Freies Endothel des Magna-Krossenstumpfes und Neoreflux/Neoangiogenese

Ziel: Die Existenz eines postoperativ inguinalen Neorefluxes (iNR) bzw. einer Neoangiogense (NA) nach korrekter V.-saphena-magna-Krossektomie wird von vielen anerkannt. Als eine Ursache wird das Endothel des Krossenstumpfes gesehen. Die Frage wird jetzt überprüft, ob es durch eine Reduktion der Menge an freiem Stumpfendothel zu einer Verringerung der Rate an postoperativem iNR/NA kommen kann. Patienten, Methode: In einer prospektiven Studie wurde 65 Beine (55 Patienten) untersucht. In allen Fällen wurde nach korrekter Magna-Krossektomie (Farbduplexkontrolle) der Stumpf bewusst lang gelassen (ca. 2 cm) mit dem Ziel, dass das freie Stumpfendothel nicht nach außen zum Subkutangewebe gerichtet war sondern miteinander verkleben konnte. Nach neun Monaten erfolgte eine erneute Duplexkontrolle mit der Frage, ob sich ein inguinaler Neoreflux entwickelt hatte. Dieses Ergebnis wurde mit anderen Studien zur NA-Protektion verglichen. Ergebnisse: In drei Fällen (5%) konnte ein refluxtragender Venenast mit Ursprung aus der V. femoralis entdeckt werden (Durchmesser 1,0-2,6 mm). Unsere einfache Technik mit Reduktion der Menge an freiem Endothel ergibt eine Rate an postoperativer iNR/NA, die vergleichbar ist mit Literaturdaten (1-14%). Schlussfolgerung: Die Wirksamkeit unserer Technik unterstützt einmal mehr die Hypothese der Neoangiogenese. Dieses kleine Detail in der Operationstechnik mag zudem erklären, warum manche Chirurgen das Phänomen der Neoangiogenese nicht zu sehen scheinen. Wenn sie schon immer ihren Stumpf etwas länger gelassen haben, dann haben sie unbewusst eine Neoangiogenese-Protektion durchgeführt.

Acute myeloid leukemia derived from lympho-myeloid clonal hematopoiesis

We studied acute myeloid leukemia (AML) patients with lympho-myeloid clonal hematopoiesis (LM-CH), defined by the presence of DNA methyltransferase 3A (DNMT3A) mutations in both the myeloid and lymphoid T-cell compartment. Diagnostic, complete remission (CR) and relapse samples were sequenced for 34 leukemia-related genes in 171 DNMT3A mutated adult AML patients. AML with LM-CH was found in 40 patients (23%) and was associated with clonal hematopoiesis of indeterminate potential years before AML, older age, secondary AML and more frequent MDS-type co-mutations (TET2, RUNX1 and EZH2). In 82% of AML patients with LM-CH, the preleukemic clone was refractory to chemotherapy and was the founding clone for relapse. Both LM-CH and non-LM-CH MRD-positive AML patients who achieved CR had a high risk of relapse after 10 years (75% and 75%, respectively) compared with patients without clonal hematopoiesis in CR with negative MRD (27% relapse rate). Long-term survival of patients with LM-CH was only seen after allogeneic hematopoietic stem cell transplantation (HSCT). We define AML patients with LM-CH as a distinct high-risk group of AML patients that can be identified at diagnosis through mutation analysis in T cells and should be considered for HSCT.

Monitoring children's health and well-being by indicators and index: apples and oranges or fruit salad?

The use of indicators is a fast and widely spread way to monitor groups of children's health and well-being. Indicators are useful in research; but they are also important tools for planners and politicians. Although they are constructed to simplify reality, in many reports they still offer a complex and confusing picture, not least by their sheer numbers. Although they are constructed to simplify reality, in many reports, they still offer a complex and confusing picture, not least by their sheer numbers. Therefore, there is an increasing demand for even further simplifications, where the indicators are combined into single summary numbers, composite indices. At the same time, as a composite index summarizes a complex and sometimes elusive process, making it more accessible for advocacy and political interventions, the combining of very dissimilar components makes the results difficult to interpret and use. There is an obvious dilemma between the need for rigour and evidence, the research orientation, and the wish for a simple and summarizing overview of the findings, the policy orientation. Models have been created to form indicator sets, either by combining them by simple addition or by weighting them or by just leaving them as separate indicators. Most index systems in operation use an equal weighting system after standardization, once the components have been selected. Examples of these models are described as well as their pros and cons, and a summary of suitable ways of handling the problems of indicators and composite indices is offered. Some surveys have taken the best from different approaches, presenting the results as a summary index for the great picture, as subindices for the various domains of child health and as separate indicators for the detailed study of the basic components. A Swedish Child Health Index is presented as an example of such a solution.

