Tele-rehabilitation for people with dementia in the COVID-19 pandemic: A case-study

Introduction

The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic.

Objectives

This qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges.

Methods

Interviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis.

Results

Video delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources.

Conclusions

The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.

The epidemiology of adolescents living with perinatally acquired HIV: A cross-region global cohort analysis

BACKGROUND

Globally, the population of adolescents living with perinatally acquired HIV (APHs) continues to expand. In this study, we pooled data from observational pediatric HIV cohorts and cohort networks, allowing comparisons of adolescents with perinatally acquired HIV in "real-life" settings across multiple regions. We describe the geographic and temporal characteristics and mortality outcomes of APHs across multiple regions, including South America and the Caribbean, North America, Europe, sub-Saharan Africa, and South and Southeast Asia.

METHODS AND FINDINGS

Through the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER), individual retrospective longitudinal data from 12 cohort networks were pooled. All children infected with HIV who entered care before age 10 years, were not known to have horizontally acquired HIV, and were followed up beyond age 10 years were included in this analysis conducted from May 2016 to January 2017. Our primary analysis describes patient and treatment characteristics of APHs at key time points, including first HIV-associated clinic visit, antiretroviral therapy (ART) start, age 10 years, and last visit, and compares these characteristics by geographic region, country income group (CIG), and birth period. Our secondary analysis describes mortality, transfer out, and lost to follow-up (LTFU) as outcomes at age 15 years, using competing risk analysis. Among the 38,187 APHs included, 51% were female, 79% were from sub-Saharan Africa and 65% lived in low-income countries. APHs from 51 countries were included (Europe: 14 countries and 3,054 APHs; North America: 1 country and 1,032 APHs; South America and the Caribbean: 4 countries and 903 APHs; South and Southeast Asia: 7 countries and 2,902 APHs; sub-Saharan Africa, 25 countries and 30,296 APHs). Observation started as early as 1982 in Europe and 1996 in sub-Saharan Africa, and continued until at least 2014 in all regions. The median (interquartile range [IQR]) duration of adolescent follow-up was 3.1 (1.5-5.2) years for the total cohort and 6.4 (3.6-8.0) years in Europe, 3.7 (2.0-5.4) years in North America, 2.5 (1.2-4.4) years in South and Southeast Asia, 5.0 (2.7-7.5) years in South America and the Caribbean, and 2.1 (0.9-3.8) years in sub-Saharan Africa. Median (IQR) age at first visit differed substantially by region, ranging from 0.7 (0.3-2.1) years in North America to 7.1 (5.3-8.6) years in sub-Saharan Africa. The median age at ART start varied from 0.9 (0.4-2.6) years in North America to 7.9 (6.0-9.3) years in sub-Saharan Africa. The cumulative incidence estimates (95% confidence interval [CI]) at age 15 years for mortality, transfers out, and LTFU for all APHs were 2.6% (2.4%-2.8%), 15.6% (15.1%-16.0%), and 11.3% (10.9%-11.8%), respectively. Mortality was lowest in Europe (0.8% [0.5%-1.1%]) and highest in South America and the Caribbean (4.4% [3.1%-6.1%]). However, LTFU was lowest in South America and the Caribbean (4.8% [3.4%-6.7%]) and highest in sub-Saharan Africa (13.2% [12.6%-13.7%]). Study limitations include the high LTFU rate in sub-Saharan Africa, which could have affected the comparison of mortality across regions; inclusion of data only for APHs receiving ART from some countries; and unavailability of data from high-burden countries such as Nigeria.

CONCLUSION

To our knowledge, our study represents the largest multiregional epidemiological analysis of APHs. Despite probable under-ascertained mortality, mortality in APHs remains substantially higher in sub-Saharan Africa, South and Southeast Asia, and South America and the Caribbean than in Europe. Collaborations such as CIPHER enable us to monitor current global temporal trends in outcomes over time to inform appropriate policy responses.

Die Indikation zur subfaszialen endoskopischen Perforantensanierung hat sich geändert

