Prevention of major venous thromboembolism following total hip or knee replacement: a randomized comparison of low-molecular-weight heparin with unfractionated heparin (ECHOS Trial).

AIM: Venous thromboembolism remains a frequent complication after total hip or knee replacement surgery despite routine prophylaxis. However, the ability of pharmacologic thromboprophylaxis to prevent major venous thromboembolism, defined as proximal deep vein thrombosis, and/or pulmonary embolism, and/or death, has not been previously validated. METHODS: In a double-blind randomized study, 2018 patients, undergoing either total hip or knee replacement surgery, were allocated to receive subcutaneous preoperative reviparin (4,200 anti Xa IU) once daily or 7,500 IU unfractionated heparin twice daily, for a minimum of 11 days. The primary efficacy outcome was major venous thromboembolism, defined as the composite of venographically confirmed proximal deep vein thrombosis, and/or symptomatic pulmonary embolism and death, recorded up to day 14. RESULTS: The primary efficacy outcome was assessed in 1,628 patients and demonstrated a significant reduction in the reviparin group (3.4% [28 of 813 patients] compared with unfractionated heparin (5.5% [45 of 815]) (odds ratio, 0.61; 95% confidence interval, 0.38 to 0.99, P=0.04) by day 11 to 14. A significant reduction in venous thromboembolism was maintained up to 6-8 weeks (3.4% [28 of 813 reviparin patients] versus 5.6% [46 of 815 unfractionated heparin patients]) (odds ratio, 0.6; 95% confidence interval, 0.37 to 0.97, P=0.03). Major bleeding events occurred in 9 reviparin-treated patients (0.9%) and in 12 unfractionated heparin-treated patients (1.2%). CONCLUSIONS: Prophylaxis with reviparin significantly reduces the risk of major venous thromboembolism compared with unfractionated heparin in patients undergoing elective hip or knee replacement without increasing the risk of bleeding.

[High temperature "matè" infusion drinking in a population at risk for squamous cell carcinoma of the esophagus]. / Mate (chimarrão) é consumido em alta temperatura por população sob risco para o carcinoma epidermóide de esôfago.

UNLABELLED: "Matè", a popular hot infusion of a herb (Ilex paraguayensis) drunk in large volumes, is a known risk factor for squamous cell carcinoma of the esophagus and there is a suspicion that high temperature of boiled water used for the infusion may contribute for carcinogenesis. METHODS: We measured the temperature of "matè" infusion drunk by a sample of the population at risk for this carcinoma in Taquara, southern Brazil. We interviewed inhabitants for drinking habits and the temperature of the infusion was measured with high precision thermometers. Temperature of the infusion was asked to consumers and their estimate compared to our measurements. We considered 60 degrees C or higher as "hot". RESULTS: In 36 residencies, 107 individuals were drinking "matè". Most individuals drank it daily (97.2%), and the medium daily volume was 1,265 ml (SD +/- 1,132 mL) ranging from 250 to 6,000 mL. The measured temperature was 60 degrees C or higher in 72% of residencies with medium of 63.4 degrees C (51-78 degrees C) and median 64.4 degrees C. CONCLUSION: In this study, "matè" was consumed in large volumes at high temperature and individuals did not estimate correctly the temperature of infusion. High temperatures of "matè" may contribute to carcinogenesis in this population.

[Prevalence of adenocarcinoma of the esophagus and esophagogastric junction in a 10 year period at a cancer referral center in southern Brazil]. / Prevalência de adenocarcinoma do esôfago e da junção esofagogástrica durante 10 anos num centro de referência para câncer no sul do Brasil.

UNLABELLED: There is increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction in the USA and Europe, however, data in Brazil are scanty. OBJECTIVE AND METHODS: We reviewed all histology confirmed esophageal and esophagogastric junction cancer reports during a 10-year period (1987-1996) obtained by upper digestive endoscopy biopsies at a cancer referral center in Southern Brazil. Cancer cases were classified in three categories: adenocarcinoma, squamous cell carcinoma, and others. RESULTS: Among 349 cases, adenocarcinoma was found in 53 (15.2%), squamous cell carcinoma in 283 (81.1%) and others in 13 (3.7%). CONCLUSIONS: In this study, the prevalence of adenocarcinoma was 15%.

Esophageal dysplasias are detected by endoscopy with Lugol in patients at risk for squamous cell carcinoma in southern Brazil.

Diagnosis of squamous cell carcinoma of the esophagus is usually late. Staining of the mucosa with Lugol's solution during endoscopy has been suggested to identify early cancer/dysplasia and may improve prognosis. Lugol was tested during endoscopy in 96 asymptomatic subjects at risk for this tumor, who were found to have atypias after exfoliative cytology in southern Brazil. Biopsies were obtained in Lugol's 'stained' and 'unstained' areas in the esophageal mucosa and the histologic results were compared. 'Unstained' areas were present in 64 (66.7%) instances: 44 'unstained' areas over mucosa with normal appearance revealed seven dysplasias (four high and three low grade), whereas 20 'unstained' areas with visible lesions contained only one dysplasia (low grade). 'Stained' areas in 96 (100%) subjects showed two additional dysplasias (one high and one low grade). In this study, Lugol 'unstained' areas were of great value for detection of dysplasias (sensitivity = 80%; specificity = 63%; p = 0.01, Fisher's exact test; CI = 95%; odds ratio = 6.7).

