[Briard's sagittal sliding osteotomy of the lateral condyle in total knee arthoplasty of the severe valgus knee]. / Die sagittale Gleitosteotomie des lateralen Kondylus nach Briard beim Oberflächenersatz des kontrakten Valgusknies.

OBJECTIVE: Distalization of the insertion of the lateral collateral ligament and popliteus tendon by sliding osteotomy of the lateral femur condyle in order to correct a residual contracture in extension in total knee arthroplasty (TKA) of the severe valgus deformity. INDICATIONS: Genuine and other valgus deformity of the knee. CONTRAINDICATIONS: Severe laxity of the medial collateral ligament; common contraindications of joint replacement. SURGICAL TECHNIQUE: Lateral parapatellar approach and stepwise osteotomy of the tubercle of the tibia, subperiostal release of the lateral contracted structures such as iliotibial band (ITB) and lateral collateral ligament (LCL) in flexion. Tibia first technique, verification of a balanced and stable flexion gap parallel to the epicondylar line. Posterior cruciate ligament (PCL) is preserved. Referencing of the distal femoral cut by a spacer filled only in the medial extension gap. Finishing femoral chamfer cuts. If extension gap remains trapezoidal, further release of the residual lateral contracted structures in extension by means of sliding osteotomy of the lateral condyle and subperiostal release of the capsule and the lateral septum intermusculare is required. Termporary fixation of the lateral condyle by K-wires, resection of the bony excess, trial of test components, definite screw fixation. POSTOPERATIVE MANAGEMENT: Comparable to TKA in varus deformities by a medioparapatellar approach. RESULTS: A total of 79 patients (61 women, 18 men, average age 71 years at the time of surgery) with fixed valgus deformities were operated between June 2001 and December 2010 using TKA and sliding osteotomy of the lateral femoral condyle. The preoperative valgus angle under defined valgus and varus stress was 19.5° (8-40), postoperative 4.7° (2-11). Mean medial angle (valgus stress) of the follow-up was 2.1° (0.5-5°), lateral angle (varus stress) 2.3° (0.5-5°). A total of 35 patients were followed-up, at a mean of 73.3 month (24-109 months). The postoperative Knee Society Score was 95 points (56-100 points), while the postoperative Function Score was 90 points (55-100 points) postoperatively. The Oxford Score improved from 22 points (3-43 points) preoperatively to 45 points (21-48 points) postoperatively. One knee had to be revised due to infection, one knee due to non-union of the tibial tubercle. Finally, there were 3 cases with complications associated with the procedure due to the sliding osteotomy of the lateral femoral condyle; all were revised successfully. No conversion to a semi-constrained or constrained knee prosthesis was necessary.

[Changes in knowledge, attitudes, and smoking behavior among young people in Germany. Results of repeated, representative surveys by the BZgA]. / Veränderungen von Wissen, Einstellungen und Rauchverhalten bei Jugendlichen in Deutschland. Ergebnisse wiederholter Repräsentativbefragungen der Bundeszentrale für gesundheitliche Aufklärung.

Following an increase in tobacco consumption among 12 to 17 year olds between 1993 and 1997, a policy mix comprising various structural and behavioral prevention measures was implemented in Germany. One element of this policy mix is the "rauchfrei" ("smoke-free") youth campaign of the BZgA (Federal Centre for Health Education), a combination of media that reaches a large number of youth, personal communication, and setting-based interventions. The aim is to prevent young people from starting to smoke and to promote the cessation of smoking at an early stage. Based on a multistage intervention model, wide coverage of the measures should be achieved among young people, as well as changes in knowledge, attitudes, social norms, and behavioral intentions. Based on the intervention model, repeated, representative cross-sectional surveys were conducted to examine the development of these indicators and of tobacco consumption. Five studies were conducted during the period from 2003 to 2008, each comprising between 1,220 and 2,780 computer-assisted telephone interviews with randomly selected young people between the ages of 12 and 17. The percentage of young people reached by information offered on the subject of not smoking rose between 2003 and 2008. Participation in school-based prevention measures also rose. There was an increase in knowledge regarding the harmful substances contained in cigarette smoke, and in the percentage of young people who rated active and passive smoking as being harmful to health. In addition, the attitude towards smoking of young people who have never smoked became more critical, as did that perceived in the social environment. The proportion of young people who smoke declined substantially, from 27.5% (2001) to 15.4% (2008), and there was been a major rise in the number who have never smoked, from 40.5% (2001) to 60.6% (2008). The change in knowledge-based risk assessments, attitudes, and social norms should be further promoted by mass media and personal communication measures, as well as by setting-based and behavioral prevention measures. In order to encourage them to quit smoking, young smokers must be motivated and convinced by means of suitable behavioral prevention interventions.