Ziel: Über die Entwicklung der Indikation zur subfaszialen endoskopischen Perforantensanierung (SEPS) am medialen Unterschenkel zu berichten. Methode: Der Bericht basiert auf den Erfahrungen, Publikationen und Workshops der 1993 gegründeten und von der Deutschen und Schweizerischen Gesellschaft für Phlebologie unterstützten Arbeitsgemeinschaft für Fasziotomie und Endoskopie (AFE), in Kontakt mit der internationalen, hauptsächlich US-amerikanischen Forschung. Ergebnisse: Seit der Einführung der SEPS sind einige Änderungen im ihrem Umfeld eingetreten. Diese haben die Indikationsstellung zur SEPS beeinflusst: Die unbeschränkt wiederholbare nicht invasive Duplexsonographie erlaubt die exakte unmittelbar präoperative Lokalisation und Markierung der insuffizienten Perforanten. Deshalb können diese Perforanten beim Fehlen schwerer trophischer Störungen, statt mit der SEPS, von einem kleinen über der Perforante liegenden Hautschnitt aus zuverlässig saniert werden. Auch wissen wir inzwischen sicherer, dass viele insuffiziente Perforanten nach der Stripping-Operation von selbst wieder suffizient werden. Zudem ist bei der Indikationsstellung die hohe Rezidivrate nach der SEPS und der Lernprozess in Rechnung zu stellen. Schlussfolgerung: Das Aufkommen der Duplexsonographie und die erwähnten neuen Erkenntnisse lassen die SEPS heute weniger häufig angezeigt und die Indikation zur SEPS klarer erscheinen. Die SEPS bleibt ein wertvolles Instrument in der phlebologischen Therapie.

Der aktuelle Stand der Magnakrossenrezidiv-Forschung

Ziel: Neue Untersuchungen zeigen, dass trotz korrekter Krossektomie in bis zu einem Viertel der Fälle klinisch relevante Krossenrezidive vorkommen. Was ist der Grund? Können auch sie verhindert oder zumindest vermindert werden? Mit diesen Fragen beschäftigt sich die Krossenrezidivforschung. Der folgende Überblick soll über ihren heutigen Stand orientieren. Methode: Als Grundlagen dienen das Studium der Literatur und eigene Beobachtungen. Ergebnisse: Die bisherige Forschung spricht dafür, dass die Neoangiogenese eine wichtige Ursache und die chronische Veneninsuffizienz ein wichtiger Risikofaktor für diese Rezidive ist. Monotubuläre Rezidive scheinen häufiger zu klinischer Relevanz zu führen als konvolut – oder strangförmige. – Die praktische Erprobung von Maßnahmen zur Krossenrezidivprophylaxe ist angelaufen. Ihre Resultate lassen hoffen, sind jedoch noch nicht schlüssig. Schlussfolgerung: Dass wir jetzt wissen, dass Krossenrezidive auch nach korrekter Krossektomie vorkommen, bedeutet (noch?) nicht, dass man sie deswegen aufgeben soll. Hingegen ist nach dem gegenwärtigen Wissensstand gut beraten, wer gegenüber technischen Innovationen und den Alternativen zur Krossektomie offen bleibt.

Das Krosserezidiv – eine Nachkontrolle nach 34 Jahren

Ziel: Erfassung der Langzeit-Rezidivrate der Krossektomie der Vena saphena magna. Methode: anamnestische, inspektorische und farbduplexsonographische Nachkontrolle von 125 Fällen im Mittel 34 Jahre nach der Krossektomie. Ergebnis: Die klinisch-inspektorische Untersuchung ergab 47% Krosserezidive, doch farbduplexsonographisch war die Rezidivrate mit 60% wesentlich höher. 42,4% waren echte Rezidive genau aus der alten Ligaturstelle, und zwar waren sie in 17,6% strang- oder knäuelförmig und in 24,8% handelte es sich um eine einläufige Varize. Die übrigen 17,6% waren Pseudorezidive aus der Umgebung der alten Magnaligatur. Schlußfolgerung: Diese Langzeitverlaufskontrollstudie bestätigt die in der Literatur beschriebenen Daten über Krosserezidive. Mit Farbduplexsonographie werden Krosserezidive häufiger erfaßt als bei der klinischen Untersuchung. Eine Krossektomierezidivrate nach einer Verlaufszeit von 34 Jahren wurde unseres Wissens bisher noch nicht publiziert. Die Resultate können als Basis dienen für die anlaufende Forschung über die Ursachen und die Verhinderung der Rezidive nach korrekter Krossektomie.

Improving participation outcomes and interventions in neurodisability: co-designing future research

There is an urgent, agreed need to improve participation outcomes and interventions for children and young people with neurodisability. We worked together with service users and providers to design research into participation outcomes and interventions in neurodisability. We built on existing evidence about participation outcomes and interventions and the WHO International Classification of Functioning, Disability and Health. We: (1) specified seven participation outcome categories for measurement; (2) prioritized these for improvement: self-care, friends and social, and physical activity ranked the highest; (3) identified 11 potential intervention categories for targeting the top priority, self-care, through eight hypothesized change mechanisms and agreed for the interventions to be delivered as a 'Menu of Interventions' for personalized self-care support; and (4) designed a before-and-after mixed methods feasibility study to evaluate the Menu with children and young people (0-12 years) and their parents and therapists.

