[The MEmbeR Multicenter Study on medical-occupational rehabilitation]

INTRODUCTION

MEmbeR is a prospective multi-center study on medical-occupational rehabilitation in Germany.

METHODS

196 neurological, psychiatric, orthopaedic, and internal medicine patients from 21 rehabilitation centres all across Germany have been enrolled and followed-up for 2 years after discharge. Primary outcome parameter was defined as return to work. Further, the SF-12 and a Mini-ICF-Rating have been used.

RESULTS

Mean age was 34.1 (9.9) years, length of stay 150.0 (223.5) days. Prior to occupational rehabilitation, 69.9% were unable to work, 2 years after discharge only 5.6%. Rate of participants seeking a job was reduced from 19.7% to 3.1%. In summary, 78.1% returned to work. Employed participants were younger (32.8 [9.7] vs. 38.5 [9.4] years, p=0.001) and less disabled (Degree of Disablement [GdB]: 20.0 [31.2] vs. 36.1 [33.7], p<0.05).

CONCLUSION

The multicenter cohort study MEmbeR provides further knowledge about the outcome of medical-occupational rehabilitation in Germany.

Should a percutaneous dilational tracheostomy be guided with a bronchoscope?

OBJECTIVE

The aim was to evaluate the complications and practicability of percutaneous dilational tracheostomy (PDT) with and without video endoscopic guidance in critically ill patients.

METHODS

In a retrospective review of patients admitted to a multidisciplinary ICU, PDT was performed under bronchoscopic control in 74 patients and without bronchoscopic control in 113 patients. Both groups were evaluated in similar technical conditions.

RESULTS

Complications in both groups were mostly minor. Bleeding or difficult tracheal cannulation occurred in 8 patients in each group. In patients without bronchoscopy, one major bleeding necessitated a switch to open revision, the Murphy eye was punctured (n = 2) and there was one pneumothorax. Furthermore, similar levels of cuff leaks, loss of airway and minor stoma infections were noted in both groups. All tracheostomies were performed bedside with similar manpower. Operation times were shorter in patients without bronchoscopy.

CONCLUSION

Our data about PDT in critically ill patients do not indicate any clear-cut difference in complication rates or practicability in the absence of bronchoscopic guidance when adequate skills and experience have been acquired and simple but effective precautions at each step are adopted. However, randomisation and long-term laryngotracheal followup should be considered in future studies.

A randomized, double-blind, controlled trial on non-opioid analgesics and opioid consumption for postoperative pain relief after laparoscopic cholecystectomy

BACKGROUND

Following laparoscopic cholecystectomy, an effective post-operative pain control is necessary, at least during the first 24 hours. We present a randomized, double-blind trial on the effect of the combined use of intravenous parecoxib, and metamizol or paracetamol on piritramide consumption using a patient-controlled analgesia (PCA) pump in patients recovering from laparoscopic cholecystectomy.

METHODS

120 patients were randomly allocated to four patient groups treated with normal saline or one of non-opioid analgesics (parecoxib 40 mg twice daily, metamizol 1 g three times daily, paracetamol 1 g three times daily) in addition to piritramide using the PCA pump. Beginning in the post-anesthesia care unit (PACU), patients were asked every 2 h for 6 hours and afterwards once every 6 h to quantify their pain experience at rest while piritramide consumption was recorded.

RESULTS

In all groups, piritramide consumption was high in PACU. Only metamizol significantly reduced piritramide consumption compared to the others upon discharge from PACU. Overall, cumulative piritramide consumption was slightly lower in the metamizol group and higher in the NaCl group; however, these findings were statistically not significant. VAS scores were highest upon arrival in PACU and dropped almost continuously after surgery. A significantly lower postoperative pain intensity was only found in the parecoxib group at 24 h after surgery compared to the metamizol group.

CONCLUSION

The efficacy of tested additive medications on piritramide consumption and pain relief is weak and there is no clear-cut difference between the non-opioid drugs used.