[Assessing the health target "Reduce tobacco consumption"]. / Evaluation des Gesundheitsziels "Tabakkonsum reduzieren".

The consortium gesundheitsziele.de has defined health targets and actions to reduce tobacco consumption of the general population. Five primary fields of action were defined: (1) tax increase, (2) ban of advertisements, (3) protection against second-hand smoking, (SHS) (4) support of smoking cessation, and (5) actions to avoid taking up smoking. The achievements in recent years are described by means of epidemiological studies and other specific data. (1) Tax increases led to a significant rise of cigarette prices. (2) A complete ban of advertisements has not yet been achieved. The tobacco industry shifted expenditures to fields where advertising is still allowed. (3) Many actions to foster protection against SHS could be implemented. Public awareness has been raised, the acceptance of smoking bans has grown, and exposure to SHS has been reduced. (4) Demand and supply of smoking cessation interventions have been enhanced. (5) Actions to avoid taking up smoking seem to be successful as the rate of smokers among young people has decreased, the number of never-smokers has increased, and a more critical attitude of non-smokers towards smoking could be observed. It is recommended that the above actions be continued because the capabilities of the structural, mass media, and behavioral interventions have not been fully exhausted.

[Transplantation of autologous oral mucosa in the treatment of a symblepharon in Wegener's disease--a case report]. / Schleimhautplastik mit autologer oraler Mukosa zur Therapie des Symblepharon bei Morbus Wegener--eine Kasuistik.

BACKGROUND: Wegener's disease, an immune vasculitis, is characterized by granulomata and vasculitis of small and large vessels. Ocular manifestations are observed in approximately half of all cases. PATIENT: We report on a 58-year-old male with severe generalized Wegener's disease which was first diagnosed in 1986. The involvement of the central nervous system became clinically manifest by a stroke, of the kidneys by incipient renal insufficiency, and of the larynx by recurrent subglottic stenosis of the trachea. The first ocular involvement, a conjunctivitis, was observed in 1988. Despite systemic immuno-suppressive therapy, local conservative therapy and repeated surgical procedures, his vision decreased bilaterally from 60/60 to hand movement (OD) and light perception only (OS) during the following years because of a massive bilateral symblepharon. Transplantation of autologous oral mucosa to the conjunctiva led to a persistent increase of vision and a good cosmetic result. CONCLUSIONS: We conclude that in patients with Wegener's disease, who have developed a symblepharon despite intensive therapy, the transplantation of oral mucosa can produce a sufficient functional and cosmetic result.

Combined copy status of 18q21 genes in colorectal cancer shows frequent retention of SMAD7.

Deletions of chromosome band 18q21 appear with very high frequency in a variety of carcinomas, especially in colorectal cancer. Potent tumor suppressor genes located in this region encode transforming growth factor beta (TGF-beta) signal transducers SMAD2 and SMAD4, and inactivation of either one leads to impaired TGF-beta-mediated cell growth/apoptosis. Following the assignment of SMAD7 to 18q21, we first refined the SMAD7 gene position within this region by genetically mapping SMAD7 between SMAD2 and SMAD4. Further, to compare the respective frequencies of genetic alterations of these three SMAD genes in colorectal cancer, we undertook a large-scale evaluation of the copy status of each of these genes on DNA samples from colorectal tumor biopsy material. Among a subset of 233 DNA samples for which data were available for all four genes, SMAD4, SMAD2, and the nearby gene DCC showed high deletion rates (66%, 64%, and 59%, respectively), whereas SMAD7 was deleted in only 48% of the tumors. Unexpectedly, we found some gene duplications; SMAD7 appears to be more frequently amplified (10%) than the three other genes (4-7%). Compiled data for SMAD genes in each tumor show that the most common combination (26% of all the tumors) consists of the simultaneous deletions of SMAD2 and SMAD4 associated with normal diploidy or even duplication of SMAD7. Since SMAD7 normally counteracts SMAD2 and SMAD4 in TGF-beta signaling, we hypothesize that the tumor might not benefit from simultaneous SMAD7 inactivation, thereby exerting selective pressure to retain or even to duplicate the SMAD7 gene.