The Manchester short splint: A change to splinting practice in the rehabilitation of zone II flexor tendon repairs

Introduction

The results of patients with primary zone II flexor tendon repairs rehabilitated using a traditional forearm-based splint were audited and compared with those who were managed in the Manchester short splint.

Method

The short splint was fabricated to permit maximal wrist flexion and up to 45° of wrist extension with a block to 30° of metacarpophalangeal joint extension. A rehabilitation regimen consisting of early combined passive flexion exercises and active motion was employed. In 2011, 62 patients (76 digits) with a mean age of 34 years (range 14–58) were rehabilitated using the forearm-based splint (group A). In 2012, 40 patients (45 digits) with a mean age of 31 years (range 15–71) were rehabilitated using the Manchester short splint (group B).

Results

Group B had significantly less flexion contracture at their proximal interphalangeal joints than group A at 6 weeks (median 15° versus 28°; p = 0.003) and 12 weeks (median 6° versus 18°; p = 0.024) postoperatively. At the final review, group B had a significantly greater arc of flexion at their distal interphalangeal joints (median 59° versus 30°; p < 0.001) and a greater proportion of patients with excellent/good Strickland’s grades. There were three (3.9%) ruptures in group A and two (4.4%) ruptures in group B (p > 0.999).

Conclusion

The use of a shorter splint would appear to enhance the outcomes whilst preserving repair integrity.

P450c17 deficiency: clinical and molecular characterization of six patients

CONTEXT

The characteristics of P450c17 deficiency include 46,XY disorder of sex development, hypertension, hypokalemia, and lack of pubertal development.

OBJECTIVE

To better understand this rare enzymatic deficiency, we analyzed the CYP17A1 gene in six affected patients.

DESIGN AND PATIENTS

We examined six patients, five 46,XY, and one 46,XX (age 9-29 yr) with complete lack of masculinization (female infantile external genitalia, no uterus) and delayed puberty, respectively, and different degrees of hypertension.

MAIN OUTCOME MEASUREMENTS

Genotype-phenotype correlation was measured.

RESULTS

Four homozygote mutations were identified by direct sequencing of the CYP17A1 gene corresponding to an alanin 302-proline (A302P) exchange; the loss of lysine 327 (K327del); the deletion of glutamate 331 (E331del); and the replacement of arginine 416 with a histidine (R416H). Both P450c17 activities were abolished in all the mutant proteins, except one, when expressed in COS1 cells. The E331del-mutated P450c17 retained 17alpha-hydroxylase activity. The mutant proteins were normally expressed, suggesting that the loss of enzymatic activity is not due to defects of synthesis, stability, or localization of P450c17 proteins.

CONCLUSION

These studies confirm lack of masculinization in 46,XY individuals as the pathognomic sign of the complete P450c17 deficiency. In XX individuals P450c17 deficiency should be considered in cases of delayed puberty. Age of onset and the severity of hypertension do not seem to be constant. Careful examination of long-term follow-ups in two of our patients suggested to us that estrogen treatment in P450c17-deficient patients might worsen the enzymatic defect, leading to aggravation of the hypertension.

The role of the Lumina intense pulsed light system in the treatment of port wine stains—a case controlled study

The pulsed dye laser has been the treatment of choice for port wine stains over the past 20 years. In the past 5 years there has been increasing discussion of the role of other light treatments, such as the intense pulsed light system in the treatment of port wine stains. These systems use high-energy lamps, which emit noncoherent broad-spectrum light. Cut off filters are applied depending on the treatment modality to limit the wavelengths emitted. We present the results of a 3-year prospective within patient controlled clinical trial using an intense pulsed light system called the Lumina, developed by Lynton Lasers of Cheshire, England. Our aims and objectives were to assess the effectiveness of the system in the treatment of port wine stains in a human model and to record the optimum treatment parameters and the incidence of side effects. Following ethical approval 12 subjects were enrolled into the trial. In order to meet the requirements of the local ethics committee these were all adults with port wine stains located in less visible areas of the body. The results showed that eight of the 12 subjects had some degree of fading of their port wine stain as measured on a percentage scoring system. Of the four who failed to show any response, all had pink port wine stains. It did seem the case that the darker the port wine stain, the better the fading seen. Furthermore, the more distal lesions tended to be less responsive than those situated closer to the head area. However, it is difficult to draw any definitive statistical conclusions due to the small number of patients in the trial.

Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein

OBJECTIVE

This study was done to determine the long-term incidence of refluxing epifascial-to-deep vein reconnections in the area of the former saphenofemoral junction after ligation of the true junction, along with all proximal tributaries, and resection of the greater saphenous vein.

PATIENTS AND METHODS

A total of 125 limbs in 77 patients, representing 66% of 117 survivors among 602 patients who underwent operation between 1960 and 1967, were evaluated clinically and with duplex sonography for possible superficial-to-deep vein reconnections and clinical recurrence of thigh varicosities at a mean follow-up of 34 years.