Transportation of a radioactive ion beam for precise laser-trapping experiments

Francium is the heaviest species among the alkali elements. Due to its properties, francium is said to be of advantage in measurements of tiny observations, such as atomic parity violation and electric dipole moment. Before executing experiments with francium, it must be produced artificially because it is one of the most unstable elements. We produced francium with the nuclear fusion reaction of an oxygen beam and gold target, ionized the produced francium through a thermal ionization process, and extracted the ion with electrostatic fields. However, the thermal ionization process is known to ionize not only an objective atom but also other atomic species. Therefore, a Wien filter was installed to analyze the composition of the ion beam and purify the beam. This allowed us to improve the beam purity from ∼10(-6) to ∼10(-3).

[Sports Activity Following Joint Arthroplasty: Experiences and Expectations of Elderly Patients--Findings from a Qualitative Content Analysis of Guided Interviews]

OBJECTIVE

The study investigated specific motives and barriers of sports activities in elderly patients with hip or knee arthroplasty.

METHODS

We conducted guided interviews and analysed them by content analysis.

RESULTS

7 women and 8 men were interviewed. In total, we coded 520 passages; on average 34.7 (SD=11.1) per interview. Our findings document severe preoperative handicaps and identified a variety of sports activities which were practiced before treatment. The most emphasized motive was the social function of sports. The main barriers were the self-definition as a sick and elderly person and insecurity and concerns over the course of illness and healing. Very constraining advises on sports activities without consideration of the individual experience in sports were not perceived as helpful.

CONCLUSION

Counselling on sports activities following joint replacement needs to consider individual motives, barriers and previous sports experience in order to be perceived as supportive.

[The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: a retrospective analysis of 1972 cases]

BACKGROUND

Dislocation is the second most frequently encountered complication in primary total hip arthroplasty (THA) and occurs more commonly in the early postoperative rehabilitation phase. Sir Charnley recommended the "avoidance of resection of the capsule" and emphasised its contribution to hip joint stability in THA. Several authors, however, doubted its significance and considered resection of the capsule to be essential. Since 2002, some surgeons increasingly adopted a modified, less invasive technique of THA via Bauer approach, including the preservation and repair of the hip joint capsule with focus on maintaining its acetabular origin. Another group of surgeons applied the traditional technique including the resection of the joint capsule via an anterolateral approach. In this case-control study we investigated whether the dislocation rate can be reduced through joint capsule reconstruction and whether any negative impact on patient satisfaction, functional results or revision rate is observed.

MATERIAL AND METHODS

All cases of primary THA performed in our institution in a timeframe between 2002 and 2009 were included with the only exceptions of resurfacing arthroplasty, dual mobility and tumour hip replacements. Joint capsule repair cases were gathered in the study group (SG), capsule resection cases in the control group (CG). Additional patient-related data were taken from the anaesthesia records. The WOMAC score and a questionnaire focusing on detection of dislocations and revision surgeries was sent out for each case. Further targeted research was conducted that included requesting records and reports from external hospitals. In the case of non-responding patients, all available data (operating room documentation, electronic files, archive, X-rays) were reviewed for incidents of dislocation and revision surgery. Groupings and classifications were exclusively performed by senior surgeons. SG and CG were compared regarding epidemiologic, implant-associated and surgery-specific data. Statistical evaluations were performed using the Chi-squared test and the Mann-Whitney U test.