Instrumentation of furcation with modified sonic scaler inserts: a study on manikins (II).

We developed a sonic scaler tip with an ellipsoid diamond-coated bud and contra-angulated shafts to overcome problems resulting from furcation anatomy. In this study, extracted molars were instrumented in a dummy model without any replicated soft tissues using 3 different instrumentation methods (i) curettes, (ii) diamond-coated sonic scaler tips with normal handle and (iii) diamond-coated sonic scaler tips in 2 handles with varying power levels. 15 extracted upper and lower molars were instrumented using each of the 3 instrumentation types. Following debridement, loss of substance and % of furcation area instrumented were assessed. In both upper and lower molars, significantly more surface area was instrumented in one instrumentation run with diamond-coated tips than with curettes. Substance loss was greater with diamond-coated tips than with hand instruments. In conclusion, an effective debridement of the furcation roof seems only possible with odontoplasty. Clinical evaluation of this approach to root debridement is needed.

Employee contributions for dependent medical coverage: balancing cost, compensation and society.

This article explores the inception of the employee contribution concept to dependent medical coverage. The author discusses the developments that have occurred in the changing workforce as well as the effects of increasing medical costs. It considers the equity issues of unfair subsidies in medical benefit premiums for dependents. Finally, a potential solution is offered that would replace the multitiered structures available today.

Outbreak of invasive mycoses caused by Paecilomyces lilacinus from a contaminated skin lotion.

BACKGROUND: Invasive mycoses are an important cause of illness and death in immunocompromised patients. Infections with molds other than aspergilli have been increasingly seen in patients with hematologic cancers, but epidemics of these infections have not yet been reported. OBJECTIVE: To describe an outbreak of invasive mycoses with Paecilomyces lilacinus in severely neutropenic patients. DESIGN: An outbreak investigation. SETTING: The hematology-oncology isolation and bone marrow transplantation unit of the University Hospital, Basel, Switzerland. PATIENTS: 25 consecutive patients admitted between 17 August 1993 (the date of the first manifestation of P. lilacinus infection) and 31 October 1993 (when the unit was closed). MEASUREMENTS: Clinical and microbiological data, including histologic findings; cultures from several patient sites; and environmental examinations of potential airborne, parenteral, enteric, and horizontal routes of transmission. Infections were defined by the isolation of P. lilacinus from clinically evident skin eruptions. RESULTS: 12 of the 25 patients (48%) were infected or colonized. Nine patients (36%), including all bone marrow transplant recipients, had documented invasive P. lilacinus infections. All 9 infected patients had papular, pustular, or necrotic skin eruptions. Two patients with severe graft-versus-host disease died with refractory fungal disease; 1 also had microbiologically documented endophthalmitis and kidney infiltrates. Seven affected patients no longer had P. lilacinus after recovery of bone marrow function. The organism was resistant in vitro to amphotericin B, itraconazole, and fluconazole. Patients did not respond clinically to these agents. The outbreak was ultimately traced to a contaminated, commercially available, pharmaceutically prepared skin lotion. The outbreak ended after the skin lotion was recalled and has not recurred after a follow-up period of 2 years. CONCLUSION: Contaminated skin lotion is a potential cause of opportunistic fungal infections in immunocompromised hosts. Paecilomyces lilacinus is a common saprophytic mold that can cause, by direct cutaneous inoculation, invasive infections associated with illness and death.

Splenectomy as an adjuvant measure in the treatment of severe aplastic anaemia.

