[Use of outcome measures in physical medicine/rheumatological rehabilitation. Results of a questionnaire study]. / Brugen af effektmål i fysiurgisk/reumatologisk rehabilitering. Resultat af en spørgeskemaundersøgelse.

BACKGROUND: As part of the EU-project ProESOR (Project for the European Standardisation of Outcome Measurement in Rehabilitation), a survey was undertaken to investigate the use of Outcome Measures (OM) within rehabilitation across Europe. This paper presents some of the Danish results of this survey. AIM: Evaluate the extent of use of OMs in rehabilitation. MATERIAL: All 37 Rheumatology/Physical Medicine and Rehabilitation departments and institutions in Denmark. METHOD: A questionnaire was mailed to the institutions. This included questions about the institution and its personnel, and nine diagnostic groups: Low back pain, multiple sclerosis, neuromuscular disorders, rheumatoid arthritis, spinal cord lesions, stroke, traumatic brain injury, hip and knee replacement, and lower limb amputees, with estimation of the number of patients treated and the extent of use of OMs. RESULTS: The majority of the departments treated more than 200 in- and out-patients per year. Patients with low back pain and rheumatoid arthritis were the largest patient groups, followed by patients with hip and knee replacement and stroke. OMs were most frequently used with rheumatoid arthritis and, to a lesser extent, patients with low back pain. Although many departments used one or more OM, several did not use any at all. For each diagnostic group more OMs were used if the patient was treated in a department specialised for patients with the particular diagnosis. More OMs were used with patients who tended to have longer inpatient stays. CONCLUSION: There is little consensus regarding which OMs should be used. We recommend that this challenge be taken up.

A prospective comparison between external fixation and plates for treatment of midshaft nonunions of the clavicle.

BACKGROUND AND AIMS: Several surgical techniques have been used to treat clavicular nonunions. The aim with this prospective study was to compare treatment of symptomatic midshaft clavicular nonunions with either external fixation or plating. PATIENTS AND METHODS: The study included two consecutive series where the first 11 patients (8 men and 3 women) were treated with external fixation (EF) while the following 13 patients (5 men and 8 women) were treated with internal fixation using a 3.5 mm reconstruction plate (RP). All patients had autologous cancellous bone graft. After on average 8.6 years (EF) and 5.4 years (RP), respectively, an independent observer evaluated the patients. RESULTS: In the EF-group 8/11 healed within 12 months while 3/11 healed after reoperation with a reconstruction plate and new bone grafting at 6-9 months. In the RP-group 12/13 healed within six months while 1/13 healed after two additional bone transplants. There was no hardware breakage. The healing time for the RP group was significant shorter when compared with the EF group even if the fractures that did not heal after the first operation were excluded. In 4 patients the plate was removed following healing. There was no significant difference in functional outcome between groups at follow up. CONCLUSION: The reconstruction plate was a better alternative than external fixation due to faster and more reliable healing. Patients commonly considered the external frame cumbersome.

Effect of local tranexamic acid gel in the treatment of epistaxis.

In patients with nosebleedings, the hemostatic effect of local application of tranexamic acid gel or placebo was compared in a randomized, double-blind, multicenter clinical trial with parallel groups. The times needed to arrest the initial bleeding were recorded, as well as any rebleedings within 10 days. The results showed no significant differences in any of the efficacy variables. Tranexamic acid was no better than placebo in the early treatment of nose bleedings, but the gel itself seemed to have a beneficial effect. The gel preparations were easy to insert into the nasal cavity and caused no discomfort to the patients.

Demonstration of dilatation of peripheral airways.

To investigate the ability of various lung-function tests to demonstrate dilatation of peripheral airways, ten asthmatics inhaled increasing doses of a beta 2-agonist by two different and controlled techniques. Low inspiratory flow with a long post-inspiratory pause favoured peripheral deposition, and a high inspiratory flow with a short post-inspiratory pause favoured central deposition of drug in the airways. Ordinary spirometry, maximum expiratory flow rates after breathing air as well as a helium-oxygen mixture, a single breath N2-test and resistance of the respiratory system were obtained before and after each of five terbutaline doses with both inhalation techniques. By using a double-dummy technique, the study could be performed double blinded. Effects were compared at doses giving equal effects on PEF, assumed to represent equal deposition of bronchodilator and effects on central airways. At such 'iso delta PEF doses', particularly FVC and the slope of phase III of the N2-test improved more following the slow inhalation technique. It is concluded that changes in those tests reflect dilatation in peripheral airways in asthmatics.

Biological equilibration of allergen preparations: methodological aspects and reproducibility.

