Supplementary orthopaedic screening for children and adolescents to prevent permanent skeletal deformities - protocol for the "OrthoKids" study

BACKGROUND

Skeletal deformities (SD) in children and adolescents can lead to arthritic conditions, impairment of quality of life, and high treatment costs in the long term. However, comprehensive data on the prevalence of SDs in children and adolescents are limited and it remains therefore unclear whether there is a healthcare gap. "OrthoKids" is a project that addresses this evidence gap by implementing an orthopaedic screening for children and adolescents that supplements existing detection examinations within statutory standard care in Germany.

OBJECTIVE

To detect SDs so that they can be treated as needed at an early stage.

METHODS

The implementation of the supplementary orthopaedic screening will be evaluated through an exploratory cohort study that is set up in the German state Baden-Wuerttemberg. 20,000 children and adolescents aged 10 to 14 years will be recruited as a prospective cohort. A retrospective control cohort will be formed based on claims data provided by two cooperating statutory health insurances (SHIs). Participating children and adolescents receive a one-time orthopaedic screening. If at least one SD is diagnosed, treatment will be provided as part of the statutory standard care. Within the scope of the project, a follow-up examination will be performed after one year. An IT-platform will complement the study. The primary outcome measure is the point prevalence of scoliosis, genu varum/valgum, hip dysplasia, and flat feet. Secondary outcome measures are (i) the point prevalence of further less common SDs, (ii) health-related quality of life (HRQoL), (iii) sports ability based on activity (physical/athletic), physical constraints, and (sports) injuries, as well as (iv) monetary consequences of the orthopaedic screenings' implementation. Implementation determinants will be evaluated, too.

DISCUSSION

If the supplementary orthopaedic screening proves to be viable, it could be considered as a supplementary examination for children and adolescents within the frame of SHI in Germany. This could relieve the burden of disease among children and adolescents with SDs. In addition, it could disburden SHIs in the medium to long term.

TRIAL REGISTRATION

The OrthoKids study was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 26th July 2022 under the number 00029057.

SARS-CoV-2 Seroprevalence in Germany: results from the second wave of the RKI-SOEP study

Introduction

The first wave of the “Corona Monitoring bundesweit” (RKI-SOEP) study showed that shortly before the start of the German vaccination program only about 2% of adults (> 18 years) had already experienced SARS-CoV-2 infection and more than half of these cases had been detected and notified. The objectives of the second wave of this study are to further investigate the spread of SARS-CoV-2 in Germanýs population aged over 14 years. It aims to determine the seroprevalence of infection- and vaccine-induced IgG antibodies against SARS-CoV-2. Finally, it examines health, demographic and socioeconomic risk and protective factors for infection and vaccine acceptance.

Methods

From November 2021 to February 2022, the second wave of this cross-sectional study collected biospecimens (capillary blood samples) and interview data, including information on infection and vaccination, from a nationwide population sample drawn from the German Socio-Economic Panel (SOEP). The dried self-collected blood samples were then analyzed for the detection of SARS-CoV-2 IgG antibodies by Euroimmun ELISA assay.

Results

Based on preliminary, unweighted data of around 11,000 participants aged >14 years (52% response rate), we expect the final seroprevalence of SARS-CoV-2 antibodies to be in the range of 80 to 90%. Thus, around 10 to 20% of the German population may still be susceptible to a severe disease progression because they are neither infected nor vaccinated. Final results, weighted for non-response and adjusted for test sensitivity and specificity, will be presented.

Conclusions

The RKI-SOEP-2 study will be pivotal in both, contributing to an improved understanding of SARS-CoV-2 propagation in different regional and sub-group settings and in identifying vulnerable target groups that need to be protected against future infections.

Key messages

• Dried blood self-sampling in a nationwide sample is a robust tool to estimate seroprevalence at a population level.

• As of February 2022, presumably 80 to 90% of the German population has previously been infected and/or vaccinated against SARS-CoV-2.

[Recommendations for the Stepwise Occupational Reintegration: Can the Characteristic of the Patients Explain the Differences Between the Rehabilitation Centers?]

BACKGROUND

The first step to initiate a stepwise occupational reintegration (SOR) is the recommendation of the rehabilitation centers. Therefore rehabilitation centers have a significant impact on the use of SOR. There is evidence that the recommendation rate between the rehabilitation centers differs clearly. The present survey therefore analyses in detail the differences of the recommendation rate and examines which patient-related factors could explain the differences.