The role of splenectomy in aplastic anaemia (AA) is controversial. The hazards of operating on a severely pancytopenic patient, the fear of compromising the patient's immune function, and the improvement of non-surgical treatment have made splenectomy unpopular in this disease. We have evaluated positive and adverse effects of splenectomy in 80 patients with severe aplastic anaemia (SAA) treated with antilymphocyte globulin (ALG) (group A), using 52 nonsplenectomized ALG patients as controls (group B). All patients survived the operation. Nonfatal complications of surgery occurred in 10 (12.5%). Splenectomy induced a significant increase of peripheral blood neutrophils, reticulocytes and platelets within 2 weeks, followed by a continuous increase of all values over the following weeks. 28/132 patients (21%) developed a late clonal disorder of haemopoiesis, paroxysmal nocturnal haemoglobinuria (PNH) or myelodysplastic syndrome (MDS), or both. Their incidence was identical in groups A and B. 13/28 (59%) died, 10/17 (59%) in group A and 3/11 (27%) in group B (not significant (n.s.)). Overall probability of survival at 18 years after ALG was 51+/-6% for group A and 61+/-7% for group B (n.s.). We conclude that splenectomy in AA is safe. It induces an immediate increase of peripheral blood counts and, thereafter, a continuous improvement of haemopoiesis. It does not increase the incidence of late clonal complications but has a borderline effect on mortality from these disorders. Splenectomy should be reconsidered in selective nontransplanted patients who have prolonged transfusion requirements despite otherwise optimal treatment.

[Skin manifestations of graft-versus-host reaction following bone marrow transplantation]. / Hautmanifestationen der Graft-versus-host-Reaktion nach Knochenmarktransplantation.

We review the cutaneous manifestations of acute and chronic graft versus host disease (GvHD). Acute GvHD is characterized by initial itching, pain on pressure and erythema which begins on posterior auricular skin, palms and soles. The disease evolves into a typical but nonspecific maculopapular rash. Confluent rashes and follicular erythema may occur. Erosive oral lesions usually develop. The most severe variant of GvHD is toxic epidermal necrolysis, which often has a fatal outcome. The onset of chronic GvHD usually occurs more than 100 days after bone marrow transplantation and may be preceded by the acute form. The spectrum of skin changes includes lichenoid pruritic lesions with violaceous color and scleroderma-like skin involvement. Investigation of unknown rashes in these patients includes skin biopsy, which clearly differentiates leukocytoclastic vasculitis and erythema exsudativum multiforme with lymphocytic vasculitis from cutaneous manifestations of GvHD. Special stains may reveal bacteria and fungus in septicemic patients. The therapeutic options are discussed.

[Autologous transplantation of hematopoietic precursor cells following CD34 selection]. / Autologe Transplantation von hmopoietischen Vorläuferzellen nach CD34-Anreicherung.

Peripheral blood is increasingly used instead of bone marrow as a source of hemopoietic precursor cells for transplantation. The optimal technique still needs to be defined. Selection of CD34+ cells in transplant material may be of benefit in allogeneic and autologous peripheral blood precursor cell transplantation (PBPCT), since it allows elimination of unwanted CD34-negative cells, such as T-cells and contaminating tumor cells. We have evaluated the feasibility of CD34 selection in PB transplants and studied hemopoietic reconstitution after autologous transplantation of CD34 selected precursor cells. Between August 1994 and June 1995 CD34 selection was performed on 12 transplants for 9 patients with malignant disease (non-Hodgkin lymphoma [n = 5]; Ewing sarcoma [n = 1]; chronic lymphocytic leukemia [n = 1]; breast cancer [n = 1]; multiple myeloma [n = 1]). PBPC were collected with a Fenwall CS 3000 harvester after stimulation with G-CSF. For selection of CD34+ cells the Ceprate LC34 system (CellPro) was used. A median CD34 purity of 73% (range 40-94%) was achieved. The median number of CD34 positive cells per transplant was 4.8 x 10(6)/kg body weight (range 0.7-15.8). The median number of colony forming cells per transplant was 31 x 10(4)/kg body weight (range 1.5-131.3). For autologous PBPCT the minimal number of CD34 positive cells required in the transplantate was arbitrarily set at 1.0 x 10(6)/kg body weight. This number was achieved in 10 of the 12 transplants. The median loss of CD34+ cells during selection was 1.5 x 10(6)/kg body weight (range 0.2-6.4). In 2 patients the total number was reduced to below the critical value of 1.0 x 10(6)/kg. 7 of the 9 patients received the CD34 selected transplant after intensive chemotherapy and irradiation. The median follow-up time after PBPCT was 196 days (range 62-278). All 7 patients are now alive and with normal hemopoietic function. A granulocyte count above 0.5 x 10(9)/l and a platelet count above 20 x 10(9)/l was achieved on day 14 (median), and on day 19 after PBPCT. We conclude that CD34 selection is technically feasible and that CD34 selected cells can be used for PBPCT. The procedure is time consuming and expensive; it requires complex organization at laboratory level, and the benefit of CD34 selection with regard to T-cell depletion and tumor purging still needs to be proven. However, CD34+ selection is likely to open new perspectives in transplantation medicine.