Towards a Mobile Intelligent Information System with Application to HIV/AIDS

The United Nations Security Council reports HIV/AIDS as the fastest growing threat to human development. In addition, the World Health Organization [1] reports that nearly 5 million persons (4.3 million adults and 700,000 children) are newly infected with HIV each year; more than 95% of them found in developing countries. Since STDs as a group are a personal problem which few people feel comfortable discussing, we believe that hand-held PDAs can provide an opportunity for learning about this disease while insuring anonymity. This device will employ the newest technologies including Bluetooth wireless technology, which can transmit and receive data via a short-range radio link using a globally available frequency band (2.4 GHz ISM band), enabling rapid and accurate synchronous and asynchronous data communication. The first generation of Bluetooth permits exchange of data up to a rate of 1 Mbps, even in areas with much electromagnetic disturbance. This emerging technology can facilitate HIV/AIDS outreach around the globe.Recent advances in learning have taken a particularly cognitive perspective and these findings have implications for education in general as well as for the development of intelligent tutoring systems in particular. In the past, effective SmartBookstrade markhave been developed for AIDS education to disseminate the critical knowledge relevant to this epidemic [2].Since 1993, the proliferation of the World Wide Web has created a plethora of new opportunities for the delivery of electronic distance learning systems. However, we feel that it is important that a whatever technology is employed is based on a sound educational theory. A new, comprehensive, web-based learning system called SmartTutor has been developed, at Brooklyn College of The City University of New York [3]. This technology provides a user-friendly, self-paced, easy to modify, software environment intended to serve the user's learning needs and is based on a generic SmartTutor methodology organized around the use of concept mapping. Early assessment of SmartTutor has shown that it is well received by students and helps significantly in their learning processes. It is readily adaptable to the presentation of academic and more general subject matter such as the latest available information on HIV/AIDS. Our new HIV/AIDS SmartTutor will incorporate this SmartTutor paradigm. Our new SmartTutor would provide worldwide access to medical professionals as well as the general public to learn about HIV/AIDS. This new device could also provide a survey tool to facilitate HIV risk assessment. Demonstrations of the SmartTutor learning system will be presented and the continued development of the applications will be discussed.

A decision technology system for health care electronic commerce

Mounting costs have escalated the pressure on health care providers and payers to improve decision making and control expenses. Transactions to form the needed decision data will routinely flow, often electronically, between the affected parties. Conventional health care information systems facilitate flow, process transactions, and generate useful decision information. Typically, such support is offered through a series of stand-alone systems that lose much useful decision knowledge and wisdom during health care electronic commerce (e-commerce). Integrating the stand-alone functions can enhance the quality and efficiency of the segmented support, create synergistic effects, and augment decision-making performance and value for both providers and payers. This article presents an information system that can provide complete and integrated support for e-commerce-based health care decision making. The article describes health care e-commerce, presents the system, examines the system's potential use and benefits, and draws implications for health care management and practice.

[Special case report: Gangrene of all 4 extremities caused by disseminated intravascular coagulation in pneumococcal sepsis]

The rare case of a child with gangrene of all extremities following intravascular coagulation in pneumococcus septicaemia is described. The two years old spanish girl showed a gangrene of all four extremities and accompanying celloid scars. The operative treatment, the orthopaedic technical fitting as well as the problems are discussed.

[The importance of neuromuscular coordination for athletic stress of the knee joint after anterior cruciate ligament injuries. A gait and locomotion analysis with EMG on treadmill]

Anterior cruciate ligament (ACL) injuries are considered of high prevalence in sports medicine and are of socio-economical relevance. Indications for operative treatment and the ability for physical activity after ACL injuries are discussed controversially. Although it is known that the ACL has neurosensory functions, no test system has been developed which takes this biological function into account. The first goal of this study was to determine the neurosensory function after ACL reconstruction, and the second goal was to develop predictive markers for functional results after surgery. 20 healthy athletes (10 male, 10 female) (control group) and twenty ACL deficient patients (10 male, 10 female) (study group) were included in a prospective, controlled study. Electromyograms (EMG) were performed under defined load conditions of the knee. Important results of our study are: 1. Previously described parameters can be reproduced with EMG techniques. Their validity was proved. Typical contraction patterns (m. quadriceps, hamstrings, m. gastrocnemius) for defined load conditions can be recorded. 2. Statistically significant differences can be shown between the control group and the study group as well as between the two legs (injured/noninjured) of the same patient in the study group. 3. The results suggest that the diminished innervation of the m. biceps femoris and m. gastrocnemius in down-ramp-running as an important parameter for ACL deficiency. 4. Distinct differences of innervation patterns of the muscles, which stabilise the knee in downramp walking suggest that despite a subjective stability, altered load conditions may result. Innervation patterns seem to vary from individual to individual. 5. Concluding from our findings, we suggest that clinical methods should be developed to allow a patient-specific assessment of physical activity.