RESULTS

1972 cases of primary THA were included: 992 in the SG and 980 in the CG. The follow-up rates were 92.7 % in the SG and 76.4 % in the CG, the mean follow-up times 33.5 months and 73.4 months, respectively, with a follow-up of at least 12 months in all cases. In the SG, the dislocation rate was 0.3 % (n = 3) and thus significantly lower than the 2.55 % in the CG (n = 25, p < 0.001). Both the WOMAC score (SG: 1.46 ± 1.73; CG: 1.53 ± 1.80; p > 0.05) and the revision rate (SG: 5.24 %; CG: 6.84 %; p = 0.139) showed no significant differences.

CONCLUSION

Preservation and repair of the hip joint capsule causes an 88-%-reduction of the dislocation rate in primary THA in this large series including 1972 cases, operated via the Bauer or the anterolateral approach. Several authors reported comparable results after THA using similar techniques of soft tissue and capsular repair through the posterior or posterolateral approach. Sparing and reconstructing the hip joint capsule therefore seems to reduce the dislocation rate after primary THA by one order of magnitude regardless of the surgical approach and, especially, if the acetabular origin is preserved. Capsule-related specific complications such as an increased revision rate, malfunction or pain were neither recorded in our study nor by others. Thus, careful preservation and reconstruction of the hip joint capsule may be expressly recommended in primary THA.

[Evidence-based recommendations for the management of undifferentiated peripheral inflammatory arthritis (UPIA). The German perspective on the international 3e initiative]

INTRODUCTION

Peripheral arthritis is the most common presenting complaint in clinical rheumatology. Unequivocal identification of the underlying entity can be difficult, particularly at an early stage. Such cases are commonly referred to as undifferentiated peripheral inflammatory arthritis (UPIA). Since evidence-based recommendations for the clinical management of UPIA are lacking, this international 3e initiative convened 697 rheumatologists from 17 countries to develop appropriate recommendations.

METHODS

Based on a systematic literature research in Medline, EMBASE, Cochrane Library, and the ACR/EULAR abstracts of 2007/2008, 10 multinational recommendations were developed by 3 rounds of a Delphi process. In Germany, a national group of experts worked on 3 additional recommendations using the same method. The recommendations were discussed among the members of the 3e initiative and the degree of consensus was analyzed as well as the potential impact of the recommendations on clinical practice.

RESULTS

A total of 39,756 references were identified, of which 250 were systematically reviewed for the development of 10 multinational recommendations concerning differential diagnosis, diagnostic and prognostic value of clinical assessments, laboratory tests and imaging techniques, and monitoring of UPIA. In addition, 3 national recommendations on the diagnostic and prognostic value of a response to anti-inflammatory therapy on the analysis of synovial fluid and on enthesitis were developed by the German experts based on 35 out of 5542 references.

CONCLUSIONS

The article translates the 2011 published original paper of the international 3e initiative (Machado et al., Ann Rheum Dis 70:15-24, 2011) and reports the methods and results of the national vote and the additional 3 national recommendations.

[Primary Prevention of Impairments of Mobility Among Nursing Home Residents with Dementia]

The main aim of the study was to investigate the effectiveness of multidisciplinary guidelines in promoting the mobility of people with dementia in 20 German nursing homes. The study was based on a semi-experimental design [pre-post design with intervention (IG) and control group]. The statistical analyses revealed a significantly slower decline of the ability to walk among the residents of the IG than among the controls. With regard to other outcome measures the results were less clear.

Suitability of biocompost as a bedding material for stabled horses: respiratory hygiene and management practicalities

REASONS FOR PERFORMING STUDY

Bedding material in stables has an important influence on air hygiene and information on the suitability of biocompost and wood shavings is incomplete.

OBJECTIVES

To compare the suitability and benefit of biocompost and wood shavings as bedding in horse stables and to determine key air factors for the evaluation of the potential impact of these materials on respiratory health.

METHODS

The study was conducted in a naturally ventilated stable with 4 horses. Air hygiene parameters were measured 24 h/day for 7 days with each bedding type: ammonia (NH3), inhalable and respirable dust, endotoxins, colony forming units (CFU) of total mesophilic bacteria, fungi, actinomycetes and thermophilic actinomycetes. Both bedding materials were analysed for general chemical composition, particle size distribution and natural microbial content. The animals' behaviour was monitored by video cameras, and their health and cleanliness status determined by clinical and visual examination.