Ondansetron plus dexamethasone is superior to ondansetron alone in the prevention of emesis in chemotherapy-naive and previously treated patients. Swiss Group for Clinical Cancer Research (SAKK).

BACKGROUND: This prospective, randomized, double-blind study assessed whether the addition of dexamethasone to ondansetron leads to improved control of chemotherapy--induced emesis, both in patients undergoing their first course of highly emetogenic chemotherapy and in chemotherapy-pretreated patients refractory to standard anti-emetics. PATIENTS AND METHODS: Patients were randomized to receive either 20 mg dexamethasone as an intravenous infusion or placebo plus ondansetron 8 mg 15 minutes prior to and 4 and 8 hours after the administration of chemotherapy. According to the randomisation code patients received from day 2 to day 5 either ondansetron 8 mg p.o. + placebo p.o., three times daily, or ondansetron 8 mg p.o. + dexamethasone 4 mg p.o., three times daily. Patients undergoing multiple-day treatment received intravenous study treatment on the days of chemotherapy and thereafter oral treatment as outlined above. RESULTS: A total of 215 patients were entered into the study. Of these, 207 were evaluable (111 previously-untreated and 96 previously-treated patients). In the chemotherapy-naive patients the combination of ondansetron plus dexamethasone was significantly superior to ondansetron plus placebo in protecting the patients completely from emesis (retching and vomiting) (81% versus 64%, p = 0.04). The mean number of vomiting episodes was significantly lower in the ondansetron-plus-dexamethasone-treated patients than in those receiving ondansetron plus placebo (0.8 versus 2.1, p = 0.03). In this group of patients there was significantly superior protection from emesis on the second day (p-value = 0.04), and a trend towards a better protection on the third and fourth days. On each day the active combination offered better protection from nausea with an approximately 20% difference in favor of ondansetron plus dexamethasone. In the group of established vomiters the combination of ondansetron plus dexamethansone was superior to ondansetron plus placebo in protecting the patients from acute emesis, with 70% versus 48% of the patients being completely protected (p = 0.03). The mean number of vomiting episodes was significantly lower in the ondansetron-plus-dexamethasone-treated-patients than in those receiving ondansetron plus placebo (0.9 versus 2.1, p = 0.02). In the ondansetron-plus-dexamethasone arm 55% of the patients had complete protection from nausea, retching and vomiting compared to 35% in the ondansetron-plus-placebo-treated group (p = 0.05). Overall 22% of the patients (20% in the ondansetron-plus-placebo and 25% in the ondansetron-plus-dexamethasone arm) experienced at least one, usually mild, adverse event. More patients in the ondansetron-plus-dexamethasone arm complained of epigastric pain or burning (8/101 versus 4/112, p-value = 0.16). The difference in patients reporting constipation (6/101 versus 0/112) was highly significant at a p-value of 0.008. CONCLUSIONS: The combination of dexamethasone plus ondansetron is more effective in protecting chemotherapy-naive patients undergoing their first course of highly emetogenic chemotherapy with cisplatin and chemotherapy-pretreated patients refractory to standard antiemetics from chemotherapy-induced nausea and vomiting compared to ondansetron plus placebo.

Weight loss in patients with hematological neoplasias is associated with immune system stimulation.