RESULTS

Clinical examination suggested saphenofemoral recurrence in 59 limbs (47%). In 11 instances these were actually varices associated with isolated superficial system reflux or reflux originating from a distally located perforating vein. Color-coded duplex ultrasonography demonstrated saphenofemoral reflux in 75 limbs (60%), versus the 48 identified on clinical examination (P <.001), and documented that the junction ligation had not been performed incorrectly by absence of the terminal valve or any patent proximal saphenous remnant. The reflux originated at the site of the ligated saphenofemoral junction in 53 limbs (71%) and from a nearby circumjunctional deep vein in the other 22 (29%). Of the real junctional recurrences, 22 appeared as a tangled cluster, and 31 involved a single-lumen varix. Only 27 recurrences were sufficiently symptomatic to warrant consideration of additional treatment; 25 of these were clinically evident, single-lumen, true junctional recurrences.

CONCLUSIONS

This 34-year clinical follow-up study shows a 60% incidence of junctional and circumjunctional reconnections after ligation of the true saphenofemoral junction and its related tributaries. Color-coded duplex sonography is a necessary concomitant to clinical examination, detecting more recurrences and defining the pathologic anatomy to direct clinically indicated additional treatments.

Exploring the risks associated with induction of labour: a retrospective study using the NIMATS database. Northern Ireland Maternity System

Induction of labour is a valuable obstetric procedure, providing obstetricians with the means to intervene should the health of the fetus be in jeopardy. Currently the most common reason for induction of labour is prolonged pregnancy, as obstetricians and midwives are concerned about the risks of postmaturity such as stillbirth, intrapartum asphyxia and birth trauma which are often associated with prolonged pregnancy (Lagrew & Freeman 1986). A retrospective comparative study was carried out in a large maternity unit to identify whether or not there was clinical evidence to support a policy of elective induction for post-term pregnancy. Three years' data were extracted from the Northern Ireland Maternity System (NIMATS) by writing new queries to the system. These data on 3262 women who delivered during 1994-96 were analysed to compare the outcomes for women who were induced with women who delivered spontaneously. Although the findings from the study in many instances failed to demonstrate statistical significance between the groups they did however, have important clinical significance. For example, those women who were induced had a 5% higher rate of caesarean section, 17% higher rate of epidural analgesia and on average a greater estimated blood loss. Statistical significance was evident when the apgar scores of the infants were compared; those induced had lower Apgars at 1 minute (7. 78 in the induced group compared to 7.9 in the spontaneous group [P < 0.01]) and at 5 min (8.99 in the induced group compared to 9.05 in the spontaneous group [P < 0.02]).

Arthroscopic partial meniscectomy: a 12-year follow-up and two-step evaluation of the long-term course

The long-term results after arthroscopic partial meniscectomy of 119 patients with a mean follow-up of 12 years are presented in this study. The same series of patients had an earlier follow-up 4 years postoperatively. Thus, an evaluation of the actual long-term course and not only a single result after partial meniscectomy is presented. Arthroscopic partial meniscectomy is shown to be the definitive means of therapy for meniscal lesion of the knee joint; 91.7% of patients had an excellent or good result 4 years after surgery, and 78.1% rated excellent or good 12 years after surgery. Full recovery regarding ability to work and sports activity level was achieved in a very high percentage of patients. Early results were mostly representative and did not change significantly during the long-term course for the isolated meniscal lesion. The factor with the highest impact on long-term results was damage to the articular cartilage, which did not influence knee function for several years after surgery but became increasingly symptomatic over time after 5 years and more. Only 62% of patients with additional cartilage damage rated excellent and good 12 years after surgery, in contrast with 94.8% good and excellent results in patients with isolated meniscal tears. Similar observations were made for the untreated rupture of the anterior cruciate ligament.

The human mitochondrial elongation factor tu (EF-Tu) gene: cDNA sequence, genomic localization, genomic structure, and identification of a pseudogene

The human mitochondrial elongation factor Tu (EF-Tu) is nuclear-encoded and functions in the translational apparatus of mitochondria. The complete human EF-Tu cDNA sequence of 1677 base pairs (bp) with a 101 bp 5'-untranslated region, a 1368 bp coding region, and a 207 bp 3'-untranslated region, has been determined and updated. The predicted protein from this cDNA sequence is approximately 49.8 kDa in size and is composed of 455 amino acids (aa) with a putative N-terminal mitochondrial leader sequence of approximately 50 aa residues. The predicted amino acid sequence shows high similarity to other EF-Tu protein sequences from ox, yeast, and bacteria, and also shows limited similarity to human cystolic elongation factor 1 alpha. The complete size of this cDNA (1677 bp) obtained by cloning and sequencing was confirmed by Northern blot analysis, which showed a single transcript (mRNA) of approximately 1.7 kb in human liver. The genomic structure of this EF-Tu gene has been determined for the first time. This gene contains nine introns with a predicted size of approximately 3.6 kilobases (kb) and has been mapped to chromosome 16p11.2. In addition, an intronless pseudogene of approximately 1.7 kb with 92.6% nucleotide sequence similarity to the EF-Tu gene has also been identified and mapped to chromosome 17q11.2.