[Hemi-alloarthroplasty with intermediary hip joint endoprosthesis]. / Die Hemi-Alloarthroplastik mit intermediären Hüftgelenks-Endoprothesen.

Intermediary (bipolar) endoprostheses have been used for the treatment of hip fractures in the past 30 years. Our cinematographic X-ray examinations have confirmed the function of the intra-prosthetic joint in vivo. Physiological load distribution in the acetabulum of "hard-top" cups was demonstrated in an experimental model by holographic interferometry. Our follow-up of 634 intermediary endoprostheses which had been implanted in a 15-years period demonstrated good clinical results. But it confirmed that "soft-top" cups should no longer be used because of the problems of polyethylene wear debris from the cup surfaces. Scintigraphic examinations in 123 cases showed the advantage of the test over X-ray examinations in early recognition of acetabular protrusion.

Postoperative monitoring of low molecular weight heparin prophylaxis in high-risk patients.

The alterations of the laboratory assays described for heparin monitoring in low molecular weight and unfractionated heparin prophylaxis groups did not correlate with the clinical outcome. Current laboratory techniques failed to detect an increased need for a higher dose of unfractionated or low molecular weight heparin to prevent DVT in these high-risk patients. The parameters commonly associated with thrombosis, that is, decreases in protein C and AT III were correlated with an increased incidence of DVT, but there was no difference in the assay values between the low molecular weight heparin and unfractionated heparin groups. Fibrinolysis activation is known to be associated with surgery; however, our data suggest an additional activation due to low molecular weight heparin compared with the unfractionated heparin group. Most interestingly, elevated PAI levels appear to correlate with thrombosis.

Thromboembolic prophylaxis in total hip replacement: a comparison between the low molecular weight heparinoid Lomoparan and heparin-dihydroergotamine.

In a prospective, randomized, assessor-blind multicentre study two antithrombotic subcutaneous regimens were compared in patients undergoing total hip replacement. Group 1 (154 patients) received 750 anti-Xa units of a new low molecular weight heparinoid (Lomoparan) subcutaneously twice a day and group 2 (155 patients) received 5000 units heparin and 0.5 mg dihydroergotamine (heparin-DHE 5000) twice a day. The incidence of deep vein thrombosis, assessed by routine bilateral venography on day 10 (+/- 1), was 17 and 32 per cent in groups 1 and 2 respectively (risk reduction 47 per cent; P = 0.007). One patient in each group developed a symptomatic pulmonary embolism confirmed by lung scanning. Major bleeding complications occurred in one patient in each group and no significant difference was observed between the two groups with respect to minor bleeding complications. Subcutaneous Lomoparan appears to be as safe as heparin-DHE 5000 at the above doses with regard to bleeding complications, and is more efficacious with respect to venous thrombosis.

[Corrective osteotomy of the head of the tibia in primary and secondary gonarthrosis--a para-articular operation]. / Die Korrekturosteotomie am Tibiakopf bei primärer und sekundärer Gonarthrose--eine gelenkerhaltende Operation.

The corrective osteotomy at the head of the tibia with degenerative or posttraumatic medial or lateral gonarthrosis and misalignment of the axis is until today a procedure to be recommended prior to a total or partial implantation of an endoprosthesis. The main advantage in comparison with a mono-condylar prosthesis is the removal of the causal damage of the misalignment. Old age and general relative risks are no contraindications to this procedure. The method used most in the operative technique is the correction of valgus deviation at the head of the tibia after osteotomy of the fibula with stabilization with a fixateur externe. On the whole, the risk of the operation is very low, the main complication is the lesion of the nervus peronaeus. With regard to the subjective result from the patients point of view the most important aspect is the relief or disappearance of pain, which is reached in comparison with a partial prosthesis of the knee joint with similar security. About two thirds of the patients are subjectively contempt with the results of the operation within a time of three to five years.

[Physical therapy treatment of distal radius fractures]. / Krankengymnastische Behandlung der distalen Radiusfraktur.

Physiotherapy of fractures of the distal radius is a concomitant treatment, not only after-care, of conservative and operative fracture therapy. Its aim is to avoid muscular atrophy and contraction and to improve circulation. For these reasons physiotherapy should begin shortly after fracture treatment and should include active mobilisation of the fingers, the elbow and the shoulder joints, as well as isometric exercises and neurophysiological physiotherapy. Physicotherapy (local ice treatment, electrotherapy, ultrasound treatment) can support physiotherapy.

[The extensor indicis brevis muscle--a rare anatomic variant. A case example and critical review of the literature]. / Der M. extensor indicis brevis--Eine seltene anatomische Variante. Fallbeispiel und kritische Literaturwürdigung.

