with the Escherichia coli enzyme. Enzymatic assays show that this is the only PNPase activity in B. subtilis. comR (pnpA) is necessary for comG-lacZ and comK-lacZ expression, but this requirement is bypassed by a mecA disruption. In B. subtilis, the loss of PNPase has little effect on expression from a fusion of the srfA promoter directly to lacZ, but is necessary for normal expression from certain srfA-lacZ fusions that include portions of the normal srfA transcript. When a srfA-lacZ translational fusion is tested in isogenic pnpA+ and pnpA derivatives of E. coli, lower expression is seen in the pnpA mutant. Since expression from lacZ fusions to comA, sinR, and mecA appeared similar in the B. subtilis pnpA and pnpA+ strains, the loss of PNPase does not have a strong general effect on gene expression. These results suggest that PNPase may be necessary for modification of the srfA transcript in order to activate translation or stabilize the transcript, and that this may be necessary for competence development. This is the first evidence of post-transcriptional effects on the development of competence in B. subtilis.

Efficacy of threaded hydroxyapatite-coated implants in the anterior mandible supporting overdentures

A data subset from an ongoing prospective multicenter clinical study of threaded hydroxyapatite-coated implants was evaluated to assess safety and efficacy of the implants when placed in the anterior mandible to support overdentures. Observations were recorded before surgery, at first-stage surgery, at second-stage surgery, at loading, and at quarterly postrestoration prophylactic exams and annual comprehensive patient visits. Implant failure criteria included mobility, radiographic evidence of bone loss greater than one-third the length of the implant or peri-implant radiolucency, fracture, exfoliation, removal for any reason, and patient reported pain upon palpation. Soft tissue indices were monitored as part of the study. Postrestoration implant performance was analyzed using life-table methodology. From the 2,062 implants restored in 720 patients in the parent study, a total of 660 implants in 174 patients were included in the anterior mandibular overdenture data subset. Twelve implants in 8 patients failed at or before second-stage surgery for a surgical success rate of 98.2 percent. Five implants failed during an observation period extending up to 72 months after completion of prosthodontic treatment. The Cutler-Ederer life table success rate after 5 years was 97.8 percent. No significant adverse events were reported during the observation period. Results of this investigation suggest that threaded hydroxyapatite-coated implants are effective when placed in anterior mandibular regions in support of overdentures.

A simple fail-safe method for the harvesting of cranial bone

The technique of cranial bone graft harvesting with the sagittal saw is described. With this technique regular bone grafts of any size can be obtained. Bone-graft size dictates the technique to be used. Small grafts (less than 3.0 cm in shortest dimension) are harvested in situ, while larger grafts are harvested by formal craniectomy.

Inactivation of mecA prevents recovery from the competent state and interferes with cell division and the partitioning of nucleoids in Bacillus subtilis

The development of genetic competence in Bacillus subtilis requires the synthesis of ComK, a transcription factor, which is normally produced as a culture enters the stationary phase. This synthesis is known to be regulated in part by the protein MecA. Loss-of-function mutations in mecA result in overexpression of ComK and its appearance early during exponential growth. We show here that mecA inactivation also causes a loss of colony-forming ability, especially during stationary phase. This loss is accompanied by the appearance of cells in which normal nucleoid separation has failed to occur. Renografin gradient fractionation of mecA cultures grown to competence reveals that nearly 100% of the cells band at the low buoyant density characteristic of competent cells, and that this low density is competence-related. The loss of viability, the low buoyant density and the nucleoid separation defect, are all comK-dependent. The loss of viability can be reversed by even the transient introduction of mecA+. It is proposed that these effects of ComK overexpression are related to the DNA replication arrest normally exhibited by the competent cell fraction and that MecA is needed to reverse this arrest and to permit escape from the competent state. The shift of nearly 100% of the cells to light buoyant density in a mecA mutant culture strongly suggests that the MecA protein is a regulator of the cell-type-specific expression of competence.

