[Treatment after anatomical and inverse shoulder TEP]. / Nachbehandlung nach anatomischer und inverser Schulter-TEP.

Shoulder arthroplasties in specialized centers are routine procedures with an increasing number of operations in the developed countries. Restoration of pain free shoulder function requires an intensive, specific and individual rehabilitation program for each patient. There is a phase-like course with different specific demands and measures that extends over a period of several weeks. Return to sport and a pain free function for activities of daily living resulting in a high patient satisfaction can routinely be expected. This excellent perspective, extent and intensity of the rehabilitation program shall be part of the preoperative decision making.

[Shoulder endoprosthesis in the elderly : Hemiarthroplasty or total shoulder arthroplasty? Anatomic or reverse?] / Schulterendoprothetik im Alter : Hemi- oder Totalendoprothese? Anatomisch oder invers?

Implantation of reverse shoulder endoprostheses is becoming more popular for elderly patients besides the well-established standard anatomic endoprostheses. The reasons for this are the increased life expectancy, age-dependent degeneration of the rotator cuff leading to cuff tear arthropathy, posttraumatic disability after failed osteosynthesis and primary reverse fracture arthroplasty. Stemless implants are more frequently used for primary osteoarthritis with the bone quality being the limiting factor. Modern implant systems allow the stepwise extension from bone preserving primary implants to modular and convertible revision implants that allow a partial exchange of components. Revision surgery, especially that of reverse arthroplasty, has limited potential for secondary treatment options and therefore implantation and revision should be performed in specialized treatment facilities.

[Current treatment options for complete ruptures of the pectoralis major tendon]. / Die zeitgemäße Therapie der kompletten Ruptur des M. pectoralis major.

The rupture of the pectoralis major tendon is an uncommon pathological condition that is reported in literature to prevail among athletes, although also case reports and case series of nursing home residents or workers can be found, as well as traumatic lesions. Among athletes, pectoralis major tendon ruptures have shown a significant increase in incidence over the last years. This may be due to the higher number of individuals taking part in high-impact sports and weight-lifting. In the recent literature, there are only few recommendations to rely on conservative treatment alone. Especially in athletes, numerous case reports and series give the recommendation for an early surgical intervention. Comparing the results of the two treatment plans, there is some evidence for a superior outcome after surgical repair with better cosmesis, better functional results, better recovery of muscle power and return to sports compared to the conservative treatment. In summary, anatomic surgical repair is the treatment of choice for complete acute ruptures of the pectoralis major tendon or muscle in athletes. In all other cases, especially in the elderly, conservative treatment remains an important option.

Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder: results at nine years.

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings.

Proximal loading of the femur leads to low subsidence rates: first clinical results of the CR-stem.

INTRODUCTION: A new femoral stem was developed with a design that leads to compression of cancellous bone in the calcar region which results in proximal loading. The cross-sectional design of the implant provides rotational stability. MATERIALS AND METHODS: In the first clinical investigation ten patients underwent uncemented total hip arthroplasty between January 1999 and May 1999 using the CR-stem((R)) (Implantcast GmbH, Buxtehude, Germany). Results were investigated using the Harris-hip-score (HHS) and antero-posterior and lateral radiographs. Migration was evaluated with the EBRA-FCA-method with a follow-up of 7 years. RESULTS: We demonstrated a mean subsidence rate of 2.23 +/- 1.13 mm 7 years after implantation thus providing basic data for extensive testing in a clinical environment. DISCUSSION: As small subsidence rates are regarded as predictor for superior long-term results in uncemented total hip arthroplasty according to the literature, the CR-stem shows promise for excellent long-term results.

[The importance of wear couples for younger endoprosthesis patients]. / Die Bedeutung der Gleitpaarung beim jüngeren Endoprothesenpatienten.

The success and long-term survival rates of modern joint arthroplasty leads to a high patient satisfaction and, together with its technical improvements, has broadened the indications to an increasingly younger population. Limitations to the established systems are the long-term survival rates, which are mainly influenced by wear of the articulating parts and the resulting problems. Beside "classic" long-stemmed cemented shafts articulating with metal against polyethylene, short-stemmed or cup designs with a hard-hard self pairing are increasingly used in total hip arthroplasty. This paper reflects the current state of the art in joint arthroplasty for younger patients with the focus on wear couples and discusses future perspectives. Special interest is focused on the advantages and disadvantages of ceramic bearings, problems with allergies to implant components and the design of endoprostheses with regard to avoidance of impingement.