A 27-year old man had a swelling over the back of his right hand that was painful on exertion. Operative revision revealed an extensor indicis brevis muscle. The frequency of this variant at autopsies is markedly below one percent; in addition to true neoplasms, the differential diagnosis includes ganglion cysts and synovialitis of the extensors.

Hypertension in children and adolescents. Results of a long-term follow-up study 1975-1985.

During a 10 year observation period hypertension was found in 105 children and adolescents. It was essential in 75% and in most cases combined with obesity. In 73% we found hypertension also in one or both parents. Large proportions of hypertensive children were associated with the risk factors (smoking, use of contraceptives, disturbed social conditions).

Abnormalities of B-cell activation and immunoregulation in splenectomized patients.

Using a reverse hemolytic plaque assay as the effector system, we studied B-lymphocyte function in 12 patients after posttraumatic splenectomy, as well as in 25 normal individuals. The time interval between the splenectomy and the immunological studies varied between 2 days and 7 years. Compared to normal individuals, the splenectomized patients had markedly elevated numbers of spontaneous immunoglobulin-secreting cells (ISC) and severely decreased responses to the polyclonal activator pokeweed mitogen. A tendency towards normalization of these abnormalities, especially the high spontaneous ISC levels, could be observed during the time interval extending up to 7 years after splenectomy. In order to characterize the mechanism responsible for the altered immune response in splenectomized patients, co-culture experiments with unseparated and separated lymphocytes were performed. These revealed an impaired T-helper cell capacity as well as an intrinsic B-cell defect. Marker analyses with monoclonal antibodies revealed normal proportions with the exception of OKT 4 positive and B 1 positive cells that identify T-helper/inducer and peripheral B-cells respectively. We conclude that immune dysfunction in peripheral blood lymphocytes of splenectomized patients involves mainly the B-cell as well as the T-helper/inducer-cell population.

[Disorders of B cell activation in splenectomized patients]. / Störungen der B-Zellaktivierung bei splenektomierten Patienten.

Using a reverse hemolytic plaque assay as the effector system, we studied in vitro B-lymphocyte function in 12 patients after posttraumatic splenectomy as well as in 25 normal individuals. The time interval between the splenectomy and the immunological studies varied between 2 days and 7 years. Compared to normal individuals, the splenectomized patients had markedly elevated numbers of spontaneous immunoglobulin-secreting cells and severely decreased responses to the polyclonal activator pokeweed mitogen, indicating an in vivo polyclonal B-cell activation. A tendency towards normalization of these abnormalities, especially the high spontaneous ISC levels, could be observed during the time interval extending up to 7 years after splenectomy. In order to characterize the mechanism responsible for the altered immune response in splenectomized patients, in vitro experiments were performed with separated lymphocytes. These revealed an impaired T-helper cell capacity as well as an intrinsic B-cell defect. Marker analysis with monoclonal antibodies revealed normal proportions with the exception of OKT 4 positive and B 1 positive cells that identify T-helper/inducer and peripheral B-cells, respectively. We conclude that immune dysfunction in peripheral blood lymphocytes of splenectomized patients involves mainly the OKT 4 positive cell population.

[Dynamic stressing of petrochanterically osteotomized femurs treated with endoprostheses (author's transl)]. / Die dynamische Belastbarkeit des endoprothetisch versorgten Knochens bei pertrochantärer Osteotomie. Beitrag zur Anwendung der Hüftgelenksprothese als Ausnahmeindikation bei pertrochantären Femurfrakturen.

In the treatment of pertochanteric fractures of the femur, the use of a hip joint prosthesis is indicated in exceptional cases for patients of advanced age. Mechanical testing of the combined system (osteotomized bone-cement-prosthesis) reveals high resistance to stress. A report is presented on stress tests on pertrochanterically osteotomized cadaver femurs which have been treated with endoprostheses. Dynamic stressing was done in four stages up to a maximal force of 2050 N. The resulting movement was measured medially and laterally along the osteotomy fissure. In the medial area it was between 0 and 0.06 mm, and in the lateral between 0 and 0.2 mm. The mechanical stability of this combined system seems to be higher than other surgical methods (Ender-nailing, combined osteosynthesis with bone cement and angle plate). Its load bearing capacity is substantially greater than that of the physiological system.

[The pros and cons of postponed primary osteosynthesis (author's transl)]. / Vor- und Nachteile der aufgeschobenen primären Osteosynthese.

The postponed primary osteosynthesis results from bad condition of the patient or from organisational problems in the clinic, although there is an indication for primary operation. Because of the loss in function, joint fractures should generally be operated within the first six to eight hours. But because of their own experience, the authors recommend the postponed primary operation in cases of fractures of the tibia plateau and the acetabulum. The advantages of the postponed operation are: careful planning and preparation of the operation, judgement of skin, and choice of an experienced surgeon. They are compared to the disadvantages: alteration of bone-fragments by resorption and disorders in nutrition of joint-cartilage. In the author's opinion the advantages outweigh the disadvantages, especially important is the performance of the operation by an experienced surgeon. The rate of 16% arthroses in a two-years postoperative study on 44 patients with fracture of the tibia plateau seems to confirm this conception.