Romosozumab in patients who experienced an on-study fracture: post hoc analyses of the FRAME and ARCH phase 3 trials

Post hoc analysis of FRAME and ARCH revealed that on-study nonvertebral and vertebral fractures by Month 12 were less common in women initially treated with romosozumab versus placebo or alendronate. Recurrent fracture risk was also lower in romosozumab‑treated patients, and there were no fracture‑related complications. Results support continuing romosozumab treatment post‑fracture.

PURPOSE

Post hoc analysis evaluating efficacy and safety of romosozumab, administered in the immediate post‑fracture period, in the FRAME and ARCH phase 3 trials.

METHODS

In FRAME (NCT01575834) and ARCH (NCT01631214), postmenopausal women with osteoporosis were randomized 1:1 to romosozumab 210 mg monthly or comparator (FRAME, placebo; ARCH, alendronate 70 mg weekly) for 12 months, followed by antiresorptive therapy (FRAME, denosumab; ARCH, alendronate). In patients who experienced on-study nonvertebral or new/worsening vertebral fracture by Month 12, we report the following: fracture and treatment‑emergent adverse event (TEAE) incidence through 36 months, bone mineral density changes (BMD), and romosozumab timing. Due to the sample sizes employed, meaningful statistical comparisons between treatments were not possible.

RESULTS

Incidence of on-study nonvertebral and vertebral fractures by Month 12 was numerically lower in romosozumab- versus comparator-treated patients (FRAME, 1.6% and 0.5% versus 2.1% and 1.6%; ARCH, 3.4% and 3.3% versus 4.6% and 4.9%, respectively). In those who experienced on-study nonvertebral fracture by Month 12, recurrent nonvertebral and subsequent vertebral fracture incidences were numerically lower in patients initially treated with romosozumab versus comparator (FRAME, 3.6% [2/56] and 1.8% [1/56] versus 9.2% [7/76] and 3.9% [3/76]; ARCH, 10.0% [7/70] and 5.7% [4/70] versus 12.6% [12/95] and 8.4% [8/95], respectively). Among those with on-study vertebral fracture by Month 12, recurrent vertebral and subsequent nonvertebral fracture incidences were numerically lower with romosozumab versus comparator (FRAME, 0.0% [0/17] and 0.0% [0/17] versus 11.9% [7/59] and 8.5% [5/59]; ARCH, 9.0% [6/67] and 7.5% [5/67] versus 15.0% [15/100] and 16.0% [16/100], respectively). In patients with fracture by Month 12, no fracture‑related complications were reported in romosozumab-treated patients. BMD gains were numerically greater with romosozumab than comparators.

CONCLUSION

Data suggest support for the efficacy and safety of continuing romosozumab treatment following fracture.

TRIAL REGISTRATIONS

NCT01575834; NCT01631214.

Selective replication and vertical transmission of Ebola virus in experimentally infected Angolan free-tailed bats

The natural reservoir of Ebola virus (EBOV), agent of a zoonosis burdening several African countries, remains unidentified, albeit evidence points towards bats. In contrast, the ecology of the related Marburg virus is much better understood; with experimental infections of bats being instrumental for understanding reservoir-pathogen interactions. Experiments have focused on elucidating reservoir competence, infection kinetics and specifically horizontal transmission, although, vertical transmission plays a key role in many viral enzootic cycles. Herein, we investigate the permissiveness of Angolan free-tailed bats (AFBs), known to harbour Bombali virus, to other filoviruses: Ebola, Marburg, Taï Forest and Reston viruses. We demonstrate that only the bats inoculated with EBOV show high and disseminated viral replication and infectious virus shedding, without clinical disease, while the other filoviruses fail to establish productive infections. Notably, we evidence placental-specific tissue tropism and a unique ability of EBOV to traverse the placenta, infect and persist in foetal tissues of AFBs, which results in distinct genetic signatures of adaptive evolution. These findings not only demonstrate plausible routes of horizontal and vertical transmission in these bats, which are expectant of reservoir hosts, but may also reveal an ancillary transmission mechanism, potentially required for the maintenance of EBOV in small reservoir populations.