Chromosomal localization of the human liver form cytochrome c oxidase subunit VIIa gene

The chromosomal loci corresponding to human cytochrome c oxidase (COX) subunit VIIa Liver (VIIa-L) isoform genes were determined utilizing a combined approach of genomic cloning, in situ hybridization, and somatic hybrid genetics. In contrast to the proposal of E. Arnaudo et al. (Gene (Amst.), 119: 299-305, 1992) that COX VIIa-L sequences are located on chromosomes 4 and 14, we found that COX VIIa-L related sequences reside on chromosome 6, while an additional COX VIIa-L cross-reacting sequence psi-gene) was located on chromosome 4.

Cloning, characterization, and chromosomal localization of human liver form cytochrome c oxidase subunit VIa related genes

The chromosomal location of human cytochrome c oxidase (COX) subunit VIa Liver (VIa-L) isoform related sequences has been determined by a combination of in situ hybridization and analysis of human-hamster somatic cell hybrid panels. COX VIa-L related sequences were present on chromosomes 6 and 12. It has been verified that at least two COX VIa-L genes are on chromosome 6, one of which is a pseudogene. In total, four COX VIa-L related sequences have been cloned and their nucleotide sequences analyzed. At least three of the sequences represent pseudogenes; their relatedness to the COX VIa-L cDNA is discussed.

Condensation of plasmid DNA with polylysine improves liposome-mediated gene transfer into established and primary muscle cells

Cationic liposomes provide a means to introduce genes into cells both ex vivo and in vivo. In the past few years their use has been described in several tissues, e.g. lungs, liver, endothelium, brain. In this study we evaluated a commercially available poly-cationic liposome formulation in delivering a reporter gene into cultured myogenic cell lines from mouse and rat, and primary fetal human myoblasts. We also examined the effect of serum on liposome-mediated transfection and designed a new procedure to enhance transfection efficiency, based on the pre-condensation of plasmid DNA with polylysine. Polylysine pre-condensation was particularly effective when transfecting the cells in the presence of serum, a finding that could be significant for in vivo transfections.

Angioplasty balloon catheters used for distraction of the ankle joint

Arthroscopy of the ankle joint is now routinely performed in diagnostic and therapeutic interventions but is still a demanding and difficult operative procedure in this very small and tight joint. Arthroscopy can be facilitated by a sufficient distraction that gives a better overview of the joint space. However, it is still a matter of debate how to obtain the adequate distraction. Distention by manual strength as well as by the help of a technical device have been proposed. We report our experience with distraction of the ankle joint by the help of one or two intraarticularily located and secondarily insufflated angioplasty balloon catheters that are routinely used in interventional radiology. These special catheters allow a careful and controlled distention of the joint with a fixed space of distraction and, according to our limited experience, without any morbidity.

Protein-tyrosine phosphatase SH-PTP2 (PTPN11) is localized to 12q24.1-24.3

A 2.1-kb cDNA probe encoding the human SH2-domain containing protein-tyrosine phosphatase SH-PTP2 (PTPN11) was hybridized to human metaphase chromosomes in three independent experiments. In each instance, hybridization was maximal to chromosome 12q24.1-q24.3. The presence of SH-PTP2 cDNA crosshybridizing sequences located on a number of other chromosomes suggested that SH-PTP2-related genes or pseudogenes are present in the human genome.

Education and audit can improve the identification of excessive drinkers among medical inpatients

This study investigated the effect of education and audit on the identification and management of medical inpatients with excessive alcohol consumptions by use of a cross-sectional survey of medical and nursing notes, compared with historical controls. We report the proportion of medical and nursing notes containing qualitative and quantitative drinking histories, the use of the CAGE questionnaire, and notification of alcohol consumption in discharge summaries. A total of 1,979 out of 2,680 (74%) notes of eligible patients were examined. The number of medical notes containing quantitative alcohol histories rose from 175/792 (22%) among historical controls, to 242/690 (35%) after training of junior medical and nursing staff, and to 241/497 (48%) after feedback of results in a clinical audit meeting. The number of medical notes with no recorded alcohol history changed from 309/792 (39%) to 287/690 (42%) to 152/497 (31%), respectively (chi 2 for trend = 97.2, p < 0.0001). The number of nursing notes containing quantified alcohol histories rose from 31/792 (4%) among historical controls, to 123/690 (18%) after training, and to 237/497 (48%) after feedback of results in a clinical audit meeting. The number of nursing notes with no recorded alcohol history fell from 309/792 (90%), to 512/690 (74%), to 205/497 (41%) respectively (chi 2 for trend = 353.7, p < 0.0001). The proportion of patients found to be drinking excessively rose from 40/792 (5.1%) to 57/690 (8.3%) to 45/497 (9.1%) (chi 2 for trend = 8.25, p = 0.004). There was little worthwhile improvement in use of the CAGE questionnaire and in discharge summaries. Education and audit are effective ways of improving the identification of excessive drinkers by both junior doctors and nurses alike. Other aspects of management are less responsive.

