[Long-term changes in multimodal intensive tinnitus therapy : A 5­year follow-up. German version]. / Langzeitveränderung bei multimodaler Tinnitustherapie : Eine 5­Jahres-Katamnese.

BACKGROUND: We present 5­year follow-up data for tinnitus-specific and comorbid depressive symptoms as well as stress-related outcome variables of an intensive multimodal 7­day tinnitus therapy. METHOD: Tinnitus burden (Tinnitus Questionnaire), stress (Perceived Stress Questionnaire), and depressive symptomatology (General Depression Scale) were measured at the 5­year follow-up after a multimodal intensive 7­day intervention. In all, 94 patients participated in the study. RESULTS: All outcome variables showed significant improvement at the end of the 7­day intensive treatment. These effects remained significant after 5 years. CONCLUSION: The results of the present study support the effectiveness of the 7­day multimodal intensive therapy for tinnitus. Posttreatment improvements were related to both tinnitus burden as well as stress and depressive symptoms and were maintained at the 5­year follow-up.

Erratum to: Long-term changes in multimodal intensive tinnitus therapy. A 5-year follow-up.

Erratum to:HNO 2018 66 (Suppl):S34-S38 https://doi.org/10.1007/s00106-017-0463-4 Figure 1 was published incorrectly in the online version of this paper. The correct Figure is reproduced below.

Long-term changes in multimodal intensive tinnitus therapy : A 5­year follow-up.

BACKGROUND: We present 5­year follow-up data for tinnitus-specific and comorbid depressive symptoms as well as stress-related outcome variables of an intensive multimodal 7­day tinnitus therapy. METHOD: Tinnitus burden (Tinnitus Questionnaire), stress (Perceived Stress Questionnaire), and depressive symptomatology (General Depression Scale) were measured at the 5­year follow-up after a multimodal intensive 7­day intervention. In all, 94 patients participated in the study. RESULTS: All outcome variables showed significant improvement at the end of the 7­day intensive treatment. These effects remained significant after 5 years. CONCLUSION: The results of the present study support the effectiveness of the 7­day multimodal intensive therapy for tinnitus. Posttreatment improvements were related to both tinnitus burden as well as stress and depressive symptoms and were maintained at the 5­year follow-up.

Ex vivo kinematic studies of a canine unlinked semi-constrained hybrid total elbow arthroplasty system.

OBJECTIVES: Introduction of the Sirius® canine total elbow arthroplasty system, and presentation of the results of a passive range-of-motion analysis based on ex vivo kinematic studies pre-and post-implantation. MATERIALS AND METHODS: Thoracic limbs (n = 4) of medium sized dogs were harvested by forequarter amputation. Plain orthogonal radiographs of each limb were obtained pre- and post-implantation. Limbs were prepared by placement of external fixator pins and Kirschner wires into the humerus and radius. Each limb was secured into a custom-made box frame and retro-reflective markers were placed on the exposed ends of the pins and wires. Each elbow was manually moved through five ranges-of-motion manoeuvres. Data collected included six trials of i) full extension to full flexion and ii) pronation and supination in 90° flexion; a three-dimensional motion capture system was used to collect and analyse the data. The Sirius elbow prosthesis was subsequently implanted and the same measurements were repeated. Data sets were tested for normality. Paired t-tests were used for comparison of pre- and post-implantation motion parameters. RESULTS: Kinematic analysis showed that the range-of-motion (mean and SD) for flexion and extension pre-implantation was 115° ± 6 (range: 25° to 140°). The range-of-motion in the sagittal plane post-implantation was 90° ± 4 (range: 36° to 130°) and this reduction was significant (p = 0.0001). The ranges-of-motion (mean and SD) for supination and pronation at 90° were 50° ± 5, whereas the corresponding mean ranges-of-motion post-implantation were 38° ± 6 (p = 0.0188). CONCLUSION: Compared to a normal elbow, the range-of-motion was reduced. Post-implantation, supination and pronation range-of-motion was significantly reduced at 90° over pre-implantation values. CLINICAL RELEVANCE: These results provide valuable information regarding the effect of the Sirius system on ex vivo kinematics of the normal canine elbow joint. Further, this particular ex vivo model allowed for satisfactory and repeatable kinematic analysis.

Patellar ligament rupture in the dog: repair methods and patient outcomes in 43 cases.

The medical records of dogs receiving surgery for unilateral patellar ligament rupture between 1999 and 2012 at 12 multidisciplinary referral centres were reviewed. Forty-three cases were identified; 26 were traumatic in origin; almost one-third were iatrogenic, of which over three-quarters occurred as a complication following surgical stabilisation of patellar luxation. Treatment involved primary reapposition of the ligament (36 cases). The repair was protected by circumpatellar and/or transpatellar loop(s) of orthopaedic wire, nylon, polypropylene or polydioxanone suture (34 cases). Wire loops were more likely to require surgical removal compared with loops of other materials (P=0.0014). The stifle joint was immobilised postoperatively by the applications of a transarticular external skeletal fixator (taESF) in 17 cases and by external coaptation (EC) in 8 cases; in 18 cases, no postoperative joint immobilisation was provided. Complications specific to the method of immobilisation occurred in seven of the cases with taESF and six of the cases with EC. Revision surgery to address failure of repair was required in five cases. Outcome was classified as acceptable or good in over three-quarters of the cases (31/40) and poor in less than a quarter (9/40). These data highlight patellar ligament rupture as a complication of surgical stabilisation of patellar luxation.

Radiographic and ultrasonographic changes of the patellar ligament following tibial tuberosity advancement in 25 dogs.

INTRODUCTION: Patellar ligament thickening is a recognized response following osteotomy of the proximal tibia as a treatment for cranial cruciate disease. In humans this is seen as a response to increased loading, