A descriptive analysis of human milk dispensed by the Leipzig Donor Human Milk Bank for neonates between 2012 and 2019

Background

Human milk banking has become an important aspect of Nutritional medicine. It is not just about the provision of mother's own milk (MOM) or donor human milk (DHM) in the hospital, but also a strategy to encourage breastfeeding in the clinical setting and beyond.

Objective

To describe the feeding patterns of hospitalised infants including human milk dispensed by the Leipzig Donor Human Milk Bank (LMB).

Design

A descriptive analysis of daily data on milk feeds dispensed by LMB for hospitalised infants distinguishing between MOM or DHM, either fresh or frozen, and raw/pasteurised milk from 2012-2019.

Results

We included 2,562 infants with median hospitalisation of 23 days, for whom human milk was dispensed on median 76% of those days and other nutrition on the remaining days. Raw MOM and raw DHM comprised 52% and 8% of the dispensed milk, respectively. Dispensing exclusive DHM instead of MOM for at least one full day was required for 55% of the infants, mostly at the beginning but also later during hospitalisation. Exclusive raw DHM was dispensed on at least 1 day for 37% of the infants, in different birthweight strata <1,000 g: 10%, 1,000-1500 g: 11%, 1,500-2500 g: 13% and > 2,500 g: 3%. At discharge, MOM was dispensed for more than 60% of the infants.

Conclusion

During an infant's hospital stay, LMB dispenses various human milk feeds with interspersed DHM resulting in complex intra-individual and time-variant feeding patterns. LMB dispenses raw MOM and especially raw DHM with the intention to retain the properties of human milk unlike a diet containing pasteurised DHM and/or formula. Although raw DHM comprises a small percentage of all dispensed milk, raw DHM is dispensed for a substantial portion of infants. Our results document that dispensing raw DHM, is possible in routine settings.

Diversity and trends of human milk banking: a scoping review from 1946 to 2021

BACKGROUND

The provision of donor human milk (DHM) through human milk banks is now widely practised globally. The study aimed to describe the current state, identify major topics and map out the emerging trends in human milk banking.

METHODS

PubMed was systematically searched for publications related to DHM, with the last update on 14 May 2021, for papers published between 1946 and 2021. Titles and abstracts were screened and indexed into 8 main and 39 subcategories. A top-up search was done in April 2022, but these results have not been incorporated.

RESULTS

A total of 1083 publications were identified, and more than a third (41%) were either observational or interventional studies. Predominant topics were milk type and milk composition. Almost half (49%) of the publications in the last decade were funded through government/research councils, and industry funding started shortly after links between formula and necrotising enterocolitis were published. Literature from high-income countries was six times more than publications from low-income or middle-income countries (LMICs).

CONCLUSION

The diversity and trends of publications included in this scoping review ranged from descriptive studies comparing biological and compositional differences of mother's own milk, DHM and/or formula. Very few studies have investigated associations of different milk types with infant outcomes. Evidence on breastfeeding and recipient psychological health outcomes is limited. Further research should identify the appropriateness of different funding sources. Future collaborations between academics, clinicians and milk banks in LMICs should be fostered to bridge the gap that exists between DHM and access.

[Degenerative forefoot : Diagnostics and treatment]

The hallux valgus deformity is the most common toe deformity of the forefoot and is often associated with a splayfoot. Malpositioning of the small toes may be isolated but are more common in other foot deformities. The understanding of the complex pathoanatomy of the foot is necessary for orthopedic treatment. Conservative treatment is reserved for the early stages. The indications for surgery should be based on clinical and radiographic findings. Countless surgical procedures are available and minimally invasive surgical techniques are also increasingly being used.

Prospective surveillance of bacterial colonization and primary sepsis: findings of a tertiary neonatal intensive and intermediate care unit

BACKGROUND

Preterm infants and critically ill neonates are predisposed to nosocomial infections as sepsis. Moreover, these infants acquire commensal bacteria, which might become potentially harmful. On-ward transmission of these bacteria can cause outbreaks.

AIM

To report the findings of a prospective surveillance of bacterial colonization and primary sepsis in preterm infants and neonates.

METHODS

The results of the surveillance of bacterial colonization of the gut and the respiratory tract, targeting meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Gram-negative bacteria from November 2016 to March 2018 were analysed. Bacterial colonization was compared to surveillance of sepsis.

FINDINGS

Six-hundred and seventy-one patients were admitted and 87.0 % (N=584) of the patients were screened; 48.3% (N=282) of the patients screened were colonized with at least one of the bacteria included in the screening; 26.2% of them (N=74) had multi-drug-resistant strains. A total of 534 bacterial isolates were found. The most frequently found species were Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca and Klebsiella pneumoniae. Three MRSA but no VRE were detected. The surveillance detected a K. pneumoniae cluster involving nine patients. There were 23 blood-culture-confirmed sepsis episodes; 60.9% (N=14) were caused by staphylococci. Gram-negative bacteria (one Klebsiella aerogenes and two E. cloacae) caused three sepsis episodes which were preceded by colonization with the respective isolates.

CONCLUSIONS

Surveillance of colonization provided a comprehensive overview of species and antibiotic resistance patterns. It allowed early detection of a colonization cluster. Knowledge of colonization and surveillance of sepsis is useful for guiding infection control measures and antibiotic treatment.

Early Detection of Infection Chains & Outbreaks: Use Case Infection Control

Within the HiGHmed Project there are three medical use cases. The use cases include the scopes cardiology, oncology and infection. They serve to specify the requirements for the development and implementation of a local and federated platform, with the result that data from medical care and research should be retrievable, reusable and interchangeable. The Use Case Infection Control aims to establish an early detection of transmission events as well as clusters and outbreaks of various pathogens. Therefore the use case wants to establish the smart infection control system (SmICS).

[Ankle cartilage repair : Therapeutic options, results and technical aspects]

BACKGROUND

Therapeutic strategies for cartilage repair of the talus are varied. With the use of biologic scaffolds and biologic agents new cell-based therapies have become the focus of attention.

