[The MRSA patient in technical orthopaedics and rehabilitation. Part 2: Hygiene management]

One of the multiresistant pathogens is methicillin-resistant Staphylococcus aureus (MRSA),which was increasingly found in the 1980's. In the USA, the ratio of MRSA rose from 2% in 1975 to 29% in 1991. A similarly steep rise was seen in Germany, with the Paul Ehrlich Society for Chemotherapy reporting a rise from 1.7% in 1990 to 15.7% in 1998. In order to control MRSA, the Clinic and Polyclinic of Technical Orthopaedics and Rehabilitation at the University Clinic Münster, Germany,has set up a comprehensive hygiene management programme for early detection and treatment of nosocomial infections. In addition to addressing the usual problems of MRSA carriers (e.g., higher mortality, longer hospital stays, stigmatisation), these preventive measures are also aimed at combating MRSA-caused cost increases.

[Link-Witzel operation for diabetics]

The inner Chopart's amputation for tuberculosis of the tarsal as performed by Link and Witzel at the end of the nineteenth century laid the groundwork for a foot-saving surgical procedure in cases of neuropathic osteoarthropathy with concomitant infection. The question was posed whether such an inner amputation can represent an alternative to the classic hindfoot amputation. Six patients with neuropathic osteoarthropathy, five of whom had diabetes mellitus,who had been operated between 1989 and 2002 were analyzed retrospectively. In all of the cases, surgery had been indicated by chronic osteomyelitis of the tarsal with concomitant, extensive, mainly plantar ulcerations. During the average follow-up period of 55 weeks, no recurrence of an ulcer or infection occurred and therefore no further proximal amputation was necessary. In addition to being provided with orthotics, the remaining five patients could be fitted with made-to-measure orthopedic shoes. In selected cases, the inner Chopart's amputation can represent a solution even in such problematic cases that cannot be solved by a typical hindfoot amputation. The surgical procedure according to Link and Witzel should thus not only be considered as an alternative to Chopart's amputation, but also as a further method to spare diabetics major amputations.

Time empty and ketone body status in the early postpartum period of dairy cows

This study aimed to assess the effect of ketone body status early postpartum on time empty in 74 multiparous dairy cows under field conditions. Animals were equally distributed across eight farms and were controlled by the same herd-fertility-monitoring programme. Cows were visited twice antepartum and six times postpartum at weekly intervals between 0530 and 0830 a.m. On these occasions, body condition scores and milk yields were measured, blood and milk samples were taken, cows were gynaecologically examined, and parameters of reproduction were recorded. Cows with a time empty of less or more than 80 days were classified as early and late conceiving cows (EC and LC, respectively). A time empty of 80 days results in calving-to-calving intervals of 1 year and classification based on this threshold value resulted in groups of equal size and equal distribution of EC and LC within farms. Ketone bodies measured were beta-hydroxybutyrate in blood and acetoacetate and acetone in blood and milk. Blood and milk ketone body concentrations, as well as the ratios of acetoacetate and acetone to beta-hydroxybutyrate, over the first 6 weeks postpartum were higher in LC than in EC, whereas plasma glucose and non-esterified fatty acids and milk fat, protein and urea concentrations did not exhibit clear differences between groups. Ketone body concentrations were as good predictors of time empty as ketone body ratios and might have practical impact in herd-fertility-monitoring programmes.

3D versus 2D ultrasound: accuracy of volume measurement in human cadaver kidneys

RATIONALE AND OBJECTIVES

Comparison of the accuracy of 3D and 2D ultrasound in assessing the volume of human cadaver kidneys.

MATERIALS AND METHODS

Before autopsy the volume of 22 kidneys was assessed from a 3D data set after manually tracing organ contours (3D volumetry) and by applying a 3D ellipsoid formula both on a 3D data set and 2D images. Measurements by water-displacement served as the gold standard.