Inoculation route-dependent Lassa virus dissemination and shedding dynamics in the natural reservoir - Mastomys natalensis

Lassa virus (LASV), a Risk Group-4 zoonotic haemorrhagic fever virus, affects sub-Saharan African countries. Lassa fever, caused by LASV, results in thousands of annual deaths. Although decades have elapsed since the identification of the Natal multimammate mouse (Mastomys natalensis) as a natural reservoir of LASV, little effort has been made to characterize LASV infection in its reservoir. The natural route of infection and transmission of LASV within M. natalensis remains unknown, and the clinical impact of LASV in M. natalensis is mostly undescribed. Herein, using an outbred colony of M. natalensis, we investigate the replication and dissemination dynamics of LASV in this reservoir following various inoculation routes. Inoculation with LASV, regardless of route, resulted in a systemic infection and accumulation of abundant LASV-RNA in many tissues. LASV infection in the Natal multimammate mice was subclinical, however, clinical chemistry values were transiently altered and immune infiltrates were observed histologically in lungs, spleens and livers, indicating a minor disease with coordinated immune responses are elicited, controlling infection. Intranasal infection resulted in unique virus tissue dissemination dynamics and heightened LASV shedding, compared to subcutaneous inoculation. Our study provides important insights into LASV infection in its natural reservoir using a contemporary infection system, demonstrating that specific inoculation routes result in disparate dissemination outcomes, suggesting intranasal inoculation is important in the maintenance of LASV in the natural reservoir, and emphasizes that selection of the appropriate inoculation route is necessary to examine aspects of viral replication, transmission and responses to zoonotic viruses in their natural reservoirs.

How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture?

In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.

Systems leadership doctor of nursing practice: global relevance

AIM

This article considers the systems leadership doctor of nursing practice degree as an option to increase nursing leadership roles and heighten presence at policy tables globally, particularly in low- and middle-income countries. Recent global reports emphasize core competencies needed for nursing leadership, particularly systems leadership and health policy, to successfully move the global health agenda forward. Using the Yale University School of Nursing programme as an exemplar, this paper is focused on the elements directly linked to leadership competencies and relevance of a systems leadership doctor of nursing practice programme globally.

BACKGROUND/INTRODUCTION

The dramatic growth and wide variability of doctor of nursing practice programmes offered in all 50 US States have generated questions and debate. According to the American Association of Colleges of Nursing as of May 2018, there are 121 schools that reported having a leadership focus in postmaster's doctor of nursing practice degree offering. Yet there has not been the same enthusiasm for development and implementation for a practice doctorate in nursing across the globe.

SOURCES OF EVIDENCE

A narrative literature review was conducted aimed at addressing the relevance of a practice doctorate globally. This analysis of the literature included a search of peer-reviewed and grey literature. Nursing school websites were visited, and opinions of nurse leaders and students were sought. In addition, global reports that supported nursing leadership and their role in policy development were reviewed.

DISCUSSION/CONCLUSION

Globally, nurses have a critical role in leading health systems. Developing a cadre of nurse leaders educated at the doctoral level who can communicate with policymakers and develop strategies to meet health systems' goals is necessary.

IMPLICATIONS FOR NURSING, HEALTH AND EDUCATION POLICY

In recent global health reports and campaigns, strengthening nursing leadership and presence at policymaking tables are recurring themes. Offering a systems leadership doctor of nursing practice degree is one viable option to increase doctorally prepared nurse leaders for nursing policy and practice engagement. This calls for work with country and regional governments, regulatory bodies and nursing associations to empower nursing to contribute fully.

Zur Anwendung der Ballon-Kyphoplastie/Vertebroplastie

In der Behandlung osteoporotischer Wirbelkörperfrakturen finden die minimalinvasiven Methoden der Ballon-Kyphoplastie und der Vertebroplastie zunehmende Verbreitung. In der aktuellen Leitlinie zur Behandlung der Osteoporose ist aufgrund der eingeschränkten Studienlage eine sehr konservative Aussage zur Anwendung der Verfahren getroffen worden. Die vorliegende Arbeit stellt eine Bewertung beider Verfahren hinsichtlich Indikation, technischer Durchführung und notwendiger Voraussetzungen dar. Sie wurde erstellt durch eine vom DVO beauftragte Arbeitsgruppe und soll bestehende Unsicherheiten im Zusammenhang mit beiden Verfahren reduzieren.

Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting

Osteoporosis represents a significant and increasing healthcare burden in Europe, but most patients at increased risk of fracture do not receive medication, resulting in a large treatment gap. Identification of patients who are at particularly high risk will help clinicians target appropriate treatment more precisely and cost-effectively, and should be the focus of future research.

INTRODUCTION

The purpose of the study was to review data on the identification and treatment of patients with osteoporosis at increased risk of fracture.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review current data on the epidemiology and burden of osteoporosis and the patterns of medical management throughout Europe.

RESULTS

In Europe in 2010, the cost of managing osteoporosis was estimated at €37 billion and notably the costs of treatment and long-term care of patients with fractures were considerably higher than the costs for pharmacological prevention. Despite the availability of effective treatments, the uptake of osteoporosis therapy is low and declining, in particular for secondary fracture prevention where the risk of a subsequent fracture following a first fracture is high. Consequently, there is a significant treatment gap between those who would benefit from treatment and those who receive it, which urgently needs to be addressed so that the burden of disease can be reduced.