OBJECTIVES

Ankle cartilage repair techniques are presented and assessed by current data. In addition, technical notes for each technique are given.

MATERIAL AND METHODS

Currently, the following established ankle cartilage repair procedures exist: microfracturing, AMIC (autologous matrix-induced chondrogenesis), OCT (osteochondral transplantation, mosaicplasty), allograft transplantation.

DISCUSSION

The success of each repair technique is dependent on the proper indication, addressing of co-morbidities like axis deviation or ligament instabilities, the experience of the surgeon and the appropriate rehabilitation. Mid- and long-term results are often good or excellent. Best results are seen in isolated cartilage defects without co-morbidities in patients younger than 40 years of age and non-smokers with normal BMI and early intervention. New cell-based therapies utilize scaffolds and biologic agents. They offer promising perspectives, although current data is inconsistent.

Infection control in german-speaking burn centres: results of an online survey

To systematically evaluate which infection control measures are in place in burn units, we conducted an online survey among 43 German-speaking burn units. The 29 units that responded and agreed to publication represented more than 125 patient beds. All units were located in advanced care hospitals. A total of 14 units provided single rooms only, and 22 units had a nurse-to-patient ratio of at least 1:2. Infection control practices included pre-emptive barrier precautions (29 units), the use of sterile filters for tap water supply (29 units), and an antibiotic stewardship program (24 units). Microbial screening of the patients on admission (23 units), regular prevalence screening (26 units) and surveillance of nosocomial infections (21 units) were also widely used. The high reply rate to the survey indicates the special relevance of infection control for burn units. Our survey shows that great efforts and several measures are being undertaken to address infection control challenges in burn patient care, but it also underlines the need for increased interdisciplinary infection control and antibiotic stewardship activities.

[Rheumatism operations in a state of flux-"Foot"]

Surgical management of rheumatic feet has dramatically changed over the last decades influenced by the development of new pharmacological drugs and tissue-preserving surgical procedures. It has switched from joint resection to joint-sparing procedures as the method of choice. Nevertheless, the surgical interventions commonly used for non-rheumatic patients cannot be applied to rheumatic patients without reflection: in addition to the basic treatment, comorbidities, degree of mobilization of the patient, orthopedic shoe engineering and orthotic treatment play a major role. Due to the decreasing incidence of the classical rheumatic foot, it has become even more important for physicians, physiotherapists and ergotherapists to recognize the development of such a disease as early as possible and immediately start the appropriate treatment.

[Examination of the wrist and hand]

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

Different Kinematics of Knees with Varus and Valgus Deformities

Few data exist of kinematics of knees with varus and valgus deformities combined with osteoarthritis. The purpose of this study was to reveal different (1) tibiofemoral kinematics, (2) medial and lateral gaps, and (3) condylar liftoff of osteoarthritic knees with either varus or valgus deformity before and after total knee arthroplasty (TKA). For this purpose, 40 patients for TKA were included in this study, 23 knees with varus deformity and 17 knees with valgus deformity. All patients underwent computer navigation, and kinematics was assessed before making any cuts or releases and after implantation. Osteoarthritic knees with valgus deformity showed a significant difference in tibia rotation relative to the femur with flexion before and after TKA, whereas knees with varus deformity did not. Knees with a valgus deformity showed femoral external rotation in extension and femoral internal rotation in flexion, whereas knees with a varus deformity revealed femoral internal rotation in extension and femoral external rotation in flexion. In both groups, gaps increased after TKA. Condylar liftoff was not observed in the varus deformity group after TKA. In the valgus deformity group, condylar liftoff was detected after TKA at knee flexion of 50 degrees and more. This study revealed significant differences in tibiofemoral kinematics between osteoarthritic knees with a varus or valgus deformity before and after TKA. Valgus deformities showed a paradoxic movement pattern. These in vivo intraoperative results need to be confirmed using fluoroscopic or radiographic three-dimensional matching before and after TKA.

[Additional emergency medical measures in trauma-associated cardiac arrest]

INTRODUCTION

More than half of all traumatic deaths happen in prehospital settings. Until now, there have been no long-term studies examining the actual additive treatment during trauma-associated cardiopulmonary resuscitation (tCPR), including pleural decompression, pericardiocentesis, tourniquets and external stabilization of the pelvis. The present cohort study evaluated forensic autopsy reports of trauma deaths occurring at the scene with respect to additive actions in preclinical tCPR as well as the potentially preventable nature of the individual death cases.

MATERIAL AND METHODS

All autopsy protocols from the Institutes of Legal Medicine in Leipzig and Chemnitz, Germany within the years 2011-2017 were retrospectively examined and all trauma deaths with professional prehospital tCPR at the scene, during transport or shortly after arriving at the emergency room were analyzed. In addition to epidemiological parameters all forms of medical procedure performed by emergency physicians and the injury patterns were recorded. Thus, the questions whether any of the trauma deaths were preventable and if failures in work-flow management were evident could be retrospectively answered through a structured Delphi method.

RESULTS

Overall, 3795 autopsy protocols were listed containing 154 trauma cases (4.1%) with various preclinical tCPR attempts (male patients 70.1%; mean age 48 ± 21 years). Most of them died at the accident site (84.4%), some during transport (2.6%) or directly after admission to a hospital (13.0%). Only 23 patients (14.9%) received 25 additional interventions exceeding the normal scope (pleural decompression 80.0%, pericardiocentesis 8.0% and external stabilization of the pelvis 12.0%). A relevant number of potentially reversible causes for trauma-associated cardiac arrest was determined. There were deficits in the performance of pleural decompression in cases of tension pneumothorax. Even if isolated traumatic hemopericardium was a rare occurrence in the examined cases, the rate of pericardiocentesis was still too low. Also, more focus needs to be placed on provisional external pelvic stabilization of trauma patients which was performed too rarely even though an instable pelvic ring was apparent during the postmortem external examination. None of the cases received a rescue thoracotomy even if a few patients might have derived benefit from this and none of the cases showed injury patterns with tourniquet indications. Furthermore, no single case of death due to incorrect or missing airway management was determined. Errors in work-flow management were found in 37.0% and potentially preventable deaths occurred cumulatively in 12.3% of the cases. The potentially preventable deaths were particularly related to penetrating chest injuries caused by a sharp force.