RESULTS

3D volumetry showed a mean absolute deviation of 31 mL (18.5%) compared with the mean gold standard measurement (168 mL), yielding a concordance correlation (Lin's rho(c) ) of 0.71. Calculation based on the ellipsoid formula revealed a mean absolute deviation of 37 mL (22.0%) when applied on the 3D data set (rho(c) = 0.65) and of 42 mL (25.0%) when applied on 2D images (rho(c) = 0.61).

CONCLUSIONS

3D volumetry showed a satisfactory concordance correlation and is superior to volume calculation based on the ellipsoid formula either applied to a 3D data set or to conventional 2D images in assessing the volume of human cadaver kidneys.

A new X-ray calibration/reconstruction system for 3D clinical assessment of spinal deformities

The main objective of this study was to develop a 3D X-ray reconstruction system of the spine and rib cage for an accurate clinical assessment of spinal deformities. The proposed system uses an explicit calibration technique and a new calibration object composed of: (1) a set of radiopaque markers embedded in a jacket worn by the patient during the X-ray exposures; (2) six control markers to define a reference vertical plane. Computer simulations were performed to evaluate the accuracy of the 3D reconstruction procedure when different kind of displacements were applied on a reference model. Clinical indices computed from the 3D X-ray reconstruction of the spine for 24 scoliotic subjects were compared to those obtained with the DLT method. The results of the evaluation study showed that the new system allows the patient to adopt a normal attitude without any constraint, compensating for its displacement between exposures.

Study of patient positioning on a dynamic frame for scoliosis surgery

The goal of this clinical trial was to measure patient geometry on a dynamic positioning frame in various prone positions. Fourteen subjects (2 males and 12 females) were recruited from the scoliosis clinic at Ste-Justine Hospital on a volunteer basis. The subjects were AIS patients who were potential candidates for surgery. The Cobb angle, averaged 50 degrees (32 degrees-64 degrees). The mean age was 14.1 years (11-17). A Polaris system (Northern Digital inc, Canada) with 10 passive reflective markers was used to measure various indices of the patient's trunk geometry. Acquisitions were made while the unanaesthetized patient was in five different prone positions: I similar to the standard positioning on a Relton-Hall frame; II addition of a force applied to the ribcage at the apex of the curve; III application of a force at the apex of the curve in the lumbar region; IV, the shoulder pads were elevated to increase the patient's kyphosis; V adjustment of each pad and the application of thoracic and lumbar forces to obtain an optimal correction. The measurements of trunk geometry at each position were compared using position I as a base. A paired student t-test determined a significant difference between positions. When comparing position I to position II there was a significant difference and correction of the rib hump. There was also a significant change in shoulder angle that resulted in over correction. Position III had a significantly negative change in the rib hump. During position IV, there was a measurable increase in kyphosis. During the optimal correction, position V, a significant increase in spine length was observed as well as a significant correction in rib hump and shoulder angle. Patient trunk geometry can be improved by the application of different forces on a dynamic positioning frame. Caution is necessary as over correction and unintended negative effects were observed. The optimal patient position has not yet been found and future studies are directed at determining this.

Evaluation of the efficiency of patient stabilization devices for 3D X-ray reconstruction of the spine and rib cage

Four devices designed to stabilize the patient's position and/or posture between X-ray exposures were investigated in order to obtain accurate 3-D reconstruction of their spine: a pelvis support, two elbow supports with handlebars, a back neck contact system and a device with three divergent laser beams pointing on subject body targets. Stability and the bearing of natural posture on a group of 10 adults without scoliosis was evaluated for the different devices using a statistical experimental design (Plackett-Burman plan of resolution IV). Small displacements of subjects were obtained by an Optotrak system with 11 infrared diodes placed on the subject's back. Results showed that the elbow supports with handlebars and pelvis support improved the subject's stability while the pelvis support was the device that produces more changes in the subject's natural posture. The elbow and back neck supports were retained for further evaluation.

Effect of estrogen on flow-induced dilation in NO deficiency: role of prostaglandins and EDHF

To investigate the role of estrogen in flow-induced dilation (FiD) in nitric oxide (NO) deficiency, FiD was examined in isolated gracilis arterioles of ovariectomized (OVX) and OVX rats with estrogen replacement (OVE). Both groups of rats were treated chronically with N(omega)-nitro-L-arginine methyl ester. Plasma concentration of NO(2)/NO(3) was reduced in both groups. Plasma concentration of estradiol was lower in OVX than in OVE rats. FiD was similar in vessels of the two groups; calculated wall shear stress and basal tone were significantly greater in OVX vs. OVE rats. Indomethacin did not affect FiD in vessels from OVE rats but abolished dilation in vessels from OVX rats. Valeryl salicylate or NS-398 inhibited FiD by approximately 50%, whereas their simultaneous administration eliminated the response in arterioles from OVX rats. In vessels from OVE rats, miconazole or charybdotoxin eliminated FiD. Thus, in NO deficiency, prostaglandins derived from both cyclooxygenase isoforms mediate FiD in gracilis arterioles of OVX rats. Estrogen replacement switches the mediation, showing dependence on endothelium-derived hyperpolarizing factor in the arterioles of OVE rats.

Pharmacologic inhomogeneity between the reactivity of intramural coronary arteries and arterioles

We hypothesized that because of their size, anatomic location, and hemodynamic function, coronary arteries and arterioles would respond differently to vasoactive substances. Intramural arteries (281.7 +/- 23.1 microm) and arterioles (77.3 +/- 6.6 microm) of the left anterior descending coronary of rats were isolated and cannulated. Spontaneous tone was lower in arteries than in arterioles (81.1 +/- 5.7 vs. 53.0 +/- 3.9% of passive diameter, p < 0.05 at 60 mm Hg intraluminal pressure). Arterial tone was adjusted by the thromboxane receptor agonist U46619 (5 x 10(-8) M ) to reach an active tone close to that of arterioles. Bradykinin elicited dilations in both types of vessels. Acetylcholine (10(-6) - 10(-5) M ) dilated arteries (by 42.6 +/- 11.5 microm) but constricted arterioles (by 16.4 +/- 9.3 microm). Sodium nitroprusside and adenosine elicited significantly greater dilations in arterioles than in arteries (by 7.9 and 11.9%, respectively, p < 0.05), whereas dilations to norepinephrine were similar. Inhibition of nitric oxide synthesis caused a significantly smaller constriction in arteries (10.2 +/- 3.31%) than in arterioles (31.6 +/- 6.9%) and completely blocked bradykinin-and acetylcholine-induced dilations, whereas it did not affect dilations to sodium nitroprusside, adenosine, and norepinephrine. Compared with arteries, arterioles have a greater spontaneous tone and enhanced nitric oxide modulation of basal tone and exhibit greater responsiveness to nitric oxide and adenosine. In addition, nitric oxide synthase is activated differently by pharmacologic stimuli in these segments. The qualitative and quantitative differences among vasoactive responses of coronary arteries and arterioles demonstrated in this study suggest segment-specific roles for endothelial and metabolic factors in regulation of coronary vascular resistance.

Creatine kinase, myosin heavy chains and magnetic resonance imaging after eccentric exercise

The aim of this study was to examine the relationship between myosin heavy chain (MHC) release as a specific marker of slow-twitch muscle fibre breakdown and magnetic resonance imaging (MRI) of skeletal muscle injury after eccentric exercise. The effects of a single series of 70 high-intensity eccentric contractions of the quadriceps femoris muscle group (single leg) on plasma concentrations of creatine kinase and MHC fragments were assessed in 10 young male sport education trainees before and 1 and 4 days after exercise. To visualize muscle injury, MRI of the loaded thigh was performed before and 4 days after the eccentric exercise. All participants recorded an increase (P < 0.05) in creatine kinase after exercise. In five participants, T2 signal intensity was unchanged post-exercise compared with pre-exercise and MHC plasma concentration was normal; however, they showed an increase (P < 0.05) in creatine kinase after exercise. For the remaining five participants, there was an increase in T2 signal intensity of the loaded vastus intermedius and vastus lateralis. These changes in MRI were accompanied by an increase in MHC plasma concentration (P< 0.01) as well as an increase in creatine kinase (P < 0.01). We suggest that changes in MRI T, signal intensity after muscle damage induced by eccentric exercise are closely related to damage to structurally bound contractile filaments of some muscle fibres. Additionally, MHC plasma release indicates that this damage affects not only fast-twitch fibres but also some slow-twitch fibres.