The major role of Spo0A in genetic competence is to downregulate abrB, an essential competence gene

We show that the major role for Spo0A in the development of genetic competence is to downregulate expression of abrB. AbrB is both a negative regulator and a positive regulator of competence. The negative effects are exerted at multiple points in competence regulation. A regulatory mechanism that is independent of mecA and abrB operates on comK expression.

Enantioselective determination of chiral 2,2',3,3',4,6'-hexachlorobiphenyl (PCB 132) in human milk samples by multidimensional gas chromatography/electron capture detection and by mass spectrometry

The enantiomeric ratio (ER) of the chiral polychlorinated biphenyl (PCB) 132 (2,2',3,3',4,6'-hexachlorobiphenyl) was determined in human milk samples. The enantiomers were separated by multidimensional gas chromatography (MDGC), using different achiral columns for pre-separation and a Chirasil-Dex column for enantiomer separation, and quantified by electron-capture detection (ECD) and by mass spectrometry (MS/SIM). The determined enantiomeric ratios varied between 0.45-0.85 (enantiomeric excess: 38-8%).

Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients

BACKGROUND/AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is a new therapy for variceal bleeding. Immediate technical and short-term clinical results have been reported. This study was undertaken to evaluate mid-term outcome after TIPS in patients who successfully underwent the procedure for variceal bleeding.

METHODS

Ninety patients were followed up prospectively by clinical examination and radiological shunt evaluation including Doppler sonography and transjugular portal venography.

RESULTS

The average follow-up in surviving patients was 2.2 years. The cumulative survival rate was 60% at 1 year and 51% at 2 years. The rate of cumulative rebleeding was 26% at 1 year and 32% at 2 years. A shunt abnormality was noted in all rebleeding patients. Rebleeding was successfully controlled in all but 1 of the patients who underwent shunt revision. Cumulative detection of stenosis or occlusion was 31% at 1 year and 47% at 2 years. Thirty-eight percent of shunt abnormalities were detected by routine surveillance. Percutaneous shunt revision was attempted in 22 patients and was successful in 21 (95%).

CONCLUSIONS

Although mid-term primary patency is limited in many patients by the development of a shunt stenosis or occlusion, shunt function can be maintained in most patients by careful surveillance and periodic percutaneous intervention.

Influence of molecular characteristics on clinical outcome in human immunodeficiency virus-associated non-Hodgkin's lymphoma: identification of a subgroup with favorable clinical outcome

The relationship between clinical and molecular characteristics of 45 treated individuals with histologically-documented human immunodeficiency virus (HIV)-associated B-cell non-Hodgkin's lymphoma was examined to determine whether differences in molecular features of lymphoma were associated with differences in clinical outcome. Tissue specimens from these tumors were evaluated for evidence of Ig heavy-chain gene rearrangements using both Southern blot analysis and reverse transcriptase polymerase chain reaction (RT-PCR). Lymphomas were also evaluated for the presence of Epstein-Barr virus (EBV) DNA sequences and c-myc gene rearrangements. Twenty-five lymphomas were characterized as polyclonal and 20 as monoclonal. PCR amplification of expressed Ig variable (V)-region genes confirmed polyclonality in three extensively studied polyclonal lymphomas. The median CD4 count was significantly higher in the group with polyclonal disease (277/microL) than in the group with monoclonal disease (123/microL), P = .04. The complete response rate to therapy was significantly higher in patients with polyclonal disease (78%) and CD4 greater than 200/microL (81%) than in those with monoclonal disease (31%) and CD4 less than 200/microL (33%). CD4 count, clonality, and presence of EBV DNA sequences were the most important predictors of survival. Both Kaplan-Meier and Cox proportional hazards analyses showed a markedly prolonged survival in those patients with both CD4 > or = 200/microL and polyclonal disease. Histologically the polyclonal lymphomas were high grade in appearance and contained prominent macrophages. All seven surviving patients were in this group. Median survival for those individuals whose tumors contained EBV sequences was only 3.2 months (range, 0.4 to 19.5), whereas those with EBV- tumors survived for a median of 9.0 months (range, 0.7 to 65.2), P = .0007. These data indicate that molecular features of HIV-associated lymphomas may be important predictors of clinical outcome. These characteristics define a distinct subset of patients with polyclonal EBV- tumors and CD4 counts greater than 200/microL that appear to have a less aggressive clinical course.