DISCUSSION

The percentage of patients who might benefit from additive treatment implemented in tCPR efforts was shown to be equal between the local situations in Leipzig and Chemnitz compared to previous reports in Berlin. A need for optimizing the professional resuscitation process still remains as not all reversible causes were appropriately addressed. Further training and education should intensively address the mentioned deficits and continuous awareness of necessary additional medical procedures in the preclinical setting in cases of traumatic cardiac arrest is inevitable. Cooperation with forensic institutes can help to impart particular issues and treatment options of emergency medicine in cases of potentially reversible causes of traumatic cardiac arrest.

What is the optimal valgus pre-set for intramedullary femoral alignment rods in total knee arthroplasty?

PURPOSE

In total knee arthroplasty (TKA), intramedullary guides are often used for aligning the distal femoral cutting block. Because of the highly varying angles between the mechanical axis and the anatomical femoral axis (AMA), different valgus pre-sets have been recommended. The present study investigated the optimal valgus pre-set (measuring the AMA in long-leg radiographs or at 5°, 6°, 7° or 8° valgus) to align the cutting block perpendicularly to the mechanical axis.

METHODS

The AMA was preoperatively measured in weight-bearing long-leg radiographs. After alignment of the cutting block by means of an intramedullary rod, deviation of the block from the mechanical femoral axis was measured with a pinless navigation device. The true AMA (tAMA) was calculated by adding the valgus pre-set of the alignment rod to the deviation measured with the navigation device. Mean deviations between the tAMA and (a) the AMA measured by the surgeon, (b) the AMA calculated with the computer software, (c) 5°, (d) 6°, (e) 7° and (f) 8° valgus pre-sets were measured for each patient. The lowest mean differences were determined.

RESULTS

The 40 knees measured showed a mean tAMA of 7.2° valgus (1.7 SD) (range 4°-11.5°). The following mean differences and 95 % limits of agreement were calculated: 2.2 (-1.2, 5.5) to the tAMA for the 5° valgus pre-set, 1.2 (-2.2, 4.5) for 6°, 0.2 (-3.2, 3.5) for 7° and -0.8 (-4.2, 2.5) for 8°. AMA measurements by the surgeon and with the digital medical planning software yielded mean differences of 0.6 (-3.1, 4.3) and 0.4 (-4.1, 4.8), respectively.

CONCLUSION

In the present setting, the best mean distal femoral cutting block alignment perpendicular to the mechanical femoral axis could be achieved with a valgus pre-set of 7° and not by measuring the AMA. Nevertheless, we recommend conducting weight-bearing radiographs of the entire leg prior to TKA for easy detection of any anatomical varieties, old fractures, long stems of total hip arthroplasties or cement. However, surgeons must be aware that exact coronal component alignment can only be achieved by navigational devices.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Cardiopulmonary resuscitation-associated injuries in still-/newborns, infants and toddlers in a German forensic collective

INTRODUCTION

Cardiopulmonary resuscitation (CPR) may lead to injuries. Forensic experts are sometimes confronted with claims that fatal injuries were caused by chest compressions during CPR rather than by assaults. We want to answer, how often CPR-associated injuries are present in younger children and if they may mimic injuries caused by abuse.

MATERIAL AND METHODS

All autopsy records of the Institute of Legal Medicine in Leipzig, Germany in a 6-year study period were used (2011-2016). There were 3664 forensic autopsies in total, comprising 97 autopsies of children ≤4 years. After exclusion criteria we were able to include 51 cases in the study. Following this, all CPR-related variables were collected according to the 'Utstein style'. Standard procedures were used for statistical evaluation of the data.

RESULTS

The most common cause of cardiac arrest was SIDS. The mean duration of CPR was 50min. Bystander CPR was performed in 43.1%. In no single case death was declared without at least partly professional CPR. Most of the children were first resuscitated out-of-hospital (41.2%). 27.5% of the children had at least one CPR injury without preference to an age group. None of the recorded CPR-associated injuries were considered significant or life-threatening. The duration of CPR or presence of bystander CPR did not correlate to the presence of any detected injury.

CONCLUSION

Skeletal injuries and relevant injuries to the soft tissue and organs seem to occur only very rarely after pediatric CPR. Whenever such injuries are diagnosed, the children should be examined thoroughly for potential abuse.

[Examination of the wrist and hand]

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Patella navigation in computer-assisted TKA : Intraoperative measurement of patellar kinematics. Video article]

INTRODUCTION

Patellofemoral maltracking is a relevant problem after total knee arthroplasty (TKA). Patella navigation is a tool that allows real time monitoring of patella tracking.

MATERIAL

This video contribution demonstrates the technique of patellofemoral navigation and a possible consequence of intraoperative monitoring. A higher postoperative lateral tilt is addressed with a widening of the lateral retinaculum in a particular manner.

CONCLUSION

In selected cases of patellofemoral problems, patella navigation is a helpful tool to evaluate patellofemoral tracking intraoperatively. Modifications of implant position and soft tissue measurements can then prevent postoperative patellofemoral maltracking.

[Operative therapy for rheumatoid arthritis of the hand]

The need for operative treatment of severe rheumatic deformities of the hand and wrist is decreasing due to the increased use of disease-modifying drugs; however, some patients do not tolerate or do not sufficiently respond to these drugs, which often results in the hands being affected and in advanced stages to severe deformity and loss of function. In these cases operative surgery can help to slow the progression of rheumatic destruction and restore the function of the patient's hand. This article describes the principles of surgery for rheumatoid arthritis of the hand. A meticulous synovectomy or tenosynovectomy is the first stage of treatment. With progression of rheumatic destruction various salvage procedures are necessary to preserve the best possible functional state.

[Hindfoot deformities in adults. Conservative and surgical treatment]

The term hindfoot deformity denotes many different disease patterns that are associated with malformations of the axis. Destruction of the hindfoot caused by chronic polyarthritis or diabetic diseases are complex examples. This article aims to qualify the reader to diagnose the most important and most common hindfoot deformities in adults and to make decisions about stage-adjusted conservative and surgical therapeutic options.

In-house coordination for organ donation--single-center experience in a pilot project in Germany (2006 to 2013)

A challenge for solid organ transplantation in Germany is the shortage of organs. In an effort to increase donation rates, some federal states mandated hospitals to install transplantation officers to coordinate, evaluate, and enhance the donation and transplantation processes. In 2009 the German Foundation for Organ Transplantation (DSO) implemented the In-House Coordination Project, which includes retrospective, quarterly, information technology-based case analyses of all deceased patients with primary or secondary brain injury in regard to the organ donation process in maximum care hospitals. From 2006 to 2008 an analysis of potential organ donors was performed in our hospital using a time-consuming, complex method using questionnaires, hand-written patient files, and the hospital IT documentation system (standard method). Analyses in the In-House Coordination Project are instead carried out by a proprietary semiautomated IT tool called Transplant Check, which uses easily accessible standard data records of the hospital controlling and accounting unit. The aim of our study was to compare the results of the standard method and Transplant Check in detecting and evaluating potential donors. To do so, the same period of time (2006 to 2008) was re-evaluated using the IT tool. Transplant Check was able to record significantly more patients who fulfilled the criteria for inclusion than the standard method (641 vs 424). The methods displayed a wide overlap, apart from 22 patients who were only recorded by the standard method. In these cases, the accompanying brain injury diagnosis was not recorded in the controlling and accounting unit data records due to little relative clinical significance. None of the 22 patients fulfilled the criteria for brain death. In summary, Transplant Check is an easy-to-use, reliable, and valid tool for evaluating donor potential in a maximum care hospital. Therefore from 2010 on, analyses were performed exclusively with Transplant Check at our university hospital.

[Prevention of periprosthetic joint infections : Not evidence-based strategies]

BACKGROUND

Surgical site infections are the most common nosocomial infections in orthopedic surgery. Strategies to prevent these infections are of enormous relevance.

OBJECTIVES

Evidence-based procedures such as hand disinfection, prophylactic antibiotic application, hair removal with electric clippers, or preoperative treatment of Staphyloccus aureus are listed in national and international guidelines. Beside these measures, several scientifically not confirmed methods, e.g., the administration of antibiotic prophylaxis for several days or the usage of helmets during surgery, are still practiced. These measures are not evidence-based and should not be performed anymore.

CONCLUSION

Only the consequent implementation of evidence-based procedures can help prevent surgical site infections.

[Arthrodesis for patients with rheumatic arthritis of the ankle and hindfoot. A reasonable option?]

BACKGROUND

Ankle and hindfoot deformities as well as degenerative changes are often found in patients with rheumatological diseases. They often suffer from severe pain and complain of increasing immobility. Corrective procedures with ankle or hindfoot arthrodesis are promising options.

OBJECTIVES

This article presents epidemiological data and describes the clinical aspects, diagnostics and treatment options for patients with ankle and hindfoot osteoarthritis.

MATERIALS AND METHODS

The retrospective results of 56 patients after ankle or hindfoot arthrodesis are presented.

RESULTS

After an average follow-up of 52 months the majority of results were good or excellent with relief of pain and reconstruction of the function of the foot.

CONCLUSION

Ankle or hindfoot arthrodesis represents a promising option for patients with severe osteoarthritis and can safeguard patients from increasing immobility.

No difference in accuracy between pinless and conventional computer-assisted surgery in total knee arthroplasty

PURPOSE

Many studies have demonstrated higher precision and better radiological results in Total knee arthroplasty (TKA) with computer-assisted surgery (CAS). On the other hand, studies revealed a lengthening of operation time up to 20 min for this technique and demonstrated rare additional complications as fractures and neurovascular injuries caused by the array pins and any intraoperative array dislocation leads to abortion of CAS. To combine the advantages and eliminate the disadvantages of standard CAS, we evaluated the accuracy of a so-called pinless CT-free version of knee navigation (pinless CAS) abandoning the reference pins and reducing the necessary workflow to a minimum.

METHOD

The present study compares the accuracy of the reference methods of two different CT-free knee navigation software versions (Brainlab Knee 2.1 and Brainlab Knee Express 2.5). Thirty patients received TKA assisted by standard CAS. Intraoperatively, the proposed bony resections of standard CAS were matched with the new pinless CAS. Postoperatively, the results were checked by evaluating the radiographs concerning leg axis, femoral flexion and tibial slope.

RESULTS

All results concerning precise cuts (femoral as well as tibial coronal/varus-valgus alignment, femoral flexion alignment and tibial slope, resection height) were comparable between both groups (n.s.). In femoral, we found a mean deviation of coronal alignment of 0.3° (SD 0.7) and flexion of 0.2° (SD 0.8). In tibial, we found a mean deviation of coronal alignment of 0.2° (SD 0.5) and slope of 0.2° (SD 0.6). The mean additional operation time for the pinless CAS was below 2 min. The postoperative mechanical leg axis was within the threshold of 3° in all patients, tibial slope and femoral flexion matched with CAS values.

CONCLUSION

In clinical routine, pinless CAS can comprise the advantages of CAS leaving the disadvantages aside. It reduces surgical time and avoids complications associated with the tracking pins of conventional CAS.

[Update on navigation in total knee arthroplasty. Where are we today and what lies in the future?]