Role of endothelial [Ca2+]i in activation of eNOS in pressurized arterioles by agonists and wall shear stress

In cultured endothelial cells, Ca2+-dependent and -independent activation of nitric oxide (NO) synthesis to agonists and flow/wall shear stress (WSS) has been demonstrated. However, the presence and function of these pathways are less well known in microvessels that can be exposed to a high level of WSS. We hypothesized that the role of changes in endothelial intracellular calcium concentration ([Ca2+]i) is different in agonist- and WSS-induced release of NO. Thus changes in endothelial [Ca2+]i and diameter of intact pressurized (approximately 100 microm at 80 mmHg) gracilis skeletal muscle arterioles of rats were measured by fluorescent videomicroscopy. Acetylcholine (ACh) and increases in WSS (by increasing intraluminal flow) elicited dilations (maximum 91 +/- 2% and 34 +/- 4%) that could be inhibited by N(omega)-nitro-L-arginine methyl ester (L-NAME), a NO synthase blocker. In diameter-clamped arterioles, ACh caused substantial increases in the endothelial calcium fluorescence ratio (ER(Ca), maximum 43 +/- 5%), which was significantly greater than changes in ER(Ca) (maximum approximately 10%) to increases in WSS. The Ca(2+) ionophore A-23187 also substantially increased ER(Ca) (maximum 38 +/- 5%) and elicited significant L-NAME-sensitive arteriolar dilations (maximum 45 +/- 7%). Intraluminal administration of the tyrosine kinase inhibitor genistein had no effect on dilations induced by ACh or the NO donor sodium nitroprusside, whereas it eliminated WSS-induced dilations. Collectively, our data suggest that, in endothelium of skeletal muscle arterioles, NO synthesis is activated by shear stress without a substantial increase in [Ca2+]i, most likely by activation of tyrosine kinase pathways, whereas NO release by ACh and A-23187 is associated with substantial increases in [Ca2+]i.

Mediation of EDHF-induced reduction of smooth muscle [Ca(2+)](i) and arteriolar dilation by K(+) channels, 5,6-EET, and gap junctions

OBJECTIVE

To characterize the role of K(+) channels, the cytochrome P-450 (CYP) metabolite 5,6-EET, and gap junctions in modulation of arteriolar myogenic tone by a non-nitric oxide nonprostaglandin mediator, termed "endothelium-dependent hyperpolarizing factor" (EDHF), released to acetylcholine (ACh) in skeletal muscle arterioles.

METHODS

In isolated rat gracilis arterioles, simultaneous changes in smooth muscle (aSM) [Ca(2+)](i) (assessed by changes in fura-2 ratiometric signal, R(Ca)) and diameter were measured in response to ACh in the presence of indomethacin and L-NAME.

RESULTS

ACh, the K(ATP) channel opener pinacidil, and the Ca(2+) channel inhibitor verapamil elicited comparable decreases in aSM [Ca(2+)](i) (max.: -32 +/- 3%, 29 +/- 3%, and -30 +/- 3%, respectively) and arteriolar dilations (max.: 90 +/- 4%, 96 +/- 2%, and 95 +/- 2%, respectively). ACh-induced responses were inhibited by KCl-depolarization, K(Ca) channel blockers (TEA, charybdotoxin), or gap junction inhibitors (18alpha-glycyrrhetinic acid, hyperosmolar sucrose). The K(ATP) channel inhibitor glibenclamide, the K(IR) channel inhibitor barium chloride, or the CYP inhibitor 17-octadecynoic acid (ODYA) were without effect. The putative EDHF analogue 5,6-EET elicited constrictions in the presence of the endothelium that could be prevented by indomethacin or a TxA(2) receptor antagonist, whereas in the absence of the endothelium, EDHF elicited only small, charybdotoxin-insensitive decreases in aSM R(Ca) and dilations (max.: -8 +/- 2% and 27 +/- 4%, respectively).