RESULTS

Concentrations of NH3, dust, endoxins and fungi were significantly higher during the monitoring period with wood shavings than with biocompost. In contrast concentrations of mesophilic bacteria, mesophilic actinomycetes and thermophilic actinomycetes microbial pollutants were highest with biocompost. The water content of bulk biocompost was considerably higher than that of wood shavings. Particles < or = 0.4 mm were not detectable in bulk wood shavings. The concentration of thermophilic actinomycetes by weight in raw biocompost was 639 times higher than in raw wood shavings. No significant differences were observed in the time spent by the horses lying down. The biocompost material tended to adhere more intensively to the animals' hair coat. Horses showed no clinical signs indicating any adverse effects of the biocompost material during the trials.

CONCLUSIONS

Biocompost cannot be recommended as bedding material for horses in stables, because the concentration of thermophilic actinomycetes and other agents that elicit and maintain recurrent airway obstructions was significantly higher with biocompost than with wood shavings. To ensure the well-being of horses, any new bedding material must be tested very carefully before it is introduced to the market.

Initial oxidation of the Rh(110) surface: Ordered adsorption and surface oxide structures

The initial oxidation of the Rh(110) surface was studied by scanning tunneling microscopy, core level spectroscopy, and density functional theory. The experiments were carried out exposing the Rh(110) surface to molecular or atomic oxygen at temperatures in the 500-700 K range. In molecular oxygen ambient, the oxidation terminates at oxygen coverage close to a monolayer with the formation of alternating islands of the (10x2) one-dimensional surface oxide and (2x1)p2mg adsorption phases. The use of atomic oxygen facilitates further oxidation until a structure with a c(2x4) periodicity develops. The experimental and theoretical results reveal that the c(2x4) structure is a "surface oxide" very similar to the hexagonal O-Rh-O trilayer structures formed on the Rh(111) and Rh(100) substrates. Some of the experimentally found adsorption phases appear unstable in the phase diagram predicted by thermodynamics, which might reflect kinetic hindrance. The structural details, core level spectra, and stability of the surface oxides formed on the three basal planes are compared with those of the bulk RhO2 and Rh2O3.

Health, economy and social capital in Nordic children and their families: a comparison between 1984 and 1996

OBJECTIVE

The aim of the study was to analyse the development in the health of children that occurred in the five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) between 1984 and 1996 and relate it to the changes in economic growth and social capital in these countries during the same period.

METHODS

Two cross-sectional studies covered a representative sample of children, aged 2-17 years in each country, a total of 10,291 in 1984 and 10,317 in 1996. The data were collected by mailed questionnaires. Statistical associations between a health indicator (the absence of psychosomatic complaints), economic indicators (social class, housing and disposable income) and social capital indicators (parents' and children's organized group activities, parents playing with their children and the absence of bullying) within samples and between corresponding values in different samples across subgroups (defined by country and area of residence) were evaluated using multiple linear regression.

RESULTS

In both surveys, there was a statistically highly significant association between the health indicator and the social capital indicators, whereas the economy indicators were not related to either of the other two types of measure. Change in health was associated positively with change in social capital and negatively with change in economy.

CONCLUSION

The study provides strong support for the concept of social capital as an important determinant of children's health.

Children's use of general practitioner services in the five Nordic countries

OBJECTIVE

To compare socioeconomic, sociodemographic, and living area differences in children's use of GP services in five Nordic countries from the 1980s to the 1990s and to analyse trends during the period.

DESIGN

Cross sectional population surveys using random samples comprising 3000 children aged 2-17 years were conducted in 1984 and 1996 in five Nordic countries. Time trends in use of GP services were studied in each country by age, sex, parents' highest level of education, and living area.

SETTING

Five Nordic countries, Denmark, Finland, Iceland, Norway, and Sweden in 1984 and 1996.

PARTICIPANTS

A total sample of 15 000 children aged 2-17 years. Altogether 3000 children were selected at random from the national population registers of the national bureaus of statistics in each country.

MAIN OUTCOME

Health services utilisation on the basis of responses to a questionnaire item asking whether the parents had consulted a GP with regard to their children's health during the previous three months.