A method for biological equilibration (BE) of allergen reference preparations using the skin-prick test (SPT) method and histamine HCl 10 mg/ml as reference substance (reference method), was evaluated. The precision was low for weals less than 10 mm2. The slope (log weal area/log concentration) of allergen and histamine did not vary significantly between investigators and allergens. The median slopes were 0.39 (n = 384) and 0.34 (n = 397), for allergen and histamine, respectively (P less than 0.01). The concentration of allergen eliciting a weal of the same size as that of histamine HCl 1 mg/ml (Chl) in the median sensitive patient, 1000 Biological Units/ml (BU/ml), did not vary significantly between clinics/geographical regions (grasses, mites and moulds). As BE is repeatable between regions, BUs estimated by this method are generally valid. A high correlation (r = 0.91, P less than 0.001) was found between the median Chl as estimated with histamine 1 and 10 mg/ml as reference substance, respectively. Thus, this reference method for BE is valid. The precision of the SPT method with histamine HCl 1 mg/ml is not as good as with 10 mg/ml, which is therefore recommended as the reference concentration.

Dose response relationship of allergen, histamine, and histamine releasers in skin prick test and precision of the skin prick test method.

The aim of the present investigation was to study the dose response relationship of allergen, histamine and histamine releasers in skin prick test (SPT) and the precision of the SPT method. In one experiment timothy allergen, histamine HCl, rabbit anti-human-IgE and compound 48/80 were studied in seven patients. In a second experiment timothy allergen and histamine and dog allergen and histamine were investigated in two groups of 10 patients. Histamine HCl 1 and 10 mg/ml induced weals about 15 and 25 mm2 (4.5 and 5.5 mm in diameter), respectively. The precision as expressed by the coefficient of variation was about 25% for histamine and 40% for allergen for weal areas greater than 10 mm2. Calculations of the regression lines to test the dose response relationships were based on the method of least squares. The best fit was to a log/log model. The slopes of allergen, histamine and histamine releasers were essentially parallel within patients. The median slope of allergen was estimated to about 0.4 based on weal areas and 0.2 based on mean weal diameters. Furthermore, no significant differences were found between the lower and upper parts of the dose response curves of allergen and histamine, although there was a tendency towards steeper slopes at lower concentrations. These results show that histamine concentrations greater than or equal to 1 mg/ml should be used as positive control in SPT and that histamine releasers do not offer advantages over histamine as reference substances in SPT. A common slope for the dose response relationship of allergen and histamine can be used for the estimation of skin sensitivity.

Relation between components of the immune response in rats sensitized by aerosol and subcutaneous injections.

Relations between the appearance of various components of the immune response were analyzed in two groups of rats sensitized by aerosol and subcutaneous injections in the neck region, respectively. The relations were expressed by Spearman rank correlation coefficient and studied by cluster analysis. In the aerosol-sensitized animals, there was a close association between IgA and IgG antibody levels in bronchial fluid and these in turn were related to IgG levels in serum and more loosely to IgE levels in bronchial fluid. There was an apparent association between IgE antibody formation and mast cell maturation in cultures of regional lymph node cells and the appearance of mucous cells in the lungs. These variables seemed associated with spontaneous cell proliferation in vitro and the numbers of mast cells in the lungs. This indicates that local stimulation with antigen induces local immune responses and immune-mediated migration of cells. In subcutaneously sensitized animals, formation of IgG antibodies in vitro seemed related to the stimulated proliferation of regional lymph node cells. The levels of IgG and IgE antibodies in bronchial fluid and in serum also appeared to be related. Unlike the findings in aerosol-sensitized animals there was no apparent relation between the differentiation of mast cells and mucous cells. This was possibly due to lack of immune-mediated antigen-induced cell migration. The different immune response patterns in aerosol and subcutaneously sensitized rats should be considered when studies are designed aiming to explore the pathogenesis of allergic inflammatory diseases. The findings also indicate that the various parameters of immunity are more closely related in aerosol than in subcutaneously immunized animals.

Environmental factors and uptake of cadmium among brazers using cadmium-containing hard solders.

The influence of different work factors on the uptake of cadmium has been studied in 102 brazers working at least 10% of their work day with cadmium-containing hard solders. The blood concentrations of cadmium varied between less than 1 and 113 micrograms/L (less than 9 and 1010 nmol/L). Blood cadmium concentrations were below 10 micrograms/L (89 nmol/L) in 71 brazers and 31 brazers had levels equal to or above that value. The importance of some environmental factors on the blood-level of cadmium was studied with discrimination analysis. The length of the splice was found to be almost the sole determining factor for the cadmium concentration in blood. All brazers working with splices shorter than 2 cm had blood concentrations below 10 micrograms/L, while 87% of the brazers working with splices longer than 10 cm had blood concentrations equal to or above 10 micrograms/L. Other factors like age, sex, exposure time, smoking habit and brazing method were devoid of any measurable importance.

Decomposition of a mixture into normal components: a review.

The problem of estimating the parameters of a finite mixture of normal distributions has been considered by several researchers in different fields of application. This paper consists of a brief historical background and a comprehensive account of the theoretical aspects behind the principal lines of approach of different techniques of estimation. These include moment- and maximum likelihood estimation, estimation by minimum variance decomposition and graphical techniques. Further, three different methods of estimation are compared on medical data.