CONCLUSIONS

In skeletal muscle arterioles, EDHF 1) substantially and rapidly reduces myogenic tone by decreasing aSM [Ca(2+)](i) via opening K(Ca) channels, 2) it is unlikely to be 5,6-EET or other CYP metabolites, but 3) requires functional gap junctions.

[Methicillin-resistant Staphylococcus aureus (MRSA). Current status and significance of preventing infection in technical orthopedics]

Many patients of the Clinic for Technical Orthopedics and Rehabilitation of the Munster University are facing several risk factors at the same time, which have to be considered for infection registration and therapy accordingly. The interaction of the known late consequences of diabetes mellitus creates the prerequisites which give way for infections of the soft parts and bones. Very often, patients are only being transferred to special university clinics after long-lasting pre-treatments as day-patients or inpatients. The integrity of patients physiological barriers is often broken through by the already existing morphological damages, and the function of the immune systems defence possibly is affected by already existing basic diseases. Parallel to the increasing importance of Staphylococcus aureus (S. aureus) being the pathogen for nosocomial infections, the resistance situation towards a lot of antibiotics has significantly and increasingly deteriorated. The methicillin resistance of S. aureus, i.e. the resistance of the pathogen towards so-called staphylococcus-effective penicillinase-resistant penicillins (isoxazolylpenicillins), is presently creating the especially for the clinical practice problematic resistance mechanisms. The methicillin (oxacillin)-resistant S. aureus (MRSA, ORSA) stems usually present the phenomenon of multiresistance, i.e. the resistance towards substances of several classes of antibiotics, and, therefore, are not only resistant to all beta-lactamantibiotics (penicillins, cephalosporins, carbapenems). Thus, MRSA infections become a significant risk factor for the respective patients. In many cases there are only a very few options left for an antibiotic therapy. The increasing and often unquestioned use of "reserve substances" is leading to a selection of pathogens creating resistances to the corresponding substances. This results in a resistance spiral which makes an antibiotic therapy more and more difficult.

Selected contribution: NO released to flow reduces myogenic tone of skeletal muscle arterioles by decreasing smooth muscle Ca(2+) sensitivity

To clarify the contribution of intracellular Ca(2+) concentration ([Ca(2+)](i))-dependent and -independent signaling mechanisms in arteriolar smooth muscle (aSM) to modulation of arteriolar myogenic tone by nitric oxide (NO), released in response to increases in intraluminal flow from the endothelium, changes in aSM [Ca(2+)](i) and diameter of isolated rat gracilis muscle arterioles (pretreated with indomethacin) were studied by fluorescent videomicroscopy. At an intraluminal pressure of 80 mmHg, [Ca(2+)](i) significantly increased and myogenic tone developed in response to elevations of extracellular Ca(2+) concentration. The Ca(2+) channel inhibitor nimodipine substantially decreased [Ca(2+)](i) and completely inhibited myogenic tone. Dilations to intraluminal flow (that were inhibited by N(omega)-nitro-L-arginine methyl ester) or dilations to the NO donor S-nitroso-N-acetyl-DL-penicillamine (that were inhibited by the guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one) were not accompanied by substantial decreases in aSM [Ca(2+)](i). 8-Bromoguanosine cGMP and the cGMP-specific phosphodiesterase inhibitor zaprinast significantly dilated arterioles yet elicited only minimal decreases in [Ca(2+)](i). Thus flow-induced endothelial release of NO elicits relaxation of arteriolar smooth muscle by a cGMP-dependent decrease of the Ca(2+) sensitivity of the contractile apparatus without substantial changes in the pressure-induced level of [Ca(2+)](i).