MAIN RESULTS

The prevalence of children's utilisation of GP services varied from 14% in 1984 in Sweden to 28% in 1996 in Iceland. A clear time trend towards increasing utilisation of GP services (p<0.05) was found in all countries except in Denmark. Odds ratios for time trends (1984 = 1.00) varied from 1.22 (1.02 to 1.46) in Sweden to 1.92 (1.62 to 2.30) in Norway. After adjusting for independent variables, a statistically borderline significant declining utilisation trend (OR = 0.85 (0.70 to 1.03)) was found for Denmark.

CONCLUSION

Children's use of GP services has increased significantly in four of the five Nordic countries.

Parental reported bullying among Nordic children: a population-based study

BACKGROUND

Bullying has been shown to be a serious problem amongst school children, but few studies have been population-based and included pre-school children.

METHODS

The study is part of a cross-sectional comparative study in 1984 and 1996, focusing on children's and their families' health and welfare in the Nordic countries. At each point of time parents of 3000 randomly selected children aged 2-17 years in each of five Nordic countries received a postal questionnaire. Altogether approximately 20,000 questionnaires were completed. The prevalence of bullying, risk factors for bullying and possible effect factors were analysed.

RESULTS

Parents reported bullying of their child in 15.1% of the cases. Bullying varied from 7.2% in Sweden to about 20% in Denmark and Finland. There was a small increase in bullying from 13.7% in 1984 to 16.4% in 1996. Bullying was most frequent in boys (OR: 1.4) and in children 2-6 and 7-12 years old (OR: 2.0 and 2.2 compared with older children). Children of single parents and of parents with low education had increased risks (OR: 1.4 and 1.4). Children with chronic conditions had higher risks for being bullied (OR: 2.3). In 1996 children with psychiatric/nervous problems and hyperactivity had high risks for being bullied (OR: 8.8 and 10.5) and for bullying others (3.9 and 3.5). Being bullied was associated with poor thriving and psychosomatic and psychological problems. No countries had national interventions before 1984, but Sweden had early focused on the problem and implemented a strong national policy before 1996. After 1996 national anti-bullying policies were strengthened in the Nordic countries, most in Sweden and Norway.

CONCLUSION

Bullying is common among Nordic children, including pre-school children. Bullying is a threat to children's health, and augments problems in children with chronic conditions. The low prevalence of bullying in Sweden may be a result from sustained, strong anti-bullying policies. There is still a need for continuing interventions.

High-coverage oxygen structures on Rh111: adsorbate repulsion and site preference is not enough

A new O induced structure on Rh(111) displaying a (2 sqaureroot[3] x 2sqaureroot[3])R30 degrees periodicity with an oxygen coverage of 2/3 has been studied by high resolution core level spectroscopy, scanning tunneling microscopy, and density functional theory. Although O favors fcc hollow sites in all other known phases, it occupies both fcc and hcp sites in this structure, which cannot be explained by pairwise adsorbate repulsion only. Both the (2sqaureroot[3] x 2sqaureroot[3])R30 degrees and (2 x 2)-3O structures also exemplify that density-of-states contrast can lead to oxygen adatoms appearing as protrusions in scanning tunneling microscopy images.

Self-limited growth of a thin oxide layer on Rh(111)

The oxidation of the Rh(111) surface at oxygen pressures from 10(-10) mbar to 0.5 bar and temperatures between 300 and 900 K has been studied on the atomic scale using a multimethod approach of experimental and theoretical techniques. Oxidation starts at the steps, resulting in a trilayer O-Rh-O surface oxide which, although not thermodynamically stable, prevents further oxidation at intermediate pressures. A thick corundum like Rh2O3 bulk oxide is formed only at significantly higher pressures and temperatures.

Indicators of children's development: considerations when constructing a set of national Child Health Indicators for the European Union

BACKGROUND

In a recent project, commissioned by the European Union, a set of Child Health Indicators were identified and recommended for use in all Member States. In that work, by a group of European experts, children's development was one of the key areas that were reviewed to clarify its role in this set of indicators. This paper deals with neurological (in a broad sense), social and moral aspects of development; other aspects, such as nutrition and physical growth, mental health, quality of life were dealt with in other areas.