BACKGROUND

The implantation of an artificial knee is one of the most common operative interventions in German hospitals. Navigation procedures have developed into an integral component of such interventions in the operating theatres of many clinics.

METHODS

For orthopedic surgeons who want to implement an as exact as possible reconstruction of the mechanical leg axis and require intraoperative control of the three dimensional positioning of components and/or the capsular ligament situation, navigation is a well-proven intraoperative tool. The immediate intraoperative control possibility of bone resection and capsular ligament soft tissue balancing means that navigation is a valuable instrument for the biomechanical fundamental understanding in training operations for further education of orthopedic surgeons in training.

DEVELOPMENTS

The greater precision obtained by the implementation of the procedure has not yet been conclusively reflected in an improved postoperative knee function or an increased durability of prostheses. New developments in navigated knee prostheses are pinless navigation and navigation kinematics. In pinless navigation the conventional reference marker system fixed in the femur and shin bones is replaced by a non-invasive reference system. With the aid of navigation kinematics it is possible to image the tibiofemoral and patellofemoral movement dynamics, intraoperatively.

PERSPECTIVE

The aim of the next generation navigation systems for computer-assisted knee prosthetics is implant positioning aligned to the individual anatomy of patients with high and stable range of movement for optimum patellar guidance and kinematics of the artificial joint.

Proximal interphalangeal joint replacement with an unconstrained pyrocarbon prosthesis (Ascension(R)): a long-term follow-up

There have been limited publications that report long-term outcomes of pyrocarbon implants. This report describes both clinical and radiographic long-term results for patients who have been treated with pyrocarbon proximal interphalangeal implants. Thirteen implants in ten patients are reported for an average follow-up of 8.3 years (range 6.2-9.3). All patients were suffering from degenerative joint disease. Five of the 13 digits were free of pain, the remaining eight digits had mild to moderate pain (visual analogue scale 2-5). The average active range of motion was 58° (SD 19°) at latest examination. X-ray results were unremarkable in six digits with an acceptable position of the prosthesis. However, in seven patients significant radiolucent lines (≥ 1 mm) were observed. Three prostheses demonstrated a migration of the proximal component, and one a subsidence of the distal component. Our study does not support the use of this implant for treatment of osteoarthritis of the finger joint owing to high complication rates and limited range of motion.

[Treatment of pediatric flat feet by shoe insoles : a scientific-based therapy?]

The differentiation of physiological pediatric flat feet and the pathological course as well as adequate initiation of therapeutic options represents a challenge the importance of which should not be underestimated. Fears and worries of parents and their insistence on inducement of therapeutic measures take center stage in the physician-patient relationship. The problem is that there are insufficient data from scientific studies dealing with the conservative treatment of flat feet in children. This paper intends to give a survey of the current status in the literature concerning indications and therapeutic success using insoles in the treatment of flat feet in children.

[Patient satisfaction and muscle torque after total knee replacement in dependence on body mass index]

AIM

In a monocentric study, we investigated patient satisfaction, clinical outcome and isokinetic muscle torque in dependence on the body mass index (BMI) in the mid-term outcome after total knee arthroplasty.

PATIENTS AND METHODS

A group-matched study with two groups (each 40 knee arthroplasties in 40 patients) with a normal body mass index (BMI 20-25) and above 25 was conducted. The groups were matched for sex, diagnosis and age. Satisfaction, HSS score and isokinetic torque parameters with the Cybex 340 system were measured.

RESULTS

There were no differences in the demographic data except for BMI. The HSS score was significantly lower in the overweight group (p = 0.04). Also there were more patients with an HSS score below 60 (bad result) in the group with the higher BMI (0 vs. 9, p = 0.002). Only one patient was not satisfied in the normal weight group, whereas 9 patients in the group BMI > 25 were not satisfied (p = 0.014). No differences between the groups could be found in maximum torque, work and power.

CONCLUSION

The patient satisfaction was much lower in patients with BMI higher than 25. There were no differences between the groups in isokinetic torque parameters.

[Treatment of patellar instability in children and adolescents]

To address recurrent patellar instability in children and young adolescents a variety of therapeutic options exist either as non-operative or operative treatment. Recent options, such as reconstruction of the medial patellofemoral ligament have evoked a new focus of attention on this topic. The intention of this article is to present diverse therapeutic options and to evaluate them by reference to the current literature.

Linkage disequilibrium between HLA-G*0104 and HLA-E*0103 alleles in Tswa Pygmies

Nonclassical human leukocyte antigen (HLA)-G and -E loci are separated by approximately 660 kb on the short arm of chromosome 6. Interestingly, some functional and expression characteristics are relatively identical or associated for both molecules. For example, expression of HLA-E on the cell surface has been linked to preferential binding of nonameric leader peptides derived from the signal sequence of HLA-G. It has been suggested that these two molecules act synergistically in modulating susceptibility to infectious or chronic inflammatory diseases. A possible explanation for these observations is that HLA-E and HLA-G are evolving under analogous selective pressures and have functions that place them under selective regimes differing from classical HLA genes. The purpose of this study was to investigate the consistency of this hypothesis based on the characterization of the molecular polymorphism of these two genes and their linkage disequilibrium (LD) in three populations, i.e. Southeastern French (n = 57), Teke Congolese (n = 84) and Tswa Pygmies (n = 74). Allelic frequencies observed for HLA-G and HLA-E and for 14-bp ins/del polymorphism in the three populations were similar to those observed in the literature for populations from corresponding geographic areas. Only one of the recently described HLA-G polymorphisms (HLA-G*01:07-01:16) was found, i.e. HLA-G*01:15 in one individual from Congo. We showed that two haplotypes in Tswa Pygmies, i.e. HLA-G*01:04-E*01:03:01 and G*01:04-E*01:01, exhibited highly significant positive and negative D' values respectively. Although these LD could have functional implications, it is more likely because of the genetic drift as the two other populations did not display any significant LD.