METHODS

This study is based on analysis of routine data provided by the German pension insurance in Baden-Württemberg (Rehabilitationsstatistikdatenbasis 2013; RSD). In the analyses rehabilitation measures were included if they were conducted by employed patients (18-64 years) with a muscular-skeletal system disease or a disorder of the connective tissue. Logistic regression models were performed to explain the differences in the recommendation rate of the rehabilitation centers.

RESULTS

The data of 134 853 rehabilitation measures out of 32 rehabilitation centers were available. The recommendation rate differed between the rehabilitation centers from 1.36-18.53%. The logistic regression analysis showed that the period of working incapacity 12 month before the rehabilitation and the working capacity on the current job were the most important predictors for the recommendation of a SOR by the rehabilitation centers. Also the rehabilitation centers themselves have an important influence.

DISCUSSION

The results of this survey indicate that the characteristic of the patients is an important factor for the recommendation of SOR. Additionally the rehabilitation centers themselves have an influence on the recommendation of SOR. The results point to the fact that the rehabilitation centers use different criteria by making a recommendation.

[The User Survey on the Revision of the Classification of Therapeutic Procedures]

INTRODUCTION

An extensive user survey was conducted in the context of updating the Classification of Therapeutic Procedures (KTL 2015). This paper reflects the results of the user survey and raises critical discussion points.

METHODS

The user survey was sent to all rehabilitation centers contracted by the German pension insurance as well as professional associations. The user survey was available both as a paper questionnaire and as an online version. The feedback of the user survey provided an important basis for the revision of the KTL.

RESULT

The survey yielded 1,868 suggestions from 360 users. Most of them related to chapters E ("occupational therapy, work therapy, other functional therapy") and C ("information, motivation, training"). The change from German diplomas to the international Bachelor's and Master's degrees, and the inclusion of diagnostic and work-related procedures were the main focus of the user feedback.

CONCLUSION

For the revision of the KTL, the user survey provided valuable information. Only by the inclusion of practitioners can the KTL meet the requirements of realistic and comprehensive acquisition of data on therapeutic procedures also in future.

[Bilateral Instability of the Interphalangeal Articulation of the Thumb in Hajdu-Cheney Syndrome]

We present the case of a 52-year-old lady suffering from Hajdu-Cheney syndrome, a rare hereditary disease, which was referred to our clinic on the basis of progressive instability of the interpalangeal articulations of both thumbs. Even if acroosteolysis of the distal phalangeal bones is typical for this disease, to the best of our knowledge the interphalangeal instability has not been described before.

[Quality assurance in outpatient neurological rehabilitation: measuring the effects of rehabilitation with the competency rating scale]

BACKGROUND

So far, there are only few studies concerning the outcome of outpatient neurological rehabilitation in Germany. Considering the statutory obligations of quality assurance there is an urgent need of appropriate instruments to assess the rehabilitation outcome. The aim of this study was to assess the appropriateness of the Competency Rating Scale (CRS), which was used to measure rehabilitation outcome, and to collect data of the effects of outpatient neurological rehabilitation as a measure of rehabilitation outcome.

METHODS

The basis of this study was data collected between 2008 and 2011. During that period the data of all patients of an outpatient neurological rehabilitation center were consecutively collected. There were no exclusion criteria. To measure rehabilitation outcome patients' self ratings with the CRS were used. To check the appropriateness of the CRS the dropout rate and the missing values were analysed. In addition, the patients' self ratings were compared with the data of a near relative rating with the CRS.

RESULTS

On examining the entire group of patients, statistically significant improvements over time were found in the motor as well as in the cognitive-psychosocial areas. The analysis of the data with regard to the appropriateness of the CRS showed considerable ceiling effects and a high dropout rate. Differences between the self and the near relative ratings could be detected.

CONCLUSION

For the overall group of patients positive effects of outpatient neurological rehabilitation can be proven. The assessment instrument used in this study is only partially suitable for assessing the outcome of outpatient neurological rehabilitation. The comparison of self and near relative ratings can systematically be used in the therapy process.

Dynamics of red blood cells and vesicles in microchannels of oscillating width

We have studied the dynamics of red blood cells and fluid lipid vesicles in hydrodynamic flow fields created by microchannels with periodically varying channel width. For red blood cells we find a transition from a regime with oscillating tilt angle and fixed shape to a regime with oscillating shape with increasing flow velocity. We have determined the crossover to occur at a critical ratio L(y)/v(m) ≈ 2.2 × 10⁻³ s with channel width L(y) and red blood cell velocity v(m). These oscillations are superposed by shape transitions from a discocyte to a slipper shape at low velocities and a slipper to parachute transition at high flow velocities.