EDHF mediates flow-induced dilation in skeletal muscle arterioles of female eNOS-KO mice

Vasodilation to increases in flow was studied in isolated gracilis muscle arterioles of female endothelial nitric oxide synthase (eNOS)-knockout (KO) and female wild-type (WT) mice. Dilation to flow (0-10 microl/min) was similar in the two groups, yet calculated wall shear stress was significantly greater in arterioles of eNOS-KO than in arterioles of WT mice. Indomethacin, which inhibited flow-induced dilation in vessels of WT mice by approximately 40%, did not affect the responses of eNOS-KO mice, whereas miconazole and 6-(2-proparglyoxyphenyl)hexanoic acid (PPOH) abolished the responses. Basal release of epoxyeicosatrienonic acids from arterioles was inhibited by PPOH. Iberiotoxin eliminated flow-induced dilation in arterioles of eNOS-KO mice but had no effect on arterioles of WT mice. In WT mice, neither N(omega)-nitro-L-arginine methyl ester nor miconazole alone affected flow-induced dilation. Combination of both inhibitors inhibited the responses by approximately 50%. 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) alone inhibited flow-induced dilation by approximately 49%. ODQ + indomethacin eliminated the responses. Thus, in arterioles of female WT mice, nitric oxide and prostaglandins mediate flow-induced dilation. When eNOS is inhibited, endothelium-derived hyperpolarizing factor substitutes for nitric oxide. In female eNOS-KO mice, metabolites of cytochrome P-450, via activation of large-conductance Ca2+-activated K+ channels of smooth muscle, mediate entirely the arteriolar dilation to flow.

Gender-specific compensation for the lack of NO in the mediation of flow-induced arteriolar dilation

Flow-induced dilation of gracilis muscle arterioles was examined in both genders of control rats and rats chronically treated with N ω-nitro-l-arginine methyl ester (l-NAME). After l-NAME treatment (4 wk), systolic blood pressure was significantly increased compared with control, whereas the plasma concentration of nitrate/nitrite was significantly reduced. Isolated and pressurized arterioles dilated significantly in response to increases in flow (0–25 μl/min). Flow-induced dilation was comparable in arterioles of control andl-NAME-treated rats but was significantly greater in female than in male rats. l-NAME + indomethacin, which abolished flow-induced dilation in arterioles of male control rats, inhibited the dilation by only ∼75% in female control rats. The residual portion of the response was eliminated by additional administration of miconazole, an inhibitor of cytochrome P-450. Indomethacin did not affect the dilation in femalel-NAME-treated rats but completely inhibited the response in male l-NAME-treated rats. The indomethacin-insensitive, flow-induced dilation in female l-NAME-treated arterioles was abolished by miconazole, 6-(2-proparglyoxyphenyl)hexanoic acid, or charybdotoxin. Thus an augmented release of endothelial prostaglandins accounts for the preserved flow-induced dilation in arterioles of male rats, whereas a metabolite of cytochrome P-450 is responsible for the maintenance of flow-induced dilation in female rats, suggesting important differences in the adaptation of the endothelium of arterioles from male and female rats to the lack of nitric oxide (NO) synthesis.

Homocysteine reduces smooth muscle [Ca2+]i and constrictor responses of isolated arterioles