[Combination of surgical therapy and interventional radiology in a recurrent myxoid liposarcoma with a 37-year history]

Extreme long-term survivals of low grade liposarcomas are rare. The authors present a case of a 75 year old man with a 37 year history of recurrent myxoid liposarcoma. The tumor dynamics are obviously related to the histology subtype. The clinical and radiological findings of the sixth tumor recurrence are discussed. The combination therapy of surgical tumor reduction and interventional radiology with implantation of endovascular prostheses for iliaco-femoral vein compression due to tumor recurrence is described.

[How often does an aneurysm of the popliteal artery rupture?]

Rupture of a popliteal artery aneurysm is an unusual complication and did occur six times in our series of 252 popliteal artery aneurysms that underwent operative repair from January 1965 to December 1991. Rupture while equally serious as thrombosis of the popliteal artery aneurysm of distal embolization from the aneurysm, is reported as an exceedingly unusual complication. Reported incidence of rupture is less than 2 to 4 percent in most large series and was 2.4 percent in the present series.

[Rupture of the patellar ligament of the tibial tuberosity as a complication after cruciate ligament-plasty]

We report a complication of a rupture of the patellar ligament at the tibial tuberositas following autologous cruciate ligament reconstruction. To our knowledge, this complication has not yet been described.

Mapping of the human NMDA receptor subunit (NMDAR1) and the proposed NMDA receptor glutamate-binding subunit (NMDARA1) to chromosomes 9q34.3 and chromosome 8, respectively

A role for the N-methyl-D-aspartate (NMDA) receptor in the molecular pathology underlying Huntington disease (HD) has been proposed on the basis of neurochemical studies in HD and the ability of the NMDA receptor to mediate neuronal cell death. The molecular cloning of the human NMDA receptor subunit (NMDAR1) and a proposed glutamate-binding subunit of the NMDA receptor (NMDARA1) have provided an opportunity to test the hypothesis that either of these genes might be directly involved in the causation of HD. We have mapped NMDAR1 to 9q34.3 using in situ hybridization studies and NMDARA1 to human chromosome 8 using a somatic cell hybrid panel. Because the gene causing HD has been localized to chromosome 4p16.3, the chromosome assignments reported here are inconsistent with either of these genes playing a causative role in the molecular pathology of HD. However, it is noteworthy that the gene for torsion dystonia has also been localized by genetic studies to 9q34.3, the same regional map location as NMDAR1.

[Arthroscopy of the shoulder joint. Technique, indications, surgery and complications]

Diagnostic and operative arthroscopy of the shoulder joint has gained considerable importance in traumatology and orthopedic surgery over the last years. Injuries of the limbus glenoidalis, in particular traumatic shoulder luxation, injuries of the rotator cuff, infection of the glenohumeral joint and unclear posttraumatic pain are indications for diagnostic and operative arthroscopy. Arthroscopy of the shoulder is a procedure, which offers exact diagnosis and the possibility of immediate surgery at the same time. The technique of the shoulder joint arthroscopy has to be carried out carefully and according to a standard protocol. The complication rate of around 5% of shoulder arthroscopy has not to be neglected.

[Proximo-distal course of the diameter of the great saphenous vein and distribution of the number of side branches as an inherent difficulty in infra-inguinal arterial in situ bypass]

The greater saphenous vein is still the best material for infrainguinal arterial bypasses, particularly if they have an infrapopliteal distal anastomosis. Although a lot of advantages have been presumed for the in-situ bypass, the reported results are not significantly better than with the reversed technique. To find some additional explanations, we studied post mortem the anatomy of 20 greater saphenous veins with regard to the diameter and the number of side branches and compared the results with 10 phlebographies. A minimal diameter (2.6 mm) and a maximum of side branches and venous valves were found at the proximal calf. Furthermore, this region was characterized by a lot of anatomic variants such as double systems (25%) or cross over variants (5%). These findings are surgically relevant and may reduce the bypass patency: 1. There is an increased hemodynamic resistance in longer bypasses, 2. The small diameter (particularly if smaller than 2 mm) means a risk for the patency of the distal anastomosis, 3. The high frequency of side branches requires a comparable exposition of the GSV as for the reversed technique, 4. The introduction of the valvulotomy from distally may overestimate the proximal diameter and underestimate the frequency of variants and may therefore cause significant endothelial damages or even perforation.