Assessment of phagocytic and antimicrobial activity of human granulocytes

A microassay for assessing two functions of polymorphonuclear leukocytes in the presence or absence of complement is presented. Requiring only minute amounts of blood (0.1 ml) and a minimum of laboratory equipment (microscope, incubator, and centrifuge), it allows the quantitation of phagocytosis and intracellular killing of microorganisms by leukocytes. To demonstrate the value of this assay, the phagocytic and microbicidal activity of leukocytes from healthy subjects and patients against Candida albicans was investigated. Apart from individual cases, no differences in the phagocytic activity between groups of healthy subjects and patients with candida vaginitis or different types of cancer could be found. However, the killing capacity of the leukocytes from women with recurrent candida vaginitis was reduced. The leukocytes of one patient showing a very low killing capacity lacked myeloperoxidase. Also, low values of killing were seen with leukocytes from three patients suffering from osteosarcoma, chronic lymphatic leukemia, or Hodgkins disease.

Surface acoustic wave actuated cell sorting (SAWACS)

We describe a novel microfluidic cell sorter which operates in continuous flow at high sorting rates. The device is based on a surface acoustic wave cell-sorting scheme and combines many advantages of fluorescence activated cell sorting (FACS) and fluorescence activated droplet sorting (FADS) in microfluidic channels. It is fully integrated on a PDMS device, and allows fast electronic control of cell diversion. We direct cells by acoustic streaming excited by a surface acoustic wave which deflects the fluid independently of the contrast in material properties of deflected objects and the continuous phase; thus the device underlying principle works without additional enhancement of the sorting by prior labelling of the cells with responsive markers such as magnetic or polarizable beads. Single cells are sorted directly from bulk media at rates as fast as several kHz without prior encapsulation into liquid droplet compartments as in traditional FACS. We have successfully directed HaCaT cells (human keratinocytes), fibroblasts from mice and MV3 melanoma cells. The low shear forces of this sorting method ensure that cells survive after sorting.

Induction of complete and sustained remission of rheumatoid pachymeningitis by rituximab

Aseptic pachymeningitis is a rare and serious complication of rheumatoid arthritis (RA). Herein, we describe a patient with rheumatoid factor-positive and anti-cyclic citrullinated peptide-positive RA who experienced a focal seizure, with aphasia and convulsions of the right side of the body. The findings of magnetic resonance imaging and histologic analysis led to a diagnosis of rheumatoid pachymeningitis. Because the patient had a large number of CD20-expressing B lymphocytes, therapy with rituximab was started and has resulted in complete and sustained remission of both the pachymeningitis and the RA for >2 years. Despite a decrease in immunoglobulins, the patient has remained free of infections, which illustrates the favorable outcome that can result from therapeutic B cell depletion in this potentially lethal manifestation of RA.

Probing the Kondo density of states in a three-terminal quantum ring

We have measured the Kondo effect in a quantum ring connected to three terminals. In this configuration nonlinear transport measurements allow us to check which lead contributes to the Kondo density of states (DOS) and which does not. The ring geometry allows a fine-tuning of the coupling to each lead through the Aharonov-Bohm effect via application of a magnetic field. When the ring is connected to two strongly and one weakly coupled leads, conductance through the weakly coupled lead provides a direct measurement of the DOS in the Kondo regime. By applying a bias between the two strongly coupled leads, we demonstrate directly the splitting of the out-of-equilibrium Kondo DOS.

Education in end-of-life care: bridging disciplinary and institutional boundaries

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

Are living beings in the state of self-organized criticality? A new interpretation of data on work incapacity due to low back pain

Using data published elsewhere I demonstrate in this paper that the frequency distribution of the duration of work incapacity from low back pain follows a power law. Power laws are not common in medicine and the question arises why we can find one here. The peculiarity of the data considered here is that they embrace not only the passive reaction but also the whole spectrum of possible active responses of a living being to a disturbance. For the duration of sick leave due to low back pain is not only influenced by the defect a person is affected by, but even more dependent on how he or she copes with it. Coping comprises a broad range of possibilities from denial of the disability to its aggravation, from therapy to malingering. In contrast to the scientific ideal none of these faculties has been excluded in the data used here. They concern the whole living being. Power laws are typical for systems in the state of self-organized criticality. The system involved in the case of low back pain is the whole living human being with all its possibilities to react and to respond. Thus, my findings support empirically the hypothesis that living beings are in the state of self-organized criticality.