METHODS

A number of methods are used to monitor children's neurodevelopment, to identify early deviations that could be treated or alleviated. Few tests fulfil basic criteria of screening and quality of evidence. For Child Health Programmes, developmental surveillance is instead recommended. As a proxy to social development, as part of children's process of adaptation into society, education indicators are recommended, such as suggested by OECD and UNICEF. Moral development is discarded as an indicator, because norms and values vary too much between countries.

CONCLUSION

For now the Child Health Indicators of Life and Development Project found no ground to recommend any particular method or combination of methods for a general monitoring of children's neurological, intellectual, language and moral development, and for including the results as national indicators of children's health and well-being in EU. For social development, indicators in the educational area seem most promising, as they have been proposed and used by OECD and UNESCO. In an ambitious monitoring programme, these indicators could be included as determinants of children's health and development.

ESSOP--25 years: personal reflections from one who started the European Society for Social Paediatrics

ESSOP--the European Society for Social Paediatrics--was initiated in Lund, Sweden in 1977, and at the annual congress in Spetses, Greece, its 25th anniversary was celebrated. At the congress, Professor Lennart Köhler, who started the organization and for 10 years was its first Secretary General, presented his recollections from the life of ESSOP, its people, activities, strategies and ideologies, and the main lines of development over the years. This paper presents an edited version of his speech for the benefit of the readers of Child: Care, Health and Development.

Organisation der Schmerztherapie in der Chirurgie

An acute pain service done by surgeons is one possibility for organizing pain therapy in surgical wards. To do this successfully, some preconditions must be kept in mind, such as 24-h presence, an integrated system of documentation, and teamwork between medical and nursing staff. Comparison of differently structured pain therapy in three different hospitals (with and without acute pain service) showed high levels of patient satisfaction with the pain therapies in all three hospitals. One of the preconditions for effective pain therapy in surgery is to formulate a concept which takes into account the specific situation of each hospital.

Port function after laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited.

METHODS

In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years.

RESULTS

Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one).

CONCLUSION

The high number of complications suggests that the port is the Achilles' heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

[Percutaneous endoscopic gastrostomy (PEG). Course, nutrition and care in 233 consecutive patients]

AIM

To evaluate the course, nutrition and care of PEG tubes on the basis of data collected from 233 consecutive patients.

PATIENTS AND METHOD

Between 1.1.1990 and 31.3.1996, a total of 243 PEG tubes were implanted in 233 patients--56.5% male and 43.5% female--with an average age of 66.2 years. 57.3% had neurological, and 19.4% neurosurgical, diseases, 11.2% suffered polytraumatization or severe burns, and 8.2% had a malignancy. Patients stayed with the implanted tube on average 153 days, with neurological patients leading the field at 189 days.

RESULTS

The overall complication rate was 14.5%, with the most common complication being local infection, which occurred in 5.4% of the cases. Severe complications were seen in 1.2%. One patient developed a necrotizing fasciltis, and in two others, migration of the tube was observed. 52.2% of the patients died with the tube still in place. In 33.6%, the PEG tube was removed after a mean of 82.7 days, when adequate oral nutrition again became possible.

CONCLUSION

In this study, PEG proved an effective method for enteral nutrition over the middle-to-long-term in multimorbid and intensive care patients, as well as in those with malignant disease.

Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology

In rheumatology and other medical specialties there is a discrepancy between the widespread use and the imprecise designation of glucocorticoid treatment regimens. Verbal descriptions of glucocorticoid treatment regimens used in various phases of diseases vary between countries and institutions. Given this background, a workshop under the auspices of the EULAR Standing Committee on International Clinical Studies including Therapeutic Trials was held to discuss this issue and to seek a consensus on nomenclature for glucocorticoid treatment. This report summarises the panel's discussion and recognises that answers derived from consensus conferences are not definitive. Nevertheless, recommendations on glucocorticoid treatment are presented that (1) reflect current and best knowledge available and (2) take into account current clinical practice. A question-answer rationale presentation style has been chosen to convey the messages, to summarise the meeting in a readable format, and to avoid dogmatism.