Chronic elevation of plasma homocysteine concentration has been shown to be associated with impaired vascular function. The acute direct effect of homocysteine on the tone and vasoactive responses of arterioles and the possible underlying mechanisms, however, have not yet been elucidated. Thus arterioles were isolated from gracilis muscle of rats (d: approximately 130 microm) and their diameter was measured by videomicroscopy. Homocysteine (10(-6)-10(-4) M) elicited dose-dependent dilation of arterioles (maximum: 44+/-6% at 10(-4) M). The dilation was not affected by the presence of the nitric oxide synthase inhibitor Nomega-nitro-L-arginine methyl ester or by removal of the endothelium, or the free radical scavenger catalase and superoxide dismutase, or the K+ channel inhibitors glibenclamide, 4-aminopyridine, or tetraethyl ammonium. Incubation of vessels with homocysteine (10(-4) M, 20 min) did not affect dilations to acetylcholine or sodium nitroprusside, whereas it significantly decreased constrictions to norepinephrine (at 10(-6) M; control: 57+/-7%, homocysteine: 21+/-5%) and to the thromboxane A2 analogue U46619 (at 10(-8) M: control: 44+/-3%, homocysteine: 20+/-4%). Homocysteine (10(-4) M), similar to the voltage-operated Ca2+ channel inhibitor nitrendipine (10(-8) M), significantly decreased the arteriolar smooth muscle [Ca2+]i as assessed by changes in the fura-2 ratiometric signal (R(Ca), -6+/-1% and -24+/-3%, respectively). These data suggest that in isolated arterioles homocysteine decreases pressure-induced tone and responses to vasoconstrictor agents, likely by altering Ca2+ signaling of arteriolar smooth muscle.

Endothelial microtubule disruption blocks flow-dependent dilation of arterioles

The cytoskeleton is believed to have an important role in the structural and functional integrity of endothelial cells. The role of the endothelial cytoskeleton, specifically microtubules, in the mediation of flow-induced dilation of arterioles has not yet been studied. Thus the aim of our study was to investigate the role of microtubules in the endothelial mechanotransduction of flow-induced dilation of isolated gracilis arterioles of the rat. The active diameter of arterioles at a constant perfusion pressure (80 mmHg) was approximately 63 microm, whereas their passive diameter (Ca(2+)-free solution) was approximately 119 microm. At a constant pressure, increases in flow of the perfusate solution (from 0 to 10 and from 10 to 20 microl/min) elicited increases in diameter up to approximately 95 microm (approximately a 53% increase). Intraluminal administration of nocodazole at concentrations of 5 x 10(-9) and 5 x 10(-8) M had no discernible effects on the structure of endothelial microtubules or on flow-induced dilation, whereas it disassembled microtubules and eliminated flow-induced dilation at a concentration of 5 x 10(-7) M. At this higher concentration, however, the basal diameter and dilations to acetylcholine (10(-8) M), sodium nitroprusside (10(-7) M), arachidonic acid (5 x 10(-6) M), and prostaglandin E2 (10(-8) M) were unaffected. Colchicine (5 x 10(-7) M) also disassembled microtubules and eliminated flow-induced dilation. We concluded that, in isolated arterioles, the integrity of the endothelial cytoskeleton is essential for the transduction of the shear stress signal that results in the release of endothelial factors evoking dilation.

Reestablishment of foot-stability with external fixation in cases of neurogenic osteoarthropathy

The localization of neurogenic osteopathy in the hindfoot often results in deformities which cannot be corrected by conservative methods. Indications for operation are recurring ulcers, deep infection, and reduced stability with progressive deformity. The aim of this study was to ascertain whether external fixation enables reestablishment of foot stability even when the osteoarthropathic processes have not entirely ceased. A bilaterally mounted Hoffman 2 fixator was used for open repositioning and restabilization on 14 patients with osteoarthropathy of the hindfoot: 12 had diabetes mellitus and 13 had florid processes. Revision with axial correction was necessary in 2 patients. One underwent amputation according to Syme and received a prosthesis. Thirteen were completely remobilized: ten were fitted with an orthosis and three with a rigid orthopedic shoe. Complicated deformities of the hindfoot from neurogenic arthropathy can be satisfactorily restabilized in the edematous and demineralizing stages by surgery and the application of external fixation.

Holt-Oram syndrome. Three case reports and their physiotherapeutic, ergotherapeutic, and technical orthopedic treatment

The combination of organ and skeletal malformation as well as the fact that Holt-Oram syndrome appears in many forms with related functional disturbances and makes it mandatory that the therapy for these patients be determined on an individual basis. Supportive statomotoric therapy of young patients plays a particularly central role, as do development-synchronized treatment aids. Physiotherapy, ergotherapy, and technical orthopedic support oriented toward functionality are all part of the therapeutic concept.