Ketamine-induced deficits in auditory and visual context-dependent processing in healthy volunteers: implications for models of cognitive deficits in schizophrenia

BACKGROUND

In patients with schizophrenia, deficient generation of mismatch negativity (MMN)-an event-related potential (ERP) indexing auditory sensory ("echoic") memory-and a selective increase of "context dependent" ("BX") errors in the "A-X" version of the Continuous Performance Test (AX-CPT) indicate an impaired ability to form and use transient memory traces. Animal and human studies implicate deficient N-methyl-D-aspartate receptor (NMDAR) functioning in such abnormalities. In this study, effects of the NMDAR antagonists ketamine on MMN generation and AX-CPT performance were investigated in healthy volunteers to test the hypothesis that NMDARs are critically involved in human MMN generation, and to assess the nature of ketamine-induced deficits in AX-CPT performance.

METHODS

In a single-blind placebo-controlled study, 20 healthy volunteers underwent an infusion with subanesthetic doses of ketamine. The MMN-to-pitch and MMN-to-duration deviants were obtained while subjects performed an AX-CPT.

RESULTS

Ketamine significantly decreased the peak amplitudes of the MMN-to-pitch and MMN-to-duration deviants by 27% and 21%, respectively. It induced performance deficits in the AX-CPT characterized by decreased hit rates and specific increases of errors (BX errors), reflecting a failure to form and use transient memory traces of task relevant information.

CONCLUSIONS

The NMDARs are critically involved in human MMN generation. Deficient MMN in schizophrenia thus suggests deficits in NMDAR-related neurotransmission. N-methyl-D-aspartate receptor dysfunction may also contribute to the impairment of patients with schizophrenia in forming and using transient memory traces in more complex tasks, such as the AX-CPT. Thus, NMDAR-related dysfunction may underlie deficits in transient memory at different levels of information processing in schizophrenia. Arch Gen Psychiatry. 2000;57:1139-1147.

[Process quality in oncologic rehabilitation. Viewpoint of the Professional Committee of Rehabilitation, After-care and Social Medicine of the German Cancer Society]

The article concerns itself with the issue of process quality in inpatient institutions for oncological rehabilitation and expresses the viewpoint of the German Cancer Society's Section for Rehabilitation, Aftercare and Social Medicine (ARNS). Standards for the organization of patients' access to the rehabilitation clinic, for the design of oncological-rehabilitational diagnostics, for the formation of therapeutic strategies and the rehabilitative services offered will be described.

[Structural quality of oncologic rehabilitation. Viewpoint of the Professional Committee of Rehabilitation, After-care and Social Medicine of the German Cancer Society]

The article discusses the structural requirements on inpatient institutions for oncological rehabilitation and expresses the position of the German Cancer Society's Section for Rehabilitation, Aftercare and Social Medicine (ARNS). Standards are formulated concerning spatial conditions, technical equipment, personnel (number, professions, qualification) and networking conditions with regard to all cancer diagnoses. These standards are also discussed with regard to various specific cancer diagnoses such as, for example, breast cancer, gastrointestinal tumours, lung tumours and brain tumours, as well as with regard to patients in specific treatment measures such as bone marrow and stem cell transplantation.

[Outcome quality in oncologic rehabilitation. Viewpoint of the Professional Committee of Rehabilitation, After-Care and Social Medicine of the German Cancer Society]

The article is concerned with the basic ideas of outcome quality within the field of oncological rehabilitation and expresses the position which is held by the Section for Rehabilitation, Aftercare and Social Medicine within the German Cancer Society. The authors explicitly express the necessity of rehabilitation-specific goals and corresponding outcome criteria as opposed to the goals and criteria of acute oncological treatment. In the formulation of goals and criteria, the medical-somatic, occupational-rehabilitative, social and psychological levels are considered. The consequences which arise from these outcome criteria with regard to the rehabilitative health care system for cancer patients are discussed.

Characteristics and prognosis of myocardial infarction in patients with normal coronary arteries

STUDY OBJECTIVES

Myocardial infarction with angiographically normal coronary arteries (MINC) is a life-threatening event with many open questions for physicians and patients. There are little data concerning the prognosis for patients with MINC.

DESIGN

Retrospective follow-up study.

SETTING

Tertiary referral center.

PATIENTS

Patients with MINC were investigated and compared to age- and sex-matched control subjects with myocardial infarction due to coronary artery disease (CAD). The patients were examined clinically using stress exercise and hyperventilation tests. Migraine and Raynaud's symptoms were determined by means of a standardized questionnaire. Serum lipoproteins; the seroprevalence of cytomegalovirus, Helicobacter pylori, and Chlamydia pneumoniae infections; and the most frequent causes of thrombophilia were assessed.