[Ochronosis--a rare cause of secondary gonarthrosis]

Ochronosis is a manifestation of the rare disease alkaptonuria. The most common presentations include pain in the lumbar spine region starting during the 3rd decade, spreading over the large joints. There exists no curative therapy for the disease at the moment. In the long-term the patients will be dependent on total joint arthroplasty.

Expression of a voltage-dependent potassium channel protein (Kv3.1) in the embryonic development of the auditory system

The present study traces the development of a voltage-dependent potassium channel protein (Kv3.1) in the avian homologue of the cochlear nucleus, in the cochleovestibular ganglion, and in the otic epithelium from early developmental stages until near hatching. Immunohistochemistry with antibodies to the carboxy terminus (recognizing the Kv3.1b splice variant) and to the amino terminus (recognizing either form of Kv3.1) was used on Hamburger-Hamilton-staged chicken embryos. There were three periods in the relative levels of immunostaining in these regions. Early (E2-6), when precursor cells proliferate, migrate, and form axons, there was staining when using either antibody. In the middle period (E6-11), marked by hair cell differentiation, dendritic growth, and early synapse formation, staining levels decreased. In the late period (E11-19), when auditory function begins, staining increased rapidly, especially for Kv3.1b. Early Kv3.1 expression occurs in neuronal and hair cell precursors before they differentiate or function. Later, in the otic epithelium, a high level of Kv3.1 in cilia may precede or coincide with the onset of hair cell function. In neurons, some features of its localization correlate with axon outgrowth and synapse formation, others with the onset of neural activity and function.

Topographic position of forelimb motoneuron pools is conserved in vertebrate evolution

The neuromotor conservatism hypothesis predicts that neuromotor patterns in homologous tetrapod muscles are conserved evolutionarily despite the musculoskeletal modifications of vertebrate limbs. A complete description of the anatomical organization of the neurons innervating homologous limb muscles is a prerequisite to any test of the neuromotor conservatism hypothesis. This study uses the retrograde neuronal tracer WGA-HRP to selectively label the motor neuron pools of seven homologous forelimb muscles in mice (Mus musculus) and iguanas (Iguana iguana): Mm. pectoralis, spinodeltoideus, biceps brachii, lateral and long heads of triceps brachii, and the supraspinatus and infraspinatus (in mice) or their reptilian homolog, the supracoracoideus (in iguanas). In vertebrates, motoneurons are arranged in longitudinal columns of cells in the ventral horn of the spinal cord. Mouse motor pools average 1,952 microns in length, except the pectoralis pool which averaged 2,949 microns in length. Iguana pools average 3,196 microns in length. The number of neurons per pool ranged from 70-199 in mice and from 58-114 neurons in iguanas. In both iguanas and mice the motor pools for the spinodeltoids, biceps, and the supracoracoideus (or its mammalian homologs) lie anterior to the pectoralis and triceps motor pools. In the transverse plane, the pectoralis pool lies medial to those of the triceps. The pools of the biceps and spinodeltoids are located dorsal and lateral to those of the pectoralis and supracoracoideus (or its homologs in mammals). The resulting motor pool maps support the hypothesis that the anatomical organization of motoneurons in ancestral reptiles has been retained in these two tetrapod descendents.

Development of a survey of asthma knowledge, attitudes, and perceptions: the Chicago Community Asthma Survey. Chicago Asthma Surveillance Initiative Project Team

Little is known about the general public's perception of the diagnosis of asthma and the impact of asthma on individuals, their families, and their communities. In addition, there appear to be no published survey instruments specifically designed to gain insights into how the general public perceives asthma. The purpose of this paper is to describe the development of such an instrument, the Chicago Community Asthma Survey (CCAS)-32. Development began with two qualitative steps. First, a review of the published literature guided the initial instrument construction (Step 1). Content domains were chosen based on clinical input and the Health Belief Model. Most items were derived from existing instruments. To assess content validity, cognitive interviews and expert reviews were conducted (Step 2). Items were added, modified, and deleted based on the information gathered at each of these steps. In the next step, item performance measurement (Step 3), testing of two samples provided quantitative data to further inform item reduction. Items with uniform correct responses or responses lacking in variability were excluded. The result of this three-step process was a 32-item survey of asthma knowledge, attitudes and perceptions, the CCAS-32. The introduction to the survey was subsequently modified to minimize respondent bias (Step 4). In conclusion, the CCAS-32 was constructed with input from experts in asthma and individuals from the Chicago area. The items in the CCAS-32 appear to have both face validity and acceptable performance characteristics.

Organization of forelimb motoneuron pools in two bat species (Eptesicus fuscus and Myotis lucifugus)

The present investigation provides further evidence of the conservation of motor nuclei in amniotes. The position of six forelimb and shoulder motor pools were mapped in two species of bat, Eptesicus fuscus and Myotis lucifugus. The intraspinal locations of motor pools were revealed by labeling with the retrograde neuronal tracer WGA-HRP injected into the bellies of six muscles: m. pectoralis, m. spinodeltoideus, mm. triceps brachii (long and lateral heads), m. infraspinatus, m. supraspinatus, and m. biceps brachii. The positions of the labeled motor pools were reconstructed from serial transverse and horizontal sections of the spinal cord. WGA-HRP-labeled cells were located midway between cervical spinal nerves four and five to midway between cervical spinal nerve eight and the first thoracic spinal nerve. Individual motor pools formed fusiform clusters of cells with little intermingling of neurons between adjacent motor pools. The pectoralis motor pool contained significantly more motoneurons than all other motor pools for M. lucifugus. The pectoralis pool in E. fuscus contained more motoneurons than the biceps, supraspinatus, and infraspinatus, but not the spinodeltoid or the triceps brachii. The biceps, spinodeltoid, infraspinatus and supraspinatus pools were located rostrally; the pectoralis and triceps pools caudally. The pectoralis pool was the most medial and the spinodeltoid pool was the most lateral. These data suggest that the locations of shoulder and forelimb motor pools are ontogenetically and phylogenetically conserved across tetrapods and independent of the function of the muscles in adults.