[Osteosynthesis of subcapital humerus fracture with unconventionally applied implants]

The osteosynthesis of proximal humerus fractures with the commonly used plates is often critical because of the small space subacromial, the irritation of the blood supply by the broad plates and the poor proximal anchorage without angle stability. The osteosynthesis with a children hip plate or a angle plate like modified DC-plate is thought to be a reliable alternative.

[Severe necrotizing fasciitis]

The pathophysiology of necrotizing fasciitis remains unclear in patients with no apparent immunologic disorders. Between 1987 and 1990 we treated six patients with necrotizing fascitis and septic-toxic multiple organ failure, three patients survived. The mean age was 38 years (25-62). In all patients the primary bacteriological examination revealed streptococcus. Between the first symptoms and an adequate therapy were 4 days in surviving patients and 7 days in patients who died. Four patients showed spread of the gangrene into the adjacent tissue: muscles (n = 3), bowel (n = 2), mediastinum (n = 1). Adequate débridement was not possible or not performed in patients with spread into the abdominal cavity or the mediastinum. These patients did not survive. The duration of intensive care treatment in surviving patients were 14 to 78 days. We conclude that survival of patients with severe necrotizing fasciitis is influenced by the delay before adequate treatment, the localisation of the gangrene and intensive care facilities.

Polymorphisms and deduced amino acid substitutions in the coding sequence of the ryanodine receptor (RYR1) gene in individuals with malignant hyperthermia

Twenty-one polymorphic sequence variants of the RYR1 gene, including 13 restriction fragment length polymorphisms (RFLPs), were identified by sequence analysis of human ryanodine receptor (RYR1) cDNAs from three individuals predisposed to malignant hyperthermia (MH). All RFLPs were detectable in PCR-amplified products, and their segregation was consistent with our initial finding of linkage to MH in the nine families previously informative for one or more intragenic markers (MacLennan et al., 1990, Nature 343:559-561). Four amino acid substitutions were identified in the study: Arg for Gly248, Cys for Arg470, Leu for Pro1785, and Cys for Gly2059. Of 45 families tested, a single family presented the Arg for Gly248 substitution where it segregated with malignant hyperthermia, making it a candidate mutation for predisposition to MH in man. The other three polymorphic substitutions failed to segregate with malignant hyperthermia in those families in which they occurred, implying that they represent polymorphisms with little or no effect on the function of the RYR1 gene.

Emergency room patients with abdominal pain unrelated to trauma: prospective analysis in a surgical university hospital

During an 8-month-period, 241 patients suffering from abdominal pain unrelated to trauma (mean age 48 years) attended the emergency room of the Department of Surgery of the University Hospital, Zürich. Forty-three percent presented during working hours, while 57% were admitted during the night or at the weekend. Clinical examination, abdominal roentgenograms (upright and supine) and sonography were the most commonly used diagnostic tools. Forty percent suffered from abdominal pain of unknown origin. The most common diagnosis on admission was appendicitis, but only half of these cases proved to be appendicitis. In 36% the diagnosis on admission corresponded both to the initial diagnosis made by a member of staff during his first visit, and to the final diagnosis. The initial diagnosis agreed with the final diagnosis in 57%. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostic evaluation are less important than the clinical evaluation. The decision between operative and nonoperative treatment was based mainly on clinical findings.

[Emergency hospitalization for acute, non-accidental abdominal pain. Prospective data of a surgical university clinic]

During a 19-month period 549 patients (278 women, 271 men) suffering from abdominal pain unrelated to trauma (mean age 48.2 years) entered the emergency room of the Department of Surgery of the University Hospital Zürich. 43% presented during business hours, whereas 57% were admitted during nighttime and/or weekends. Clinical examination, abdominal roentgenograms (upright and supine) as well as sonography were the most commonly used diagnostic tools. 40% suffered from abdominal pain of unknown cause. The most common diagnosis on admission was appendicitis. Only half of these cases really proved to be an appendicitis. In 36% the diagnosis on admission corresponds both to the initial diagnosis made by a member of staff during his first visit, as well as to the final diagnosis. The initial diagnosis agrees in 57% with the final diagnosis. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostics are less important than the clinical evaluation. The decision between operative or nonoperative treatment was mainly based on clinical findings.