MEASUREMENTS AND RESULTS

From > 4,300 angiographies that were performed between 1989 and 1996, 21 patients with MINC were identified. The mean +/- SD patient age at the time of myocardial infarction was 42 +/- 7.5 years. When compared to control subjects (n = 21), patients with MINC had fewer risk factors for CAD. In contrast, MINC patients had more frequent febrile reactions prior to myocardial infarction (six patients vs zero patients; p < 0.05), and the migraine score was significantly higher (7.1 +/- 6.3 vs 2.2 +/- 4.1; p < 0.01). The seroprevalence of antibodies against cytomegalovirus, C pneumoniae, and H pylori tended to be higher in patients with MINC and CAD as compared to matched healthy control subjects. Three patients with MINC vs none with CAD had coagulopathy. During follow-up (53 +/- 37 months), no major cardiac event occurred in the MINC group; no patients with MINC vs nine with CAD (p = 0.0001) underwent repeated angiography.

CONCLUSION

High migraine score and prior febrile infection together with a lower cardiovascular risk profile are compatible with an inflammatory and a vasomotor component in the pathophysiology of the acute coronary event in MINC patients. The prognosis for these patients is excellent.

Sport related proximal femoral fractures: a retrospective review of 31 cases treated in an eight year period

In an eight year period, 31 patients with proximal femoral fractures resulting from sports accidents were treated by implantation of either a Gamma nail or a dynamic hip screw. Return to work or sports and the time to bone healing did not differ very much between the treatments. Gamma nailing was clearly the best with regard to stability and time to full mobilisation (4.5 days), but required 39 minutes to perform compared with insertion of a dynamic hip screw (27 minutes). The incidence of complications and malalignments did not differ very much between the two, although, when Gamma nailing was first used in the authors' clinic, more intraoperative complications occurred than with the dynamic hip screw. Stable pertrochanteric fractures may be treated with a dynamic hip screw. Unstable pertrochanteric or subtrochanteric fractures are treated with a Gamma nail at the authors' institution.

Comparison of ender nails, dynamic hip screws, and Gamma nails in the treatment of peritrochanteric femoral fractures

Three hundred seventy-six patients with peritrochanteric fractures treated over a 10-year period were reviewed. In 85 patients treated with Ender nailing, the most frequent complications were leg shortening (34), external rotation failure (21), and postoperative distal gliding of the nails (7). In 183 patients treated with dynamic hip screws or a 95 degree condylar or a 130 degree blade plate, 3 presented with infection, 5 with instability, and 4 with femoral head necrosis. In 105 patients treated with Gamma nailing, the most serious complications were infections (3), inward rotation failure (2), postoperative bleeding at the insertion site (2), and shaft fracture (1). Because of its inherent instability, Ender nailing is no longer used. The implantation technique for the dynamic hip screw is safer and simpler than the various models of the ASIF blade plate. However, the dynamic hip screw has been superseded by the Gamma nail because of its absolute stability. In the beginning, Gamma nailing was technically more demanding with a higher number of intraoperative complications. In this study, the number of malalignments did not differ significantly between the dynamic hip screw (14) and the Gamma nail (11), but was high with Ender nailing (56).

[Lifelong heavy agricultural work and development of arthrosis of the hand--a case study]

Heavy physical work load is a known determinant of osteoarthritis of the hip, which may account for the high risk observed among farmers. On the other hand, the data on influence of heavy manual work in the pathogenesis of hand osteoarthritis are still controversial. We examined 25 retired farm laborers who strenuously worked for more than 50 years. The investigation included a history of professional activity, clinical and radiological examination of the hands, hips and knees, MRI of hand and laboratory evaluation of 4 participants. Interestingly, the farm laborers with osteoarthritis of the hands, hardly complained. In many of the proximal interphalangeal joints, a discrepancy was observed between the clinical hypertrophic changes and the radiological osteoarthritis which was weak or absent. This difference was less pronounced in the distal interphalangeal joints. Furthermore the distribution pattern of the osteoarthritis of the hand was striking with an over-proportional involvement of the metacarpophalangeal joints and less pronounced of the intercarpal joints. Most often both hands have been affected and the typical localization of the metacarphophalangeal joint osteoarthritis was the first, second and third finger. In all but one participant we found at least unilateral osteoarthritis of the hip and compared to the hands, complaints were more severe. Our findings support the hypothesis that the distribution of osteoarthritis in the hand is affected by lifelong farming. As shown by the data on proximal interphalangeal joints, the periarticular tissue can adapt to the mechanical load in the strength grip.

Five year results of rotator cuff repair

In thirty nine patients with either an acute rotator cuff rupture or a chronic impingement syndrome plus a cuff tear, a standard acromioplasty was performed along with a cuff repair using a bone detaching approach. Postoperative active motion was allowed in all but three. Follow up examination was performed two and five years after the operation. Continuous improvement in function, range of movement, and strength was observed, while pain increased slightly. The size of the tear and delay in treatment were determining factors in the outcome.