[New aspects of bacteriological pathogen diagnosis in rheumatic diseases]

Microbiological diagnosis for rheumatic diseases is increasingly used as part of the diagnostic work-up in rheumatological practice due to growing knowledge about bacteria-induced rheumatic diseases. This review's focus lies on rheumatic diseases, which in contrast to septic-infectious arthritis, are characterized by the inability to culture bacteria from the inflammed joint. These reactive arthritides occur after primary extraarticular bacterial infection. The etiological diagnosis of reactive arthritis is based on the detection of a previous or ongoing bacterial infection. Diagnosis is performed by serology or direct detection of the bacterial organism or parts thereof at the site of entry and recently by molecularbiology-based detection of the bacteria in the inflamed joint. This review reflects the current diagnostic approaches and formulates diagnostic algorithms for specific and well-directed microbiological diagnosis.

A rare complication of laparoscopic adjustable gastric banding

The most common complications of laparoscopic gastric banding (LGB) are band dislocation, port problems, and leakage in the band system. We present a case of an aneurysmal dilatation of the balloon portion of the band by filling as a rare complication of LGB. A 53-year-old male patient with morbid obesity (body mass index 40 kg/m2) was treated with LGB (adjustable Bioenterics gastric band). Six months after the operation there was no evidence of weight reduction. X-ray examination showed the band to be in the correct position. The port punction revealed no spontaneous fluid loss. The contrast filling of band demonstrated no signs of leakage but there was an abnormal dilatation of one part of the balloon. Only one filling segment of balloon was dilatated and the rest was empty. Two and a half years after the initial operation, we carried out laparoscopic band exchange. Six weeks later, the band was adjusted with 2 ml saline, and the patient reported successful reduction of food volume. He had lost 18 kg 3 months postoperatively. We conclude that band function requires careful intraoperative monitoring. In patients who do not lose weight after gastric restriction surgery, uncommon complications must also be considered.

Evaluation of amplicor chlamydia PCR and LCX chlamydia LCR to detect Chlamydia trachomatis in synovial fluid

OBJECTIVES

PCR has been successfully used in research for the detection of C. trachomatis DNA in synovial samples. However, each research laboratory has developed its own PCR, making inter-laboratory comparisons difficult. To allow for standardization we evaluated two commercially available amplification systems originally designed for the examination of urogenital samples (Roche Amplicor Chlamydia PCR and Abbott LCX Chlamydia LCR), using them to analyse spiked and clinical synovial fluid (SF) samples from reactive arthritis (ReA), undifferentiated arthritis (UA), and rheumatoid arthritis (RA) patients. We compared their sensitivity in assays of clinical SF samples with our in-house developed C. trachomatis specific nested PCR.

METHODS

SF was spiked with purified C. trachomatis elementary bodies (EB) and analyzed by the commercial assays. Clinical SF samplesfrom ReA (n=21), UA (n=79) and RA (n=50) patients were examined by the two commercial assays and our in-house PCR.

RESULTS

Using SF samples spiked with defined numbers of C. trachomatis EB, the sensitivity of the commercial tests was high and similar to published PCR sensitivity. In clinical SF specimens the commercial assays was also able to detect CT; however, the in-house PCR was more sensitive. Out of 10 PCR-positive SF samples Amplicor tested positive in only 4/10 and LCX in only 3/10. The in-house PCR detected chlamydial DNA in synovialfluidfrom 5/21 ReA (24%), 5/79 UA (6%) and in none of the 50 RA patients.

CONCLUSION

Commercial amplification assays allow the detection of C. trachomatis in clinical specimens, although with a lower sensitivity than optimized PCR. Potential explanations are discussed.

Socioeconomic differences in children's use of physician services in the Nordic countries

OBJECTIVE

To assess the relation between socioeconomic factors and the use of physician services among children and whether variations of the level of co-payment are correlated with different levels of inequalities in health services use.

DESIGN

Description of the socioeconomic differences in the use of health care using data from countrywide postal surveys to parents.

SETTING

The five Nordic countries in 1996.

SUBJECTS

Samples of 15 000 children aged 2-17 years: 3000 children at random, from the national registry in each country.