Metabolic and hemodynamic changes during isokinetic muscle training. A controlled clinical trial

Twenty-one healthy males aged 20-36 years were examined for hemodynamic and metabolic parameters such as heart rate, oxygenation, lactate, blood pressure, under isokinetic and ergometric loadings. The healthy volunteers were tested by increased loads and constant times with an identical isokinetic and ergometric power. The important results are: Heart frequency and blood pressure are higher under isokinetic than under ergometric conditions. Oxygenation is equal in both tests. The lactate values show for the isokinetic maximal and for the ergometric submaximal loadings. The definitive factor for this variation is the relation between force and velocity. The higher tension of the muscles and the higher activity of the fast-twitch fibers seem to be responsible for the increasing of sympathicotonia. The clinical impact of this controlled study is: 1. Isokinetic testing might be dangerous for patients with cardiac diseases or circulatory disturbances. 2. Isokinetic training programs have to pay attention to joint and internal diseases at the same level. 3. During the first isokinetic test all precautions for a possible emergency case have to be taken.

Deuterium oxide (heavy water) arrests the cell cycle of PtK2 cells during interphase

Deuterium oxide (D2O, heavy water) exerts an antiproliferative effect on a variety of cells in vitro and on some organisms. This effect is mainly ascribed to a tubulin-mediated antimitotic action. We evaluated the morphology, the mitotic activity, and the dynamics of the cell cycle of PtK2 cells grown in vitro in the presence of 75% D2O for up to eight weeks by microspectrophotometric DNA measurements as well as flow cytometric analysis and a determination of mitotic indices. Substitution of heavy water for water in the culture medium initially increased the mitotic index by a (pro-) metaphase block but after 2 to 3 days of incubation no mitotic figures were seen. Analysis of cells grown for 6 days in medium containing 75% D2O revealed accumulation of cells in S/G2-phase. Extended treatment stabilized the high level of cells in this specific phase, when compared to normal growing cells. Cells grown for 1 to 6 weeks in the presence of D2O remained non-proliferating, nevertheless, they were able to divide again after recovery in non-deuterated medium. The time needed for resumption of the mitotic activity was proportional to the duration of deuterium oxide exposure. Cells incubated for 8 weeks in 75% D2O did not recommence mitotic activity. Light and electron microscopic examination revealed characteristic morphological changes of size and ciliation in PtK2 cells subjected to prolonged deuteration.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA index and cell cycle analysis of primary breast cancer and synchronous axillary lymph node metastases

The DNA Index (DI) and the percentage of cells in S-phase (S-phase fraction, SPF) were measured by flow cytometry in 80 primary breast carcinomas and in 80 accompanying axillary lymph node metastases. The DI in primary tumors and metastases agreed in 61 cases (76%). Cases with diploid primary tumors revealed more constancy of the DI in comparison to the metastases than the cases with aneuploid primary tumors (91% and 70% respectively). The mean values of the SPF were in close agreement in the primary tumors and in the lymph node metastases (6.1% and 6.0% respectively). Differences between the SPF of the two groups could be detected only by the consideration of case-related data pairs. In 50 cases (62%), the percentage of SPF agreed approximately in primary tumors and in the correspondent metastases. The cases with diploid primary tumors revealed more agreement of the SPF in the primary site and the metastases than did cases with aneuploid primary tumors (78% and 56% respectively). In conclusion, diploid carcinomas and their metastases revealed more constancy of the DI and the percentage of SPF than aneuploid carcinomas. These findings agree well with a better prognosis of diploid mammary carcinomas, as reported in the literature. Comparisons between the DI and the SPF in primary tumors and the corresponding metastases could be a source of valuable information on the biological behaviour and the aggressiveness of mammary carcinomas.

A case of Sjögren's syndrome with severe anemia due to myelitis

An unusual case of Sjögren's syndrome presenting with severe anemia as the predominant clinical feature is described. Histological examination of a bone marrow biopsy specimen demonstrated that the patient's anemia was caused by myelitis and vasculitis of the small intraosseous vessels. Our report might stimulate a more thorough investigation of bone marrow in patients with connective tissue diseases and anemia.