Spiral bundle nailing for subcapital humeral fractures: preliminary report of the method of Henning

This is a preliminary report of 31 patients treated with Henning's spiral bundle nails for subcapital humeral fractures. Complications included motion restriction at the elbow joint (n = 4), elbow pain caused by pin migration (n = 2), misalignment attributable to incorrect reduction (n = 4), and redislocation attributable to improper technique (n = 1), humeral head perforation (n = 3), caudal subluxation of the humeral head (n = 3), and local infections at the insertion site (n = 1). Immobilization was 3 weeks on average. By using the scoring scheme of Constant and Murley, 11 patients showed a moderate result, whereas 19 patients had an excellent outcome.

Fibrinogen St. Gallen I (gamma 292 Gly--> Val): evidence for structural alterations causing defective polymerization and fibrinogenolysis

Fibrinogen St. Gallen I was detected in an asymptomatic Swiss woman. Routine coagulation tests revealed a prolonged thrombin and reptilase time. Functionally measured fibrinogen levels were considerably lower than those determined immunologically. Polymerization of fibrin monomers derived from purified fibrinogen was delayed in the presence of either calcium or EDTA. Normal fibrinopeptide A and B release by thrombin was established. An abnormal degradation of fibrinogen St. Gallen I by plasmin was observed. Fragment D1 of normal fibrinogen was fully protected against further proteolysis in the presence of 10 mM calcium, whereas fibrinogen St. Gallen I was partially further degraded to fragments D2 and D3. In the presence of 10 mM EDTA, the conversion of variant fragment D1 to D2 was accelerated whereas the degradation of fragment D2 to D3 was delayed in comparison to degradation of fragments D1 and D2 of normal fibrinogen. Three high-affinity calcium binding sites were found in both normal and variant fibrinogen. Mutation screening with SSCP analysis suggested a mutation in exon VIII of the gamma-chain gene. Cycle sequencing of this gene portion revealed a single base substitution from G to T of the base 7527, leading to replacement of gamma 292 glycine by valine. The same mutation has already been described for the fibrinogen variant Baltimore I. Molecular modeling was performed of a part of the gamma-chain containing the mutation site, based on recently published X-ray crystal structures of human fibrinogen fragment D and of a 30 kD C-terminal part of the gamma-chain. Significant structural alterations due to the substitution of glycine by valine at gamma 292 were observed, e.g. spreading of the protein backbone, probably leading to a modified accessibility of the plasmic cleavage sites in the gamma-chain at 356 Lys and 302 Lys. A shift of gamma 297 Asp that is involved in interactions of fragment D with the Gly-Pro-Arg-Pro-peptide was noted by molecular modeling. The latter observation is compatible with delayed polymerization of fibrin monomers.

Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns

The study assessed leaders' perceptions of adolescent alcohol use as a public health issue in 28 small communities in northern Minnesota, as part of formative evaluation for a community-based intervention to reduce adolescent alcohol access and consumption. One hundred and eighteen leaders from five key community sectors were interviewed about their perceptions of social, health and alcohol-related problems in their communities. Analyses indicated that school representatives and police chiefs perceived adolescent alcohol use and related problems to be serious; newspaper editors mentioned other social problems more often; and mayors and business representatives did not perceive adolescent alcohol problems to be as serious. In relation to efforts to affect local policy, the study suggested government and business sectors in these communities may need to be educated about the problem to build its importance on the community agenda of health issues. Thus community leaders in some sectors may comprise a key target audience for intervention.

Bilateral fracture of the sacrum associated with pregnancy: a case report

We describe a 33-year-old woman with a bilateral fracture of the sacrum associated with pregnancy. Dual-energy X-ray absorptiometry of the lumbar spine and femoral neck showed normal bone mineral density, whereas bilateral osteopenic areas in the massae laterales were demonstrated by the initial CT-scan. The question remains whether the correct diagnosis is so-called insufficiency fracture due to transient osteoporosis of the sacrum associated with pregnancy or so-called fatigue fracture due to unaccustomed stress related to rapid and excessive weight gain in the last trimester of pregnancy.

[Eye movement abnormalities as a sign for the diagnosis in Niemann-Pick disease type C]

BACKGROUND

Eye movement abnormalities in familial mental retardation syndrome should lead to the suspicion of a storage disorder, including Niemann Pick disease type C, Gaucher's disease, abetalipoproteinemia and Wilson's disease. The eye movement abnormalities in our two patients were suggestive of Niemann Pick disease type C, characterized by initial loss of voluntary vertical eye movements and subsequent loss of horizontal eye movements, with preservation of the vestibulo-ocular response. The characteristics of eye movements in storage disorders are different. In Gaucher's disease a progressive horizontal gaze palsy, in abetalipoproteinemia a particular type of internuclear ophthalmoplegia with nystagmus of the adducting eye and in Wilson's disease slowing of saccades may be observed.