Weight loss is the main symptom of so-called tumor cachexia. The pathogenetic mechanisms underlying cachexia are poorly understood; however, it appears that enhanced formation of cytokines such as interferon-gamma and tumor necrosis factor-alpha are involved. In 94 patients suffering from hematological neoplasias we compared body weight changes with serum neopterin, tryptophan, and kynurenine. Biochemical changes, the formation of neopterin, the degradation of tryptophan are closely related to interferon-gamma activity. The majority of our patients had increased neopterin and decreased tryptophan concentrations. Weight loss was seen particularly in patients with higher neopterin and lower tryptophan values. An association between higher neopterin levels and greater weight loss was apparent at study entry and during the follow-up of patients. Our data support the concept that weight loss is closely linked to endogenous interferon-gamma activity.

Serum soluble tumour necrosis factor receptor 55 is increased in patients with haematological neoplasias and is associated with immune activation and weight loss.

Enhanced concentrations of soluble forms of the receptor for tumour necrosis factor (TNF)-alpha have been detected in the serum of cancer patients. We determined serum concentrations of soluble TNF receptor p55 (sTNF-R55) in patients with haematological neoplasias, 50 patients suffering from non-Hodgkin's lymphoma (n = 35), Hodgkin's disease (n = 10) and multiple myeloma (n = 5). Compared with healthy controls and with patients with potential thyroid disease, significantly elevated concentrations of sTNF-R55 were found (mean +/- standard error: 2.68 +/- 0.22 vs. 1.23 +/- 0.21 ng/ml, P < 0.0001 and 2.18 +/- 0.32 ng/ml, P = 0.03). Likewise, neopterin concentrations were raised (19.6 +/- 3.66 vs. 5.3 +/- 0.25 nmol/l in controls, P < 0.0001). We found a significant correlation between sTNF-R55 and neopterin concentrations (Rs = 0.544, P < 0.001). Patients with weight loss showed higher sTNF-R55 concentrations than patients with stable weight. Our results confirm the relevance of sTNF-R55 concentrations in serum of patients with cancer.

Association between the activation of macrophages, changes of iron metabolism and the degree of anaemia in patients with malignant disorders.

In this study, we investigated a possible association between the degree of macrophage activation - as measured by serum neopterin concentrations - and disturbances of iron metabolism, determined by the concentrations of ferritin and serum iron, in patients with malignant disorders. Additionally we evaluated correlations between these factors and the degree and type of anaemia. Seventy-three patients, who suffered from non-Hodgkin's lymphoma (NHL) (n = 43), Hodgkin's disease (n = 11), myeloma or monoclonal gammopathy of unknown significance (n = 9), myelodysplastic syndrome (n = 1), and solid tumours (n = 9), were examined. Mean neopterin levels were raised in all groups, patients with NHL showing the highest concentrations. Ferritin but not neopterin concentrations were higher in males than in females. A significant correlation was found between neopterin and ferritin concentrations (p less than 0.01). Considering only female patients the strength of the correlation was the same (p less than 0.02). In addition, we found inverse correlations of neopterin with haemoglobin and iron concentrations (all p less than 0.01). Similar relationships existed in patients during follow-up. Our results support the hypothesis of an association between the degree of activation of macrophages and the development of anaemia by a shift or iron towards the storage sites.

[Prediction of goal-directed behavior: attitude, subjective behavioral competence and emotions]. / Zur Vorhersage zielgerichteten Handelns: Einstellung, Subjektive Handlungskompetenz und Emotionen.

Ajzen's (1985) theory of planned behavior explaining and predicting goal-directed behavior is extended by an emotional component. The extended theory of planned behavior is tested experimentally. N = 64 subjects play with two video games (a speed- and a problem-oriented game) under an achievement-motivational orientation. One half of the subjects plays both games in an easy version, the other half in a difficult version. The verbal emotional reactions to playing video games are grouped factor-analytically into an "activity emotion" and a "security emotion". Subjects playing video games in the difficult condition feel significantly more insecure, and perceive their behavioral control as significantly lower than subjects playing in the easy condition. Tests of the extended theory of planned behavior lead to significant squared multiple correlations for the dependent variables within the range of R2 = .20 to .58. The activity emotion accounts predominantly for a significant part of the variance of the attitude and the security emotion accounts for a significant part of the variance of the perceived behavioral control. No predictive power was found for the intention to play the games successfully.