[The modular MML revision system in knee revision and tumor arthroplasty]. / Einsatz eines modularen Knierevisionssystems MML im Rahmen des Knieprothesenwechsels und der Tumorendoprothetik.

Increasing age and a higher level of mobility lead to an increasing incidence in revision arthroplasty after total knee replacement and tumor surgery. So far, the reconstruction of large defects in bony and soft tissue environments can be accomplished by the modern modular components of revision implants. The consecutive reconstruction of the extensor mechanism in extended revision has its own drawbacks and is often associated with significant functional limitations for the patient. Specially designed implants and methods are required to generate good functional results. The modular knee revision system MML provides specific modifications of the tibial component for reconstruction of the extensor mechanism. Combined with artificial strips, an excellent functional outcome could be achieved. In this study, 70 patients were operated with the MML endoprosthesis in knee revision or tumor surgery. An excellent functional outcome could be determined. At 7 years after surgery, an average of 32+/-13 points was achieved on the Oxford Knee Score. The outcome measurement using the functional scoring system of the American Knee Society (AKS score) showed similarly good results with 71+/-25 points out of 100. A minor deficit of only 2 degrees in active extension could be observed after reconstruction of the extensor mechanism. In conclusion, we have demonstrated that the MML modular revision system is appropriate for reconstruction of segmental bone defects.

Cardiovascular and electrodermal responses to support and provocation: interpersonal methods in the study of psychophysiological reactivity.

This study examined the joint and independent effects of experimentally manipulated social contexts and individual differences in hostility and perceived social support on physiological responses to a social stressor, while illustrating the use of the interpersonal circumplex for integrative social psychophysiological research. Undergraduate women completed a speech task in a supportive, neutral, or provoking context and completed measures of hostility and perceived social support. The provoking context evoked the largest blood pressure and heart rate (HR) responses, followed by the neutral and the supportive context. Social context also influenced HR and electrodermal reactivity during task preparation. Hostility elicited higher systolic blood pressure (SBP) reactivity during preparation, speech, and recovery. Perceived social support interacted with context to affect SBP and HR during speech and preparation. The roles of interpersonal characteristics and contexts in the physiological stress response and the utility of interpersonal methods in studying these associations are discussed.

Social determinants of cardiovascular reactivity: effects of incentive to exert influence and evaluative threat.

The effects on cardiovascular reactivity of incentive to influence the judgements of the experimenter and the threat of social evaluation were examined in a sample of 60 male and 60 female undergraduates. Participants either were guaranteed $5.00 to prepare and deliver a brief speech or were told that the money was contingent on an evaluation by the experimenter. Participants believed that their speech would be rated for either simple clarity or verbal intelligence. The contingent incentive increased systolic blood pressure reactivity by 6.5 mmHg (32%). Evaluative threat increased systolic reactivity by 7.1 mmHg (36%). These interpersonal processes could increase the risk of cardiovascular disease and are likely to affect the degree of cardiovascular reactivity in laboratory studies.

The role of comparison questions in physiological detection of deception.

Comparison questions in physiological detection of deception were studied with 60 "guilty" and 60 "innocent" participants in a mock crime experiment. Different types of comparison questions were used in four conditions: relevant-irrelevant (R-I) participants answered only relevant and neutral questions; trivial directed lie participants were instructed to lie to three of the six neutral questions; personal directed lie participants were instructed to lie to personally relevant questions; and probable lie participants received traditional probable lie comparison questions. Respiration, cardiovascular, vasomotor, and electrodermal activity were recorded. Manipulation of the comparison questions produced different patterns of physiological responses for innocent but not for guilty participants. The R-I test produced an unacceptable rate of false positive decisions.

The effects of social context and defensiveness on the physiological responses of repressive copers.

In previous research (T.L. Newton & R.J. Contrada, 1992), social context was found to moderate exaggerated physiological reactivity among individuals identified as using a repressive coping style. In this experiment, 119 undergraduates were classified into low-anxious, high-anxious, repressor, and defensive high-anxious coping categories. All participants completed a stressful speech task under either a public or private social context condition. The experimental social context was related to physiological reactivity and self-reported affect but did not moderate reactivity among repressive copers. Additionally, reactivity among repressive copers was not attributable to high defensiveness alone. Consistent with a theory of emotional inhibition, nonspecific skin conductance responses, but not heart rate, discriminated between repressors and nonrepressors.

Children and adolescents with neurofibromatosis 1: a behavioral phenotype.