MAIN OUTCOME MEASURE

Odds ratios of use of GP, specialist, and hospital services between children according to the educational level of both parents and the disposable income of the family, for all countries together and for each country separately. Odds ratios were adjusted for age, sex, urbanisation grade, and health status.

RESULTS

There was little difference in the use of GP services according to socioeconomic factors. Parents from lower socioeconomic groups used telephone services of physicians less than parents from the higher groups and children of lower socioeconomic groups were seen less often by specialists. The reverse was true for hospitalisation of the children. The differential use of those three types of services was more marked in Denmark, Finland and Norway than in Iceland and Sweden. When controlled for other socioeconomic factors, the largest differences were observed according to the education of the mother.

CONCLUSION

The specialist services and use of telephone services for children in the Nordic countries do not meet the criteria of equal use for equal need whereas the GP services and hospital services do to some extent. The education of the mother is a more important determinant than income for the use of each service.

Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum

BACKGROUND

Within a 5-year period, 380 rectal carcinoma patients undergoing laparoscopic abdominoperineal excision or laparoscopic anterior resection were recruited to a multicenter study by 23 institutions in Germany and Austria. This study was initiated by the Laparoscopic Colorectal Surgery Study Group.

RESULTS

One hundred forty-nine patients (39.2%) underwent abdominoperineal resection (APR), and 231 patients (60.8%) were treated by anterior resection (AR). The mean operating time was 208 min, and the conversion rate was 6.1%. Intraoperative complications, mostly vascular or bowel injuries, were observed in 22 patients (5.8%). Overall, a total of 257 postoperative complications and problems occurred in 143 patients, resulting in a morbidity rate of 37.6%. In the AR group, the anastomotic leakage rate increased as the distance of the tumor from the anal verge decreased. The perioperative mortality rate was low (6/1.6%). Most of the patients received a high transsection of the inferior mesenteric artery with radical lymph node dissection (342/90.0%); the mean number of recovered lymph nodes was 13.0, with considerable variation among the individual institutions. Intraoperative tumor cell spillage was reported in 12 patients (3.2%). Sufficient follow-up findings are available for 288 (77%) patients. To date, 19 patients have sustained a local recurrence (6.6%), and 30 (10.4%) have developed distant metastases. Within the (admittedly limited) mean follow-up of 24.8 months, the overall survival rate is 86.6%, the disease-free survival (freedom from both local recurrence and distant metastases) rate is 62.4% for APR, with the corresponding rates for AR being 71.7 and 54.8%, respectively, as established by the Kaplan-Meier function. These data show no alarmingly high recurrence rates at this time.

CONCLUSION

In principle, laparoscopic anterior resection with curative intent generates considerably more reservations than laparoscopic abdominoperineal resection, which is technically much easier to perform.

Quality of life among children aged 2-17 years in the five Nordic countries. Comparison between 1984 and 1996

BACKGROUND

The aim of the study was to analyse children's quality of life (QoL) in the five Nordic countries from 1984 to 1996, a period in which major economic recessions occurred.

METHODS

The study design was cross-sectional based on a random sample of 3000 children in each country, aged 2 to 17 years, totalling 15,000 in 1984 and 15,000 in 1996. The data were collected by mailed questionnaires. QoL was analysed for three spheres of life: external, interpersonal, personal including both factual and perceived variables. The external sphere represented the socio-economic conditions for the child's family, the interpersonal sphere the structure and the function of the child's social networks and the personal sphere the psychological well-being of the child.

RESULTS

The total QoL for Nordic children from 1984 to 1996 increased, but there were differences in the development of QoL between the countries. The objective QoL became better, at the same time the subjective QoL worsened, except in Denmark and Iceland. The external QoL became better, whereas the interpersonal QoL was nearly unchanged but there were differences in the development between countries. The personal QoL worsened slightly except for children in Iceland. The ranking between countries changed. Danish children had the highest subjective and Norwegian children the highest objective and external QoL. Swedish children had the highest personal QoL. Children 7-12 years had the highest QoL. Girls had a tendency to higher QoL in all ages.

CONCLUSION

Nordic children still enjoy a high standard of living in spite of economic constraints, and the prerequisites for a high QoL are fulfilled. Further research is suggested for clarifying the complex background of these results.