CONCLUSIONS

Implementation of global fracture prevention strategies is a critical need. Future research should focus on identifying specific risk factors for imminent fractures, periods of high fracture risk, patients who are at increased risk of fracture and therapies that are most suited to such high-risk patients and optimal implementation strategies in primary, secondary and tertiary care.

[Supportive drugs for improved implant healing]

BACKGROUND

Improvement of implant healing in orthopedic and trauma surgery serves to improve the life expectancy of the implant. Good primary stability by clamping is a prerequisite for secondary stability and for the actual integration and healing of the implant.

RESULTS

Possible causes of implant loosening are abrasive particles, which arrive at non-integrated implants at the unsealed prosthesis-bone interface and provoke a macrophage-mediated foreign body reaction, resulting in periprosthetic osteolysis. Numerous animal studies have already described the use of bisphosphonates to inhibit osteolysis induced by abrasion and secondary instability. In patients with total knee arthroplasty, a decrease in prosthetic migration under the influence of bisphosphonates could be shown. The stimulation of bone formation around the implants and the resulting implant healing was demonstrated both in animal experiments for bone morphogenetic proteins (BMP) and in case reports for intermittent parathyroid hormone administration.

CONCLUSION

By using supportive drugs, it is possible to achieve an improvement in the osseointegration of implants; thus, more rapid secondary stability and load-bearing are expected.

Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014

We report two cases of confirmed Ebola virus disease in pregnant women, who presented at the Médecins Sans Frontières Ebola treatment centre in Guéckédou. Despite the very high risk of death, both pregnant women survived. In both cases the critical decision was made to induce vaginal delivery. We raise a number of considerations regarding the management of Ebola virus-infected pregnant women, including the place of amniocentesis and induced delivery, and whether certain invasive medical acts are justified.

Differences in persistency with teriparatide in patients with osteoporosis according to gender and health care provider

This analysis investigated the persistence of teriparatide for treatment of osteoporosis in 829 patients according to gender and health care provider treated with teriparatide. This study showed that female patients were less persistent than males and those patients treated in the practices of orthopedic surgeons were more treatment persistent than patients treated in general practitioner (GP) practices.

INTRODUCTION

The optimal persistency of teriparatide (TPTD) is of the upmost importance to ensure fracture risk reduction and pain relief. Data reporting on gender-specific or health care provider-dependent differences on health care provider-dependent persistence is currently lacking.

METHODS

We analyzed a large dataset extracted from the Disease Analyzer database (IMS Health, Germany). Out of a dataset of 15 million patients, we identified patients with osteoporosis who received first-time teriparatide prescriptions from January 2005 to December 2012.

RESULTS

All 829 patients (677 females and 152 males) were included in the study. The patients were treated by 214 general practitioners (GPs) and 143 orthopedic surgeons. After 18 months of follow-up, 39.5 % of the female and 34 % of the male patients discontinued their treatment (p = 0.0308). We found a significant difference in the discontinuation rate of patients treated by orthopedic surgeons (35.0 %) compared to patients treated by GPs (44.2 %) (p = 0.0445). Additionally, at the end of the 18 months of follow up, 39.4 % of female and 47.8 % of male patients were still on treatment. We found a highly significant decreased risk for treatment discontinuation in patients with fractures prior to treatment initiation compared to those without such fractures (hazard ratio (HR) 0.77; 95 % confidence interval (CI) 0.66-0.90). There was a significantly increased risk of treatment discontinuation for female patients (HR 1.38; 95 % CI 1.10-1.74) compared to male patients.

CONCLUSIONS

In conclusion, female patients presented higher discontinuation rates of TPTD compared to males. Patients treated in the practices of orthopedic surgeons were more persistent than patients treated in GP practices. TPTD persistence in patients with osteoporosis is higher than with antiresorptives but is still suboptimal and needs to be improved to ensure fracture risk reductions comparable to randomized controlled trial (RCT) results.

The non-interventional BonViva Intravenous Versus Alendronate (VIVA) study: real-world adherence and persistence to medication, efficacy, and safety, in patients with postmenopausal osteoporosis

Adherence and persistence to oral bisphosphonates in women with postmenopausal osteoporosis is suboptimal. In this study, patients were treated with either oral or intravenous bisphosphonates. The increased adherence and persistence observed in patients receiving intravenous medication compared with those receiving oral medication may improve health outcomes.

INTRODUCTION

Poor adherence and persistence to oral medication are often observed in women with postmenopausal osteoporosis (PMO). The purpose of the non-interventional BonViva Intravenous Versus Alendronate (VIVA) study was to determine whether, in a real-world setting, (1) increased adherence and persistence to medication would be observed in women with PMO receiving intravenous (i.v.) ibandronate versus oral alendronate, (2) a correlation exists between adherence and persistence to medication and drug efficacy, and (3) any unexpected adverse events/serious adverse events (AEs/SAEs) may occur.