Medical students act as Big Brothers/Big Sisters to support human immunodeficiency virus-infected children's psychosocial needs

OBJECTIVE

To address the special psychosocial and emotional needs and concerns of human immunodeficiency virus-infected children through a medical student-based Big Brother/Big Sister program.

DESIGN

A telephone survey of 9 medical students who participated in the program in the last 4 years was undertaken to assess their experiences and feelings about the program.

RESULTS

The experiences resulting from participation in the program were unanimously positive. The medical students stated that in no other medical setting were they able to develop a better understanding of the feelings and emotions of living with a terminal illness. The volunteers also believed that the program increased the benefits for the child and the medical student.

CONCLUSIONS

Initial evaluation of the Big Brother/Big Sister program for human immunodeficiency virus-infected children suggests that it helped establish a strong, supportive relationship between the affected child and the medical student. A modified program in other medical schools may help to serve many other communities affected by the human immunodeficiency virus epidemic.

Basic fibroblast growth factor (FGF-2) affects development of acoustico-vestibular neurons in the chick embryo brain in vitro

The effects of basic fibroblast growth factor (FGF-2) on presumptive auditory and vestibular neurons from the medulla were studied in primary cell cultures. The part of the rhombic lip that forms nucleus magnocellularis (homologue of the mammalian anteroventral cochlear nucleus) was explanted from white leghorn chicken embryos at Hamburger-Hamilton stage 28 (E5.5), the time when precursors of the magnocellularis bushy cells migrate and begin to differentiate in situ. In vitro the neuroblasts migrated onto 2-D substrates of purified collagen, differentiated, and expressed neuronal markers. One-half of the cultures were supplemented with human recombinant FGF-2 (10 ng/ml daily) for 5-7 days; the others, with fetal bovine serum. FGF-2 more than doubled the length of neurite outgrowth during the first 3 day treatment compared to serum, but the number of migrating neuroblasts was unaffected. Although neurites attained greater lengths in FGF-2, they usually degenerated after 4-5 days; in serum their growth continued for several weeks. Differentiation of neuronal structure, including axons and dendrites, began within 1-2 days in bFGF but required at least 5-7 days in serum. Histochemical observations in vitro and in situ with antibodies to FGF receptor demonstrated immunopositive patches on acoustico-vestibular neuroblasts at stage 28, when they are migrating and first forming their axons. The findings suggest that FGF-2 stimulates neurite outgrowth in the cochlear and vestibular nuclei. FGF-2 may accelerate cell death by overstimulating neuroblasts, but other factors are needed to sustain their further development.

Cerebellar activation during classical conditioning of the human flexion reflex: a PET study

The present study investigated the involvement of the cerebellum in classical conditioning of the cutaneomuscular flexion reflex in four normal volunteers using positron emission tomography (PET). The flexion reflex was elicited by electrical pulses applied to the medial plantar nerve (unconditioned stimulus, US). A tone was presented as the conditioning stimulus, which co-terminated with the US. The incidence of conditioned responses was correlated with changes in rCBI during the acquisition process of flexion reflex conditioning. Blood flow was significantly increased in an area extending from the ipsilateral cerebellum and hippocampus to bilateral frontal regions (p = 0.009). These data provide support for an involvement of the cerebellum as well as hippocampus among other neural systems in classical flexion reflex conditioning.

[Skin electrodes for electroretinography in unsedated children]

Contact lens electrode ERG is not well tolerated by children. So far, skin electrode ERG has suffered from a weakly defined geometrical relationship to the sources of ERG potentials. Because of the cuplike electric ocular field distribution, skin electrodes were placed: (1) in the middle of the lower eyelid (in order to be positioned in close proximity to the anterior apex of the cornea, which belongs to the electropositive inner surface of the cup); (2) 20 mm laterally to the temporal canthus (in proximity to the cup's electronegative outer surface). (3) Grounding was achieved by attaching a third skin electrode in the forehead midline. Instead of complete dark adaptation, adaptive illumination of 0.1 cd.m-2 was used to avoid frightening the children. After 10 min of adaptation, the examination started. Feeling safe on mother's lap, the little patient looked into a frosted glass screen (about 75 degrees of visual angle, depicting Mickey Mouse) on which a series of strobe flashes was delivered along the lines of the ISCEV ERG Standard: (1) blue flashes: filter no. 625 (Röhm and Haas); repetition rate 0.1 Hz; stimulus strength of white flashes 1.5 cd.m-2 s; (2) red flashes: filter no. S502 (Röhm and Haas); repetition rate 1 Hz; stimulus strength of white flashes 21.75 cd.m-2.s; (3) weak white flashes: stimulus strength 1.5 cd.m-2.s; repetition rate 0.3 Hz; (4) strong white flashes: stimulus strength 11.25 cd.m-2.s; repetition rate 0.3 Hz; (5) white flicker flashes: stimulus strength 1.5 cd.m-2.s; frequency 10, 30, 60 Hz. Recording of single stimulus responses turned out to be feasible; however, to achieve the best results, between 8 and 32 ERG responses were averaged. To illustrate the benefits of skin electrode ERGs in practice, the results of some cases are presented and discussed with respect to clinical findings.