PATIENTS

We evaluated two mentally retarded sisters with unclear diagnosis at the age of 34 and 27 years. At the age of 24 and 21 a vertical gaze palsy led to the diagnosis of Parinaud syndrome.

RESULTS

At the time of our examination both sisters were unable to perform voluntary horizontal or vertical saccades or pursuit eye movements. The vestibulo-ocular reflex was present in all directions. Optokinetic nystagmus and convergence were absent. This clinical picture led us to a suspicion of Niemann-Pick disease type C, confirmed by the presence of sea-blue histiocytes in the bone marrow biopsy.

CONCLUSION

These cases demonstrate that the pattern of eye movement disorders in some syndromes associated with mental retardation can give important clues in the determination of the diagnosis.

Preoperative values of molecular coagulation markers identify patients at low risk for intraoperative haemostatic disorders and excessive blood loss

Conventional laboratory investigations of haemostasis like prothrombin time and activated partial thromboplastin time are not useful in predicting and managing intra-operative bleeding complications. In order to establish a possible "perioperative reference range" for thrombin generation prothrombin fragment F1+2 (F1+2) and fibrin degradation (D-dimer) markers, we measured F1+2 and D-dimer concentrations before surgery (but after induction of anaesthesia), 30 minutes into surgery, 10 minutes after the event expected to induce the maximal activation of the haemostatic systems, 90 minutes after surgery and on postoperative days 1 and 2 in 226 consecutive patients. Samples were collected from arterial lines. Twenty patients developed a clinically defined, intraoperative disorder of haemostasis, 206 did not. Patients with an intraoperative disorder of haemostasis had significantly higher preoperative F1+2 and D-dimer concentrations. Preoperative values for F1+2 and D-dimer concentrations above the 75th percentile of patients without an intraoperative disorder of haemostasis indicated a 2.70 to 2.88 fold risk of developing an intraoperative disorder of haemostasis (odds ratios were 3.04, 3.12 and 3.29 for D-dimer, ELISA, F1+2, and D-dimer latex tests, respectively with 95% confidence intervals from 1.20 to 8.46) with negative predictive values of 94%, but positive predictive values of only 16% to 26%. These data suggest that preoperative determination of molecular markers might be helpful in identifying a group of patients at high risk for intraoperative disorder of haemostasis by exclusion of low risk patients. Validation of such an approach requires a prospective trial.

Plasma hypercoagulability in haemodialysis patients: impact of dialysis and anticoagulation

BACKGROUND

Thrombotic complications are common in patients with endstage renal disease and contribute substantially to the morbidity and mortality in this population. The aim of the present study was to: i) determine the prevalence and the extent of hypercoagulability in patients undergoing dialysis treatment by measuring parameters that directly reflect thrombin concentrations; ii) assess changes in coagulation status during haemodialysis (HD); iii) quantify the relative impact of heparin, dialysis and their combined effects on coagulation status and iv) detect factors that modify coagulation haemostasis in dialysis patients.

METHODS

A total of 39 patients (HD: n = 29, CAPD: n = 10) was analysed for procoagulatory and fibrinolytic activity determined by measurements of partial thromboplastin time, prothrombin fragments F1 + 2, thrombin-antithrombin complexes and D-dimer concentrations. HD patients were investigated prior to and during dialysis. A subgroup of patients was infused heparin alone without dialysis or was dialysed without heparin administration. Furthermore, subgroup and correlation analyses were performed for the type of dialysis (HD vs CAPD), dialyzer and shunt, Kt/V, underlying disease and treatment with recombinant erythropoietin (rhEPO).

RESULTS

Baseline levels of all parameters-procoagulatory and fibrinolytic--were substantially elevated in all patients, but to a higher degree among those on CAPD. Moreover, haemodialysis treatment increased procoagulatory markers even further, suggesting stimulated coagulation and/or insufficient anticoagulation during dialysis. However, after 3 h of dialysis thrombin concentrations, determined by quantification of prothrombin fragments, were inversely correlated with Kt/V. Selective heparin infusion diminished procoagulatory activity only slightly and incompletely, whereas HD without heparin resulted in excess thrombin accumulation. Finally, subgroup analyses revealed more pronounced thrombin formation among patients treated with polysulfon dialyzers, whereas erythropoietin dosage was positively related with lower procoagulatory activity.