METHODS

The study was conducted in 632 centers in Germany. A total of 6,064 females with PMO were enrolled and recruited into one of two treatment arms: quarterly i.v. administration of 3 mg ibandronate or weekly oral medication of 70 mg alendronate, for 12 months. At the end of the study, adherence and persistence to medication, new osteoporotic fractures, mobility, use of analgesics, and AEs/SAEs were determined.

RESULTS

Greater adherence and persistence to medication were observed in the ibandronate treatment arm compared with the alendronate treatment arm. Although there was no significant difference in the number of patients with new vertebral, hip, or forearm fractures between treatment arms, a significantly greater increase in mobility and decrease in the use of analgesics were reported in the ibandronate treatment arm. No unexpected AEs/SAEs occurred in either arm.

CONCLUSIONS

Adherence and persistence to medication were greater in women with PMO receiving i.v. ibandronate compared with those receiving oral alendronate. This may have led to an increase in mobility and a decrease in pain in these patients.

[Patient pathways in thrombosis prophylaxis after hip and knee replacement surgery : results of a survey]

A key element of patient care after hip and knee replacement is medication-based thrombosis prophylaxis. Due to decreasing lengths of acute hospital stays the question arises to what extent outpatients are taking responsibility thrombosis prophylaxis (patient pathway analysis).To analyze patient pathways a telephone survey of 668 patients was conducted. On average patients were interviewed 38 days following surgery with a focus on low molecular weight heparins. The analysis showed that nearly 90% of patients need to carry out thrombosis prophylaxis in an outpatient or home environment for at least 1 day and for 47.2% of patients a linking period between acute and rehabilitation stay is relevant. The obviously existing quantitative importance of outpatient thrombosis prophylaxis is also reflected by its duration and 45.7% of interviewed patients needed at least 5 days of outpatient prophylaxis.Outpatient thrombosis prophylaxis clearly makes high demands on the patients, in particular when combined with the task of administering complex forms of injections. Those involved in inpatient and outpatient provision of care should not assume that all patients carry out the necessary prophylaxis at the required level of reliability. On the contrary initial evidence shows that the non-adherence of patients during ambulatory thrombosis prophylaxis presents a genuine challenge to care providers.

[Total knee replacement in haemophilic arthropathy. A clinical and radiological evaluation of 30 patients]

Purpose of this retrospective study was to evaluate our own results after total knee replacement in patients with haemophilia. Patients, material, method: 30 patients with haemophilia who underwent total knee replacement between 1987 and 2005 were included. We used the clinical and radiological Knee Society Score. Furthermore, the Petterson and the Arnold and Hilgartner score were applied.

RESULTS

The mean age at the time of surgery was 43.2 (27-66). At the time of follow-up examination the mean age was 51.6 (30-82) years. The mean follow-up was 7.1 (2-20) years. Preoperative, he mean Arnold and Hilgartner score was 4.17 (±0.59) and the mean Petterson-Score was 9±2.29. Compared to the preoperative deficiency in knee function (KSS-Score 88.17±33.58) an improvement with 166.67 (±22.73) points was seen. 1 patient showed an aseptic loosening after 11 years.

DISCUSSION

Total knee replacement in patients with haemophilia improves knee function and quality of life. The results of our study represent results in earlier published studies. Compared to a non-haemophilic normal population the rate of perioperative complications was not increased.

[Conservative treatment in haemophilia - Improving effectivity and establishing standards]

Rehabilitation and physical therapy in the sense of functional health is based on the international classification of function. It takes in two considerations: function and structure of the body and their influence on personal and social activity. The integrative concept of joint function translates the basic concept of body function and structure on to the motion of the locomotive system. Stability needs motoric control. Motoric control and the integrated neural components are to be influenced through regulation of muscle tonus (massage, manual therapy, medical training therapy, electrotherapy and thermotherapy). The stability of the joint is controlled by the passive components. Passive structures are optimised through passive therapies like joint mobilisation. Active components of joint function are optimised through activation (medical training therapy, stabilisation, mono or multisegmental levels). Emotional and neuronal components can be triggered through kinesthetic exercises like PNF, Jacobsen relaxation, biofeedback training, mental training. Exact examination of the locomotive system will help finding all symptoms. This is how we individualise the therapy of symptoms and structures. The motion pattern generator shows us how to use the possibilities of functional influence on the motion pattern. We have a lot of afferent signals that need individualised functional therapy. This is why we need functional measurements like motion analysis on the basis of ultrasound. An other tool is the kinetic superficial EMG measurement of muscle function. We can use it to determine the status of the joint and it will lead to therapeutical decisions. All functional measurements will help to improve quality control of the physical therapy process. Even if the haemophilic patient is healthy he is not fit at all. Measurements of fitness will help us to improve special skills and establish the human being as a subject in society and environment. The main skill to be improved in haemophiliacs is coordination, strength of the stomach muscles and the vastus medialis and the flexibility of the hamstrings.