Efficacy of threaded hydroxyapatite-coated implants placed in the anterior mandible

A data subset from an ongoing prospective multicenter clinical study of threaded hydroxyapatite-coated implants was evaluated to assess safety and efficacy of the implants in anterior maxillary regions when used to support fixed prostheses. Observations were recorded before surgery, at first-stage surgery, at second-stage surgery, at loading, and at quarterly post-restoration prophylactic exams and annual comprehensive patient visits. Of 2,062 implants restored in 720 patients in the parent study, a total of 95 implants in 54 patients met the criteria for inclusion into this portion. Implant failure criteria included mobility, radiographic evidence of bone loss greater than one-third the length of the implant or peri-implant radiolucency, fracture, exfoliation, removal for any reason, and patient reported pain upon palpation. Soft tissue indices were monitored as part of the study. Post-restoration implant performance was analyzed using life-table methodology. No failures were observed before prosthodontic rehabilitation. Three implants failed during an observation period of up to 5 years after completion of prosthodontic treatment. The Cutler-Ederer life table success rate after 5 years was 93.4 percent. Results of this investigation suggest that threaded hydroxyapatite-coated implants are safe and effective when placed in anterior maxillary regions to support fixed prostheses.

Enantioselective degradation of alpha-hexachlorocyclohexane and cyclodiene insecticides in roe-deer liver samples from different regions of Germany

Remarkably high concentrations of alpha-hexachlorocyclohexane (alpha-HCH), cis-heptachlorepoxide and oxychlordane were found in roe-deer liver samples both from the northern and southern German states Schleswig-Holstein and Baden-Württemberg, respectively. The data revealed no significant regional differences, but they showed some common characteristics: a preferential degradation of (+)-alpha-HCH, and a preferential enrichment of (+)-oxychlordane and of (+)-cis-heptachlorepoxide as determined by chiral capillary gas chromatography using modified cyclodextrin phases. Calculation of the spearman rank correlation coefficients rS supported the assumption that higher concentrations of alpha-HCH may result in a stronger decomposition of the (+)-enantiomer, while higher levels of cis-heptachlorepoxide and oxychlordane appear to lead to a faster decomposition of the respective (-)-enantiomer or a preferential formation of the respective (+)-enantiomer.

[Refuse incinerators in industrial areas (pro and contra)]

Update refuse incineration plant is meanwhile available as complete residue utilisation and recycling plant at reasonable waste disposal cost. Residual refuse of unknown composition is transformed into defined raw materials. The resulting "products" of such high-temperature treatment plant are energy, glass slake, gypsum, hydrochloric acid and metal fractions that can be re-introduced, i.e. recycled, into the cyclic process applicable to raw and engineering materials.

The regulation of competence transcription factor synthesis constitutes a critical control point in the regulation of competence in Bacillus subtilis

comK, which encodes the competence transcription factor, is itself transcriptionally activated at the transition from exponential growth to stationary phase in Bacillus subtilis. MecA, a negative regulator of competence, also inhibits comK transcription when overexpressed, and a mecA null mutation results in comK overexpression. Although null mutations in mecA, as well as in another gene, mecB, are known to bypass the requirements for nearly all of the competence regulatory genes, the comK requirement is not suppressed by mecA inactivation. Various competence regulatory genes (comA, srfA, degU, abrB, sin, and spo0A) are shown to be required for the expression of comK. srfA transcription is shown to occur equally in cells destined for competence and those destined not to become competent. In contrast, comK transcription is restricted to the presumptive competent cells. These and other results are combined to describe a regulatory pathway for competence.

Implant and prosthetic principles according to the desired prosthesis

In restoring our patients to comfort, form, function, and aesthetics, it is often necessary to place one or more implants to provide support to the desired prosthesis. This presentation and paper discuss the principles of implants and prostheses, based on the author's 25 years of clinical experience in implant dentistry. Occlusal scheme, treatment of overdenture, use of abutments and attachments, single tooth replacements, quality and quantity of bone, and the selection of implants are considered.