[Polycythemia in kidney cysts. A report on an unusual case]

A 43-year-old woman with a solitary renal cyst developed polycythaemia. 21 well documented cases of this type have been previously published. In the majority of them a causal connection could be assumed between the renal cyst and polycythaemia: in 13 of the 15 cases (as in the reported one), the polycythaemia disappeared after surgical removal of the cyst. Measurement of serum erythropoietin can help in the differential diagnosis, but exclusion of polycythaemia vera may be difficult in the individual case.

[Systemic lupus erythematosus. Brown-Sequard syndrome, spinal ataxia and peripheral polyneuropathy as the sole manifestations]

Neurologic manifestations were the sole symptoms of disease in three patients with systemic lupus erythematodes (SLE): one case presented with Brown-Séquard's syndrome, a second with spinal ataxia and polyneuropathy, and a third with polyneuropathy. In all three patients there was a considerable delay in making the diagnosis after onset of neurological symptoms. The diagnosis was established either by demonstration of antinuclear antibodies in combination with antibodies against dsDNA or by the demonstration of antibodies against dsDNA alone. In two patients perivascular deposits of IgG and C3 were seen in skin-muscle biopsies from the calf region.

[Immunologic parameters in pericholangitis and primary sclerosing cholangitis with and without ulcerative colitis]

Immunological parameters and histocompatibility antigens (HLA) were determined in seven patients with non-bacterial cholangitis. Four patients had pericholangitis and ulcerative colitis, three had primary sclerosing cholangitis, one of these with ulcerative colitis. All 7 patients had antinuclear antibodies; however, there were no antibodies against DNA, against mitochondria or liver membrane antigens. One patient had low-titre rheuma factors. Immunoglobulins G, A and M and complement components C3 and C4 were mostly in the normal range. HLA constellation was positive for B8 in 6 patients. These were male patients with disease manifestations between the 12th and 45th year of life. The results support the concept that pericholangitis and primary sclerosing cholangitis with or without ulcerative colitis are related hepatological disease entities with an immunological pathogenesis and an underlying genetical determination.

Comparative DNA/DNA reassociation kinetics in three hamster species

1. Three major DNA repetition classes can be distinguished in the genomes of three hamster species Mesocricetus auratus, Cricetulus griseus, and Phodopus sungorus sungorus: A very fast reassociating fraction of about 13% of the DNA, a fast reassociating fraction comprising 10-23% of the DNA, and a slowly reassociating fraction containing single-copy sequences of 63-78% of hamster DNA. 2. In the DNA of the Syrian and Djungarian hamster 43%-53%, and in the DNA of the Chinese hamster 80% of the single-copy sequences are interspersed with repetitive sequences. 3. The lengths of repetitive DNA sequences, vary between more than 3 kb and 0.3 kb, with the majority of sequences having a length of 0.3 kb to 0.5 kb. 4. The findings suggest that the genomes of the hamster species studied are organized in a short period interspersion pattern. 5. Unlike other vertebrate and invertebrate genomes, moderately repetitive sequences exhibit a high degree of intraspecific homology in the hamster genome.

[Endometriosis of the terminal ileum: differential diagnosis to the Crohn's disease (author's transl)]

We report on the clinical course of a 30 year old female patient with endometriosis of the terminal ileum. The course was complicated by development of intestinal abscesses, entero-cutaneous and entero-vesical fistulas and stenosis of the terminalö ileum. A diagnosis of Morbus Crohn was made and was only corrected after the patient had to be operated upon because of mechanical obstruction of the terminal ileum. The problems of diagnosis and management are presented.

[Circulating immune complexes and in vivo fixation of immunoglobulin G, A and C3 onto hepatocytes in patients with Crohn's disease (author's transl)]

In vivo fixation of immunoglobulin and C3 onto the hepatocellular membrane of patients with Crohn's disease was studied by immunofluorescence. IgG binding was observed in 93% of patients with disease activity but not in patients without disease activity. C3 binding was present in 21% of patients with active disease. IgA binding was found in approximately one half of all patients with Crohn's disease irrespective of disease activity. The immunoglobulin and C3 binding to hepatocytes was not correlated with histopathological findings. Circulating immune complexes were detected with the Raji cell assay in approximately one half of all patients with Crohn's disease and showed no correlation to disease activity. The following conclusions can be derived from these studies: 1. The in vivo fixed IgG represents immune complexes, which is eliminated by the liver as part of the physiological clearance function. 2. These aggregates bind to hepatocytes predominantly via IgGFc receptors. 3. Hepatocellular bound IgG and C3 show no correlation to histopathological liver alterations. 4. In vivo bound hepatocellular IgG aggregates have different properties than the immune complexes detected by the Raji cell assay.