Functional results after giant cell tumor operation near knee joint and the cement radiolucent zone as indicator of recurrence

BACKGROUND

Giant cell tumor of bone near the knee joints is a dilemma for the operating surgeon. Curettage and bone grafting have a high recurrence, whereas wide resection has a reduced recurrence rate with the compromise of limb function.

MATERIALS AND METHODS

Thirty-eight patients with histologically proven giant cell tumor near the knee joint were treated. All patients were reviewed with regard to the operative method, recurrence rate, postoperative arthritis and functional results of the joint. In cases of cement filling, the radiolucent zone and the sclerotic rim were assessed as possible markers for recurrence.

RESULTS

14 male and 24 female patients were included in this study (mean age 28 years, range 13-56 years). All patients underwent surgery, 21 patients were treated with a bone cement filling and additional osteosynthesis after curettage. Seventeen patients were filled with cancellous bone or curettage alone. In the group with bone cement filling after curettage, the recurrence rate was 23.8%, whereas a recurrence rate of 52.9% was detected in the group with cancellous bone filling or curettage alone. The average time to recurrence was two years (5 months to 6 years). An increase of the radiolucent zone was seen in 80% of all patients with a recurrence.

CONCLUSION

Cement filling after extensive curettage does not increase the recurrence rate and does not induce osteoarthritis, as long as the continuity of articular cartilage is maintained. Patients with giant cell tumor of bone near the knee joint can be treated satisfactorily with intralesional resection and bone cement packing. The extension of the radiolucent zone after bone cement filling is a reliable indicator for a possible local recurrence.

Konservative Hämophiliebehandlung unter Berücksichtigung der Optimierung und Standardisierung

Rehabilitation and physical therapy in the sense of functional health is based on the international classification of function. It takes in two considerations: function and structure of the body and their influence on personal and social activity. The integrative concept of joint function translates the basic concept of body function and structure on to the motion of the locomotive system. Stability needs motoric control. Motoric control and the integrated neural components are to be influenced through regulation of muscle tonus (massage, manual therapy, medical training therapy, electrotherapy and thermotherapy). The stability of the joint is controlled by the passive components. Passive structures are optimised through passive therapies like joint mobilisation. Active components of joint function are optimised through activation (medical training therapy, stabilisation, mono or multisegmental levels). Emotional and neuronal components can be triggered through kinesthetic exercises like PNF, Jacobsen relaxation, biofeedback training, mental training. Exact examination of the locomotive system will help finding all symptoms. This is how we individualise the therapy of symptoms and structures. The motion pattern generator shows us how to use the possibilities of functional influence on the motion pattern. We have a lot of afferent signals that need individualised functional therapy. This is why we need functional measurements like motion analysis on the basis of ultrasound. An other tool is the kinetic superficial EMG measurement of muscle function. We can use it to determine the status of the joint and it will lead to therapeutical decisions. All functional measurements will help to improve quality control of the physical therapy process. Even if the haemophilic patient is healthy he is not fit at all. Measurements of fitness will help us to improve special skills and establish the human being as a subject in society and environment. The main skill to be improved in haemophiliacs is coordination, strength of the stomach muscles and the vastus medialis and the flexibility of the hamstrings.

Kniegelenksendoprothetik bei hämophiler Arthropathie

Purpose Purpose of this retrospective study was to evaluate our own results after total knee replacement in patients with haemophilia. Patients, material, method: 30 patients with haemophilia who underwent total knee replacement between 1987 and 2005 were included. We used the clinical and radiological Knee Society Score. Furthermore, the Petterson and the Arnold and Hilgartner score were applied. Results: The mean age at the time of surgery was 43.2 (27–66). At the time of follow- up examination the mean age was 51.6 (30–82) years. The mean follow-up was 7.1 (2–20) years. Preoperative, he mean Arnold and Hilgartner score was 4.17 (± 0.59) and the mean Petterson-Score was 9 ± 2.29. Compared to the preoperative deficiency in knee function (KSS-Score 88.17 ± 33.58) an improvement with 166.67 (± 22.73) points was seen. 1 patient showed an aseptic loosening after 11 years. Discussion: Total knee replacement in patients with haemophilia improves knee function and quality of life. The results of our study represent results in earlier published studies. Compared to a non-haemo-philic normal population the rate of perioper-ative complications was not increased.