Regular exercise enhances blood pressure lowering effect of acetylcholine by increased contribution of nitric oxide

This study is aimed to test the hypothesis, that short-term daily bouts of exercise alter the endothelial regulation of peripheral vascular resistance by nitric oxide. Rats ran on a treadmill once a day, 5 days a week, for an average of three weeks with gradually increasing intensity (EX), while a control group remained sedentary (SED). Dose dependent reductions in mean arterial blood pressure (resting MABP; SED: 120.0 +/- 3.4 and EX: 127.8 +/- 4.0 mm Hg) of pentobarbital anesthetized rats to intravenous endothelium independent dilator sodium nitropmsside (SNP; 0.6-3.0 microg/kg) were not different in EX and SED animals. In contrast, dose dependent reductions in MABP to endothelium dependent dilator acetylcholine (ACh) were significantly enhanced in EX compared to those in SED rats (at 0.5 and 1.0 microg/kg ACh: 60.3 +/- 2.4 and 66.5 +/- 1.8 vs 52.8 +/- 2.0 and 59.8 +/- 1.7 mmHg, respectively, p<0.01). There was no significant difference in the heart rate (HR) response to ACh and SNP in the two groups of rats. Intravenous administration of 20 mg/kg Nomega-nitro-L-arginine (L-NNA, a nitric oxide synthase inhibitor) elicited a similar increase (approximately 30%) in the MABP in the two groups and eliminated the difference between ACh-induced blood pressure lowering responses in EX and SED rats (at 0.5 and 1.0 microg/kg ACh: 44.6 +/- 4.7 and 56.3 +/- 4.4 vs 50.9 +/- 4.5 and 59.4 +/- 3.6 mm Hg, respectively). Thus, we suggest that the enhanced acetylcholine-induced decrease in systemic blood pressure following regular daily exercise is primarily due to the augmented synthesis of nitric oxide in the endothelium of peripheral vasculature. This change in the function of endothelium could be important in the adaptation of circulation to exercise training.

[Syme amputation in heel defects]

The main advantage of Syme's amputation is the end-bearing stump. A defective heel pad often leads to below-knee amputation. The question of interest is whether an atypical cutaneous flap also provides a covering for the stump adaptable to weight-bearing. Thirteen patients with heel pad ulcers or tumors who could not be attended to with a classic Syme's amputation were operated on in a modified fashion. Skin from the dorsum of the foot or a medial flap was used for covering the stump. Two patients underwent transtibial amputation. The remaining 11 patients received a covering for the end of the stump composed of tissue thick and bulky enough for weight-bearing in a prosthesis typical for a Syme stump. The results show that a transtibial amputation can be prevented by atypical soft-tissue coverage of a Syme stump with satisfactory results regarding function and cosmetics.

[Incidence and detection of nosocomial infections in technical orthopedics]

The significance of nosocomial infections is increasing. The reasons for this are a higher concentration of problematic patients in hospitals due to the increasing number of outpatient surgeries, the increase of invasive therapeutic and diagnostic procedures, the growing share of immunodeficient patients as well as the increase in antibiotic-resistant and multiresistant pathogenic organisms. Basic changes in the medical system call for a systematic discussion about directed quality management. Surveillance, i.e., the systematic registration and evaluation of occurred diseases as well as the feedback to the personnel in charge is very important in this context, particularly when complemented by comprehensive hygienic measures. The growing significance of hospital infections increasingly triggered by multiresistant pathogenic organisms emphasizes the importance of general prevention. Each hospital has to determine which surveillance methods for the registration of nosocomial infections and multiresistant pathogenic organisms are the most appropriate under their respective conditions. To get a first idea of possible problem areas, prevalence studies are very suitable for the start before moving on to well-directed incidence studies in certain wards and for certain kinds of infection.