Twenty 6- to 17-year-old children with neurofibromatosis 1. (NF1) were compared to 20 age- and sex-matched siblings on a wide range of neuropsychological and behavioral dimensions. In familial cases, diagnostic status was confirmed by gene linkage with greater than 98% accuracy. Visual examinations that included assessments of visual evoked responses (VER) were performed on subjects with NF1. Forty-two percent of NF1 subjects had abnormal VER and underwent magnetic resonance imagery or computed tomography scans of the brain. On a variety of skills, subjects with NF1 performed more poorly than unaffected siblings. Children with NF1 were found to be less competent on measures of cognitive, language, and motor development, visual-spatial judgment, visual-motor integration, and academic achievement. Learning disabilities were common in children with NF1. Parents and teachers reported that NF1 subjects had internalizing problems and difficulty interacting with peers. A behavioral phenotype for NF1 and recommendations for preventative interventions are proposed.

Mental and physical countermeasures reduce the accuracy of the concealed knowledge test.

The effects of a physical (pressing the toes to the floor) and a mental (counting backward by sevens) countermeasure on the concealed knowledge test (CKT) were examined in a mock crime experiment with 40 subjects. Some knowledgeable subjects were informed about the nature of the CKT and were trained in the use of a countermeasure, whereas others remained uninformed. All subjects were offered a monetary reward if they could produce a truthful outcome. Subjects were tested using standard field techniques and instrumentation. The physical and, to a lesser extent, the mental countermeasures reduced the accuracy of the CKT. These results clearly demonstrate that the CKT has no special immunity to the effects of countermeasures.

Polygrapher's dilemma or psychologist's chimaera: a reply to Furedy's logico-ethical considerations for psychophysiological practitioners and researchers.

We respond to Furedy's article in this journal where he raised an issue he referred to as the "Polygrapher's dilemma" (Furedy, J.J. (1993) Int. J. Psychophysiol., 15: 263-267). Furedy claimed that the control question test, the most commonly applied psychophysiological detection of deception test, is inherently subjective and harmful to subjects in both the field and the laboratory. Fortunately, Furedy's arguments were based on inaccurate representations of the control question test and on flawed logic. To correct Furedy's misrepresentations, we present an accurate description of how the control question test is used and evaluated. We then examine the results of empirical research that address Furedy's concerns. Furedy's concerns are found to be lacking on almost all counts. Finally, we discuss the findings from several studies that Furedy failed to mention but are directly relevant to the issues he raised.

Effects of methylphenidate on reward strength in boys with attention-deficit hyperactivity disorder.

OBJECTIVE: To test the hypothesis that methylphenidate reduces thresholds for reward in children with attention-deficit hyperactivity disorder (ADHD). METHOD: A double-blind crossover design was used in which 16 ADHD boys, aged 8 to 13 years, received methylphenidate on one testing occasion and placebo on another. On each occasion, subjects performed a task that required progressively greater numbers of button presses to earn a fixed monetary payoff. RESULTS: The "breaking point" above which the hyperactive child was unwilling to continue with the task was significantly higher during drug than placebo trials. CONCLUSIONS: The results support an assumption that underlies the reward system dysfunction hypothesis of ADHD, and they suggest that reward mechanisms may underlie the therapeutic effects of stimulants observed across a wide range of tasks and settings.

Provider-assisted suicide: a survey of PA attitudes. Results of the 1994 Michigan survey conducted by the Michigan Academy of Physician Assistants Public Policy Committee.

Assisted suicide continues to be a topic of debate among health care providers, including PAs. The Public Policy Committee of the Michigan Academy of Physician Assistants surveyed all licensed PAs in Michigan regarding assisted suicide in an effort to determine whether a public policy statement should be developed, and whether that could be extrapolated into a resolution to be taken to the House of Delegates (HOD) of the American Academy of Physician Assistants in 1994. Based on the divergent results of the survey, the Michigan delegation did not submit a resolution to the HOD.

Mental and physical countermeasures reduce the accuracy of polygraph tests.

Effects of countermeasures on the control-question polygraph test were examined in an experiment with 120 Ss recruited from the general community. Ss were given polygraph tests by an examiner who used field techniques. Twenty Ss were innocent, and of the 100 guilty Ss, 80 were trained in the use of either a physical countermeasure (biting the tongue or pressing the toes to the floor) or a mental countermeasure (counting backward by 7) to be applied while control questions were being presented during their examinations. The mental and physical countermeasures were equally effective: Each enabled approximately 50% of the Ss to defeat the polygraph test. The strongest countermeasure effects were observed in the cardiovascular measures. Moreover, the countermeasures were difficult to detect either instrumentally or through observation.