Examining landscape factors influencing relative distribution of mosquito genera and frequency of virus infection

Mosquito-borne infections cause some of the most debilitating human diseases, including yellow fever and malaria, yet we lack an understanding of how disease risk scales with human-driven habitat changes. We present an approach to study variation in mosquito distribution and concomitant viral infections on the landscape level. In a pilot study we analyzed mosquito distribution along a 10-km transect of a West African rainforest area, which included primary forest, secondary forest, plantations, and human settlements. Variation was observed in the abundance of Anopheles, Aedes, Culex, and Uranotaenia mosquitoes between the different habitat types. Screening of trapped mosquitoes from the different habitats led to the isolation of five uncharacterized viruses of the families Bunyaviridae, Coronaviridae, Flaviviridae, and Rhabdoviridae, as well as an unclassified virus. Polymerase chain reaction screening for these five viruses in individual mosquitoes indicated a trend toward infection with specific viruses in specific mosquito genera that differed by habitat. Based on these initial analyses, we believe that further work is indicated to investigate the impact of anthropogenic landscape changes on mosquito distribution and accompanying arbovirus infection.

Comparison of periprosthetic bone remodelling after implantation of anatomic and straight stem prostheses in total hip arthroplasty

INTRODUCTION

Total hip arthroplasty changes bone loading conditions in the proximal femur and induces adaptive remodelling of the periprosthetic bone. These remodelling processes depend on many implant-specific qualities, e.g. material and elasticity of the stem. The objective of this study was to investigate the effect of the stem design on periprosthetic bone remodelling after insertion of an anatomic stem with proximal fixation and the direct comparison to a straight stem prosthesis.

MATERIALS AND METHODS

In a prospective study, the changes in periprosthetic bone mineral density (BMD) after implantation of 68 CTX-S anatomic and 22 PPF straight stem prostheses were assessed in the first post-operative year by means of DEXA and zone analysis by Gruen (Clin Orthop 141:17-27, 1979) "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Furthermore all patients with CTX-S prostheses were monitored in the second post-operative year. The correlation of adaptive bone remodelling and the systemic bone density was also investigated.

RESULTS

In the distal one-third of the straight stem prosthesis, a clearly greater, although not significant, hypertrophy of the periprosthetic bone was observed. No differences in the extent of bone loss between the two prostheses in the regions of interest (ROI) of the proximal bone were observed. The greatest decrease in BMD was registered in the medial femoral neck in both groups. Bone atrophy decreased progressively as the ROI moved distally, ending in a slight increase in BMD in the distal ROI. No significant changes in periprosthetic BMD occurred in the second post-operative year. A strong positive correlation in the regions with the greatest BMD decrease with the systemic BMD was ascertained.

CONCLUSION

After implanting a CTX-S prosthesis, as opposed to PPF prostheses, a different pattern of periprosthetic bone remodelling with a slighter hypertrophy of the distal periprosthetic parts was observed. This implies that the extensive proximal, more physiological bone loading of the anatomic stem as well as the removal of less bone while implanting the stem reduces the negative effects of unphysiological strain distribution and stress shielding. The BMD loss in the medial proximal neck cannot be avoided with this stem design either. The lack of significant BMD changes in the second post-operative year suggests that a stabilisation of bone remodelling processes occurs.

Inhibition of osteosarcoma cell proliferation by the Hedgehog-inhibitor cyclopamine

Osteosarcomas (OS) are the most frequent primary malignant bone tumors in humans. Even though OS are chemosensitive, about 30% of patients must be considered poor responders and consequently have a dismal long term prognosis. The Hedgehog (Hh) gene is crucial in the signalling pathways of proliferation and differentiation during embryonic development. There is evidence that uncontrolled activation of this pathway results in specific types of cancer and that inhibition of Hh signalling is able to suppress tumour growth and to induce apoptosis of neoplastic cells. This study investigates the impact of the steroidal alkaloid and Hh-inhibitor cyclopamine on osteosarcoma cells. Thus we demonstrate the drug's impact on cellular proliferation, cell cycle cell death as well as the cells' metabolism. We here demonstrate that cyclopamine exhibits a high efficacy against the osteosarcoma cell lines HOS, SaOS and OS-KA, a self-established primary osteosarcoma cell line. In particular, cyclopamine is able to inhibit proliferation and to promote cell death. Our results provide evidence for the potency of the Hh-inhibitor cyclopamine as a future treatment of osteosarcomas.

Einfluss der Bisphosphonate auf die Frakturheilung

As the population ages and the prevalence of osteoporotic fractures increases, perioperative medical care of the elderly will continue to present challenges. Bisphosphonates, in combination with calcium and vitamin D have become the first-line therapy for patients with osteoporosis. Thus, one of the frequently asked questions concerning such patients is whether individuals who have recently sustained a fracture should take inhibitors of bone resorption. This discussion is relevant because many of the patients treated with bisphosphonates do have fractures, such as patients with osteoporosis, tumor bone disease, Paget's disease or osteogenesis imperfecta. A recent fracture should not preclude the initiation of therapy, because bisphosphonates have not been shown to interfere with overall fracture strength. Bisphosphonates appear to affect callus formation differently from either estrogen or raloxifene, but no significant difference in callus strength was seen 16 weeks after fracture. In addition, current studies demonstrate a significant reduction in periprosthetic bone loss after uncemented primary hip arthroplasty.