Basic fibroblast growth factor (FGF-2) affects development of acoustico-vestibular neurons in the chick embryo brain in vitro

The effects of basic fibroblast growth factor (FGF-2) on presumptive auditory and vestibular neurons from the medulla were studied in primary cell cultures. The part of the rhombic lip that forms nucleus magnocellularis (homologue of the mammalian anteroventral cochlear nucleus) was explanted from white leghorn chicken embryos at Hamburger-Hamilton stage 28 (E5.5), the time when precursors of the magnocellularis bushy cells migrate and begin to differentiate in situ. In vitro the neuroblasts migrated onto 2-D substrates of purified collagen, differentiated, and expressed neuronal markers. One-half of the cultures were supplemented with human recombinant FGF-2 (10 ng/ml daily) for 5-7 days; the others, with fetal bovine serum. FGF-2 more than doubled the length of neurite outgrowth during the first 3 day treatment compared to serum, but the number of migrating neuroblasts was unaffected. Although neurites attained greater lengths in FGF-2, they usually degenerated after 4-5 days; in serum their growth continued for several weeks. Differentiation of neuronal structure, including axons and dendrites, began within 1-2 days in bFGF but required at least 5-7 days in serum. Histochemical observations in vitro and in situ with antibodies to FGF receptor demonstrated immunopositive patches on acoustico-vestibular neuroblasts at stage 28, when they are migrating and first forming their axons. The findings suggest that FGF-2 stimulates neurite outgrowth in the cochlear and vestibular nuclei. FGF-2 may accelerate cell death by overstimulating neuroblasts, but other factors are needed to sustain their further development.

Basic fibroblast growth factor affects neuronal migration and differentiation in normotypic cell cultures from the cochleovestibular ganglion of the chick embryo

To study the role of basic fibroblast growth factor (FGF-2) in the development of sensory neurons, the cochleovestibular ganglion of the chicken embryo provides a well-characterized structure. This permits use of morphological markers in a cell culture preparation comparable to the normal embryo (normocytic). Otocysts were explanted from white leghorn embryos at Hamburger-Hamilton Stages 14-16, when ganglion cell precursors normally start migrating from the otic epithelium. The cultures were supplemented with either fetal bovine serum or human recombinant FGF-2 (in defined medium or serum) for 2 or 5 days. FGF-2 increased explant growth, neuroblast migration, and neurite outgrowth 2- to 10-fold in the first 2 days. Neuronal morphology appeared within 2-3 days with FGF-2 but required at least 4-5 days with serum. FGF-2 in defined medium stimulated early migration and differentiation, but without serum led to degeneration after 5 days. In serum, growth was later and slower but continued for at least 3 weeks. When explants were cultured in serum with a neutralizing antibody to FGF-2, but no FGF added, neuroblast migration and elongation were decreased by 2- to 4-fold, compared to serum alone. Immunocytochemistry demonstrated FGF receptor sites on the migrating ganglionic neuroblasts, on their processes and growth cones, and in the incipient ganglion and otic epithelium at Stages 15-17, both in the embryo and in vitro. The findings suggest that FGF-2 stimulates early migration and differentiation of ganglion cells by activating the receptors of neuroblasts or their precursors in the embryonic otocyst. However, other factors must sustain their later development.

[Psychometric changes as well as analgesic action and cardiovascular adverse effects of ketamine racemate versus s-(+)-ketamine in subanesthetic doses]

The intravenous anaesthetic ketamine is widely used in subanaesthetic doses as a potent analgesic in emergency and disaster medicine. At present, ketamine is commercially available only in its racemic form, although the S(+)-isomer has proved to be approximately three times as potent than the R(-)-isomer. In first clinical trials in Germany, S(+)-ketamine was reported to be markedly advantageous with regard to analgesia in anaesthetized patients. We therefore evaluated ketamine's analgesic and psychotropic effects in subanaesthetic doses given to healthy volunteers. MATERIALS AND METHODS. After institutional approval of the study by the university's Ethics Committee, 16 volunteers received ketamine racemate (1 mg/kg) and S(+)-ketamine (0.5 mg/kg) i.m. with 1-week intervals between injections in a randomized, double-blind fashion. Analgesia (electric pain stimulation of the median nerve), long-term memory, anterograde amnesia (recognition of simple pictures), motor coordination (Trieger test), immediate recall (short test of general intelligence) and concentration capacity (CI test: recognition of a preselected symbol among several symbols) were measured over a 60-min period and mean arterial pressure, heart rate, and ketamine plasma levels in venous blood samples were determined. Values were calculated as means and data were analysed by Wilcoxon's paired test for group comparison. RESULTS. Within 15 min, both agents induced a measurable degree of analgesia. After ketamine racemate, the level of pain tolerated increased from 38.8 +/- 14.0 to 57.0 +/- 13.7 mA and after S(+)-ketamine, from 36.9 +/- 10.5 to 53.3 +/- 15.2 mA. Ketamine racemate did not exert measurable effects on long-term memory, whereas anterograde amnesia was observed in 46% and 54% of the study subjects after 15 and 30 min, respectively. However, after S(+)-ketamine, only 8% of the volunteers demonstrated anterograde amnesia (P < 0.05). Immediate recall also declined in both groups (baseline: 5 points, after 15 min: 3.5 points for ketamine racemate, 4 points for S(+)-ketamine), whereas concentration capacity worsened from 14.5 +/- 3.8 s to 35.9 +/- 18.6 s after ketamine racemate and significantly less, from 14.8 +/- 2.5 s to 22.9 +/- 7.6 s, after S(+)-ketamine (P < 0.01). Furthermore, after 15 min, ketamine racemate induced an increase in heart rates from 73 +/- 15 b/min to 97 +/- 11 b/min, while S(+)-ketamine raised heart rates from 74 +/- 13 b/min to 89 +/- 11 b/min only (P < 0.05). Mean arterial pressure increased from 97 +/- 11 mmHg to 111 +/- 9 mmHg after ketamine racemate and from 92 +/- 11 mmHg to 110 +/- 13 mmHg after S(+)-ketamine (not significantly different). CONCLUSION. S(+)-Ketamine at half-dose of ketamine-racemate is as potent as ketamine-racemate in subanaesthetic doses with powerful analgesic properties. The (+)-isomer exerts less adverse effects on measurable cerebral functions and induces a significantly smaller increase in heart rate. Since states of impaired consciousness and disorientation are especially disturbing under emergency conditions, further investigations should be carried out to define S(+)-ketamine's position as a potent analgesic for therapeutic use in emergency and disaster medicine.