K-lymphocytes (killer-cells) in Crohn's disease and acute virus B-hepatitis

Total lymphocyte counts, B-, T-, C'3 receptor-bearing lymphocytes, and K-cell activity were studied in peripheral blood in patients with Crohn's disease and inflammatory liver disease. Patients with active untreated Crohn's disease and acute virus B hepatitis exhibited a markedly increased K-cell activity measured in a plaque assay when compared with normal controls (P less than 0.01). Patients with immunosuppressive treated Crohn's disease, HBsAg-positive chronic active hepatitis, and cirrhosis of the liver showed only a slight increase of K-cell activity (P less than 0.01). In the postacute phase of hepatitis (four to 12 weeks from onset) K-cell activity fell to normal levels. The number of B-lymphocytes showed a relative and absolute decrease in all groups of patients. With the exception of patients with acute HBsAg-positive hepatitis and the post-acute phase of hepatitis all the other groups showed statistically decreased absolute numbers for C'3 receptor-bearing lymphocytes. The significant decrease in K-cell activity and the number of T-lymphocytes in Crohn's disease treated with immunosuppressive drugs was interpreted as an effect of azathioprine and prednisone on these lymphocyte subpopulations.

[Surgical and medical treatment of Crohn's disease (author's transl)]

Regional enteritis does present therapeutical problems because of the unpredictable course of this disease. 162 patients were operated upon in the Surgical Department of the University of Mainz Medical School between 1964 and 1976. Medical and surgical treatment of these patients has been rather different due to the heterogenity of the patient group. Curative therapy of regional enteritis does not exist. Medical treatment is aimed at converting the active form of the disease into an inactive, 'burnt out' form. One therapeutic regimen widely used is the combination of salazosulfapyridin and corticosteroids, another regimen is the combination of azathioprine and prednisolone. Surgery is indicated when complications arise and after medical treatment has failed. The optimal approach is resection of the afflicted part of the intestine. Even after surgery prognosis is doubtful and depends upon the activity of the disease in each individual case.

Cellular immune reactions against common antigen, small intestine, and colon antigen in patients with Crohn's disease, ulcerative colitis, and cirrhosis of the liver

Patients with ulcerative colitis showed in 71-93%, patients with cirrhosis of the liver in 64-91%, cellular immunity against Common Antigen (CA) and human fetal intestinal antigens as measured by the leucocyte migration test (LMIT). Patients with Crohn's disease exhibited cellular immune reactions to a lesser degree - from these only patients without immunosuppressive therapy differed significantly from normal controls (p less than 0.05). Approximately 30% of patients with Crohn's disease and ulcerative colitis had elevated antibody titers against intestinal antigens and CA. A high percentage of patients in both diseases showed a reciprocal relationship between cellular and humoral immunity. It was concluded that Crohn's disease and ulcerative colitis can be separated in most cases using intestinal antigens and CA in the LMIT. The occurrence of cellular immunity against these antigens cannot be interpreted as being the only pathogenetic principle in these two diseases. It is also concluded that there appears to be only a weak immune tolerance against intestinal antigens. The high percentage of cellular immune reactions in patients with cirrhosis of the liver demonstrates that this group may have an impairment of the physiological elimination of antigens by the liver.

[Congenital mitral stenosis. Report on 33 patients]

Thirty-three patients with congenital mitral stenosis are presented. Congenital mitral stenosis occurs as an isolated malformation and in combination with additional cardiac lesions. A new classification into 5 groups is suggested. It is possible to classify congenital mitral stenosis with and without additional lesions according to these 5 groups. This is of particular clinical advantage. Isolated congenital mitral stenosis is a rare malformation. In combination with additional obstructive left-sided cardiac malformations mitral stenosis occurs more frequently. In infancy and early childhood the so-called parachute valve is a stenotic lesion. According to our experience the parachute valve tends to the development of additional mitral incompetence in older children. This observation is of clinical and diagnostic importance. In patients with additional valvular aortic stenosis the mortality is very high. The operative treatment of congenital mitral stenosis with a parachute valve in combination with other obstructive lesions of the left ventricular outflow tract and the aorta without removal of the parachute valve seems to be unable to improve the hemodynamic situation and the prognosis of these patients. There is not enough experience with artificial valves in congenital mitral stenosis in early childhood.