Generation of recombinant Norovirus-like particles (VLP) in the human endothelial kidney cell line 293T

Noroviruses (NVs) are the major cause of non-bacterial outbreaks of gastroenteritis. Here we report a new alternative system to generate recombinant NV virus-like particles (rNV-VLP) in a human endothelial kidney cell line (HEK). Transfecting HEK-293T cells with an expression vector coding for the ORF-2 gene lead to the expression of the viral structural protein VP1 which spontaneously assembled into virus-like particles (VLP), as shown by electron microscopy. The transfected cells did not show a cytopathic effect and released rNV-VLP into the culture medium. The HEK-293T cell derived particles were morphologically indistinguishable to the rNV-VLP produced from baculovirus and the Venezuelan equine encephalitis virus (VEE)-replicon. The produced particles were stable for at least 2.5 months at 4 degrees C.

[Effects of the intensity of a post partum examination on the fertility performance of high yielding dairy cows]

Two methods for a scheduled post partum examination were compared on a commercial dairy farm. In Group 1, all cows (n = 601) were examined by rectal palpation between day 20 and 26 post partum for signs of endometritis (vaginal discharge, enlarged uterus). In Group 2, all cows (n = 652) were examined by external inspection for vaginal discharge as a sign for endometritis. In both groups all cows with endometritis were treated twice with prostaglandin F2 alpha (25 mg of dinoprost) in a 14-day interval. The proportion of cows with signs of endometritis was 33.3% and 17.2% in Group 1 and Group 2, respectively (p < 0.05). In Group 1, the conception rate (39.0% vs 49.3%) and the proportion of cows pregnant (60.5% vs 72.6%) were lower for cows with endometritis than for cows without endometritis. In Group 2, no significant differences were found in reproductive performance for cows with and without signs of endometritis. No significant differences in reproductive performance were found for cows with endometritis between the two groups. Also, for cows without endometritis no significant differences in reproductive performance were found between the groups. It is concluded that the post partum examination by rectal palpation was more sensitive in finding cows with endometritis. However, with regard to the reproductive performance the more sensitive method was not more effective than the method based on systematic external inspection.

Moving from apprehension to action: HIV counseling and testing preferences in three at-risk populations

This study sought to identify factors influencing HIV testing decisions among clients at a sexually transmitted disease clinic, gay men, and injection drug users. Focus group and intensive interview data were collected from 100 individuals. The AIDS Risk Reduction Model was adapted to describe factors that affect test decisions. Testing barriers and facilitators were grouped as factors affected by "Individual" beliefs, "System" policies and programs, "Testing" technology, and "Counseling" options. Individual factors (fear of death and change), system factors (anonymous test availability, convenience), and counseling and testing factors (rapid results, counseling alternatives) interact to determine whether an individual does not test ("apprehension") or does test ("action"), and ultimately, tests routinely ("integration"). In conclusion, traditional HIV testing presents barriers to some populations at risk for HIV. These findings suggest several strategies to improve HIV test acceptance: acknowledge fears, address system barriers, utilize available test technologies, and expand counseling options.

Reproductive and sexual health benefits in private health insurance plans in Washington State

CONTEXT

Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems.

METHODS

A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations.

RESULTS

Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally.

CONCLUSIONS

A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.

Treatment of BK virus-associated hemorrhagic cystitis and simultaneous CMV reactivation with cidofovir

Hemorrhagic cystitis (HC) is a common complication following high-dose chemotherapy and bone marrow transplantation, and the treatment of virus-associated HC remains to be optimized. This is the first report on the successful use of cidofovir in a patient with HC and polyoma viruria concomitant with CMV reactivation after allogeneic BMT. Treatment led to a significant decrease in viruria and to sustained suppression of CMV reactivation. Administered with probenecid and hydration, cidofovir was well tolerated, and there were no side-effects.

Cauda equina compression due to a laminar hook: A late complication of posterior instrumentation in scoliosis surgery

Whilst neurologic injury following correction of scoliosis with CD-instrumentation is generally known to be an early complication, any late occurrence of cauda compression secondary to employment of a laminar hook-rod construct is exceptional. We report on such a rare case of late occurrence of cauda equina syndrome, when a laminar hook at level L2 became symptomatic causing compression of the cauda equina almost a decade after spine surgery. This case demonstrates that one should not only be aware of a potential neural injury at intraoperative placement of laminar hooks, but also one is reminded that a laminar hook poses the threat of late neurologic injury years after successful osseous spinal fusion. The surgeon treating patients with scoliosis must be aware of the possible complication described in our patient in addition to those that have already been well documented.