[False aneurysm in a vascular surgery patient population]

40 false aneurysms have been diagnosed at the University Hospital in Zürich during the last three years. These aneurysms are mainly (24) anastomotic aneurysms with synthetic arterial substitutes. 6 false aneurysms were found after arterial catheterization. The majority of these 40 aneurysms (60%) were localized in vicinity of joints. The time interval between the original procedure (anastomosis, arterial catheterization, trauma) and the diagnosis of false aneurysm varies from a few days to 21 years. In seven cases a endarterectomy preceded the development of a false aneurysm. Three therapeutic groups are presented.

Ryanodine receptor gene is a candidate for predisposition to malignant hyperthermia

Malignant hyperthermia (MH) is a potentially lethal condition in which sustained muscle contracture, with attendant hypercatabolic reactions and elevation in body temperature, are triggered by commonly used inhalational anaesthetics and skeletal muscle relaxants. In humans, the trait is usually inherited in an autosomal dominant fashion, but in halothane-sensitive pigs with a similar phenotype, inheritance of the disease is autosomal recessive or co-dominant. A simple and accurate non-invasive test for the gene is not available and predisposition to the disease is currently determined through a halothane- and/or caffeine-induced contracture test on a skeletal muscle biopsy. Because Ca2+ is the chief regulator of muscle contraction and metabolism, the primary defect in MH is believed to lie in Ca2+ regulation. Indeed, several studies indicate a defect in the Ca2+ release channel of the sarcoplasmic reticulum, making it a prime candidate for the altered gene product in predisposed individuals. We have recently cloned complementary DNA and genomic DNA encoding the human ryanodine receptor (the Ca2(+)-release channel of the sarcoplasmic reticulum) and mapped the ryanodine receptor gene (RYR) to region q13.1 of human chromosome 19 (ref. 14), in close proximity to genetic markers that have been shown to map near the MH susceptibility locus in humans and the halothane-sensitive gene in pigs. As a more definitive test of whether the RYR gene is a candidate gene for the human MH phenotype, we have carried out a linkage study with MH families to determine whether the MH phenotype segregates with chromosome 19q markers, including markers in the RYR gene. Co-segregation of MH with RYR markers, resulting in a lod score of 4.20 at a linkage distance of zero centimorgans, indicates that MH is likely to be caused by mutations in the RYR gene.

Gene inactivation as a mechanism for the expression of recessive phenotypes

A series of Chinese hamster ovary cell hybrids were constructed which were heterozygous at the emtB and chr loci. These loci encode two recessive drug-resistance genes (emetine resistance and chromate resistance, respectively) located on a structurally hemizygous region on the long arm of chromosome 2. These heterozygous hybrids therefore exhibit wild-type sensitivity to both emetine and chromate. Drug-resistant variants were then selected in medium containing either emetine or chromate, and the mechanism of reexpression of the recessive drug-resistant allele was determined by karyotypic analysis of the resultant colonies. In previous studies at these loci we have determined that segregation of the recessive phenotype occurs primarily by (1) the loss of the chromosome 2 carrying the wild-type, drug-sensitive, allele, (2) deletion of the long arm of chromosome 2, or (3) loss of one chromosome 2 followed by duplication of the remaining homologue. However, a small proportion of segregants have also been detected which may have arisen by the mechanisms of de novo gene inactivation or mutation. In this report, hybrids are described which were constructed to allow selection for the retention of the chromosome carrying the wild-type allele and which therefore optimize isolation of these rare segregants. We demonstrate by karyotypic analysis, mutation frequency analysis, and microcell-mediated chromosome transfer that these rare segregants occur primarily by gene inactivation. We also demonstrate a dramatic increase in the proportion of segregants occurring by gene inactivation in two of these hybrids as compared with those previously reported, indicating that this mechanism may be an important mode of phenotype segregation in diploid cells and, therefore, in the development of cancers--such as the childhood tumors retinoblastoma and Wilms tumor--resulting from recessive alleles

[Surgery of retroperitoneal pheochromocytoma]

Retroperitoneal pheochromocytomas are very uncommon tumors. During the last 10 years only 3 cases have been operated on in our clinic. Two of them were primary retroperitoneal paragangliomas. These two patients are now well and without recurrence 1 and 10 years respectively after operation. The third patient had retroperitoneal metastases of an adrenal pheochromocytoma. Now, after 1 year he has disseminated metastases without response to therapy with (131I)metaiodobenzylguanidine (MIBG). The surgical procedure includes often extended resection and replacement of retroperitoneal blood vessels and requires therefore an experienced surgical team and optimal anesthetic management (Swan-Ganz-katheter). In two cases the aorta was resected and replaced with a Dacron-graft. Reimplantation of both renal arteries into the graft was necessary in one case. Further interventions were: nephrectomy (2x), resection and ligation of the inferior vena cava (1x), resection and replacement of the left renal vein (1x).