CONCLUSION

A majority of patients on dialysis are in a hypercoagulable state, which is further aggravated by the haemodialysis procedure itself and may not be sufficiently controlled with current anticoagulation regimens. Intensified heparin treatment and the use of rhEPO are likely to improve coagulation haemostasis, whereas the type of dialyzer should be considered as a relevant procoagulatory factor.

Intermittent exposure to doxorubicin in vitro selects for multifactorial non-P-glycoprotein-associated multidrug resistance in RPMI 8226 human myeloma cells

The purpose of the present study was to evaluate whether intermittent exposure to a constant dose of doxorubicin selects for multidrug resistance (MDR) in RPMI 8226 human myeloma cells and, if so, to determine the molecular mechanism. In an attempt to approximate clinical doxorubicin treatment in vitro, cells were exposed to a fixed dose of doxorubicin for 4 d alternating with growth in drug-free medium for 17 d. An MDR subline emerged, termed 8226/DOXint5, which was 3-4-fold resistant to doxorubicin, etoposide and m-AMSA, and 1.6-fold resistant to vincristine. Sensitivity to docetaxel, melphalan and cisplatin was normal. Verapamil normalized vincristine sensitivity but had little effect on resistance to the other agents. Cellular uptake and retention of daunorubicin and vincristine were reduced by approximately 10%. The 8226/DOXint5 cells showed diminished DNA topoisomerase IIalpha expression and increased expression of the multidrug resistance protein MRP. Expression of MDR1/P-glycoprotein was not detected. Immunostaining showed 70% of the cells to over-express the lung-resistance protein LRP. This new MDR myeloma cell line may prove to be a useful model for the development of strategies to overcome low-level, multifactorial MDR, which might be a common phenomenon in clinical myeloma treated with doxorubicin.

Post-remission therapy of adult acute myeloid leukaemia: one cycle of high-dose versus standard-dose cytarabine. Leukaemia Project Group of the Swiss Group for Clinical Cancer Research (SAKK)

BACKGROUND

Intensification of post-remission therapy improves the cure rate of acute myeloid leukemia (AML) but is often accompanied by unacceptable toxicity. From 1985 to 1992 the Swiss Group for Clinical Cancer Research (SAKK) performed a randomized phase III trial to evaluate the effectiveness of one single postremission course of high-dose cytarabine (HDAC) in terms of leukaemia-free and overall survival in adults with de novo AML.

PATIENTS AND METHODS

Adult (15-65 years) AML patients in remission after two induction courses were randomly assigned to one consolidation course either with standard (SDAC: 100 mg/sqm 24 hours infusion over seven days) or with high-dose cytarabine (HDAC: 3000 mg/sqm every 12 hours as one-hour-infusion for six days). In addition, both arms included daunorubicin (45 mg/sqm daily on days 1 to 3). Thereafter, patients were observed without maintenance until relapse.

RESULTS

After two induction courses 208/276 eligible patients achieved remission (CR: 169, 61%, PR: 39, 14%), 41 were resistant (15%) and 20 died early (7%). Seventy-one patients in remission were not randomized. One hundred thirty-seven were randomized in CR/PR (67 SDAC, 70 HDAC). 4/70 patients randomized to HDAC did not receive it. Treatment-related mortality in HDAC was 1.4% (1/66). WHO grade 3-4 toxicities occurred in 14/67 SDAC and in 38/66 HDAC patients (P < 0.0001). The median event free survival was 10.8 (SDAC) vs. 12.2 months (HDAC; P = 0.18). The median overall survival was 24.6 (SDAC) vs. 32.6 months (HDAC; P = 0.07). Although statistically uncertain, HDAC reduced the hazard of progression (hazard ratio: 0.69, P = 0.08) and of death (hazard ratio: 0.70, P = 0.13). For 112 patients stratified as CR the estimated four-year disease-free survival was 25% (+/-6%) with SDAC and 37% (+/-6%) with HDAC (P = 0.09). The overall survival rates at four years were 38% (+7%) and 48% (+7%), respectively (P = 0.10). In multivariate analysis HDAC significantly reduced the hazard of relapse by 39% compared to SDAC (hazard ratio = 0.61, 95% CI: 0.37-0.99; P = 0.049).

CONCLUSIONS

We conclude that early consolidation of adult AML in CR with a single course of HDAC is superior in terms of outcome to one cycle of SDAC. The results of our intensive, single course HDAC group compare favourably with less intensive, repetitive HDAC cycles, suggesting that Ara-C dose intensity may be more important than total dosage. In addition, our treatment strategy is much less toxic and less expensive.