New chimaeric hepatitis B virus core particles carrying hantavirus (serotype Puumala) epitopes: immunogenicity and protection against virus challenge

Virus-like particles generated by the heterologous expression of virus structural proteins are able to potentiate the immunogenicity of foreign epitopes presented on their surface. In recent years epitopes of various origin have been inserted into the core antigen of hepatitis B virus (HBV) allowing the formation of chimaeric HBV core particles. Chimaeric core particles carrying the 45 N-terminal amino acids of the Puumala hantavirus nucleocapsid protein induced protective immunity in bank voles, the natural host of this hantavirus. Particles applied in the absence of adjuvant are still immunogenic and partially protective in bank voles. Although a C-terminally truncated core antigen of HBV (HBcAg delta) tolerates the insertion of extended foreign sequences, for the construction of multivalent vaccines the limited insertion capacity is still a critical factor. Recently, we have described a new system for generating HBV 'mosaic particles' in an Escherichia coli suppressor strain based on a readthrough mechanism on a stop linker located in front of the insert. Those mosaic particles are built up by both HBcAg delta and the HBcAg delta/Puumala nucleocapsid readthrough protein. The particles formed presented the 114 amino acid (aa) long hantavirus sequence, at least in part, on their surface and induced antibodies against the hantavirus sequence in bank voles. Variants of the stop linker still allowed the formation of mosaic particles demonstrating that stop codon suppression alone is sufficient for the packaging of longer foreign sequences in mosaic particles. Another approach to increase the insertion capacity is based on the simultaneous insertion of different Puumala nucleocapsid protein sequences (aa 1-45 and aa 75-119) into two different positions (aa 78 and behind aa 144) of a single HBcAg molecule. The data presented are of high relevance for the generation of multivalent vaccines requiring a high insertion capacity for foreign sequences.

Critically sized osteo-periosteal femoral defects: a dog model

A 21-mm defect was created in 1 femoral diaphysis each of 15 dogs. Periosteum as well as a cylinder of bone was removed, and the defect was stabilized with a bone plate. Twelve of the defects were filled with an equal volume of autogenous cancellous bone harvested from the ipsilateral ilium. Three defects were left untreated. Cranial to caudal radiographs were taken postoperatively and every 4 weeks for 16 weeks. The radiographs were evaluated for healing using two ordinal scales. At 16 weeks, the dogs were euthanized and the femurs harvested for biomechanical testing and histologic evaluation. Both operated and contralateral not operated femurs were mechanically tested to failure in torsion, and load at failure and stiffness were calculated. All dogs tolerated the procedure well, and were using the operated limb within 1 or 2 days postoperatively. There were no complications noted during the 16 weeks of the study. Unfilled defects did not heal and became atrophic nonunions. The defects filled with autogenous cancellous bone healed in a consistent pattern of consolidation, incorporation, and remodeling, with uniform increases of both ordinal scales used. The femoral cortex opposite the bone plate demonstrated most mature remodeling, evident both radiographically as well as histologically. Unoperated femurs failed at 13.61 +/- 3.88 N-m and grafted femurs failed at 2.96 +/- 1.3 N-m, which was 23% of the measurement of the unoperated femur. Relative stiffness of the unoperated femurs was 5974 +/- 4316 N-m2/radian, and grafted femurs had a relative stiffness of 642 +/- 561 N-m2/radian, which was 10.4% of the measurement of unoperated femur. This model proved to be a critically sized defect, which when left unfilled resulted in an atrophic nonunion, and when filled with cancellous bone resulted in a consistent healing pattern.

Structural demands on computer-based medical documentation in the hospital setting

During the last years physicians are confrontated with a significant increase of their duties in clinical documentation. By law the medical diagnoses and procedures were linked with the aspect of liquidation. In consequence it is very important that physicians work out a detailled list of options concernig the features of the medical database, which has to cover the complete clinical data input and deliver flexible utilities for detailed evaluation. Beside documentation the system has to perform as an essential tool of clinical organisation and quality control to optimize the medical and commercial efficiency of the hospital. An open interface technology should be postulated to avoid a stand alone system in the long run.

[Structural requirements of computer-based medical documentation in a hospital setting]

During the last years physicians are confronted with a significant increase of their duties in clinical documentation. By law the medical diagnoses and procedures were linked with the aspect of liquidation. In consequence it is very important that physicians work out a detailed list of options concerning the features of the medical database, which has to cover the complete clinical data input and deliver flexible utilities for detailed evaluation. Beside documentation the system has to perform as an essential tool of clinical organisation and quality control to optimize the medical and commercial efficiency of the hospital. An open interface technology should be postulated to avoid a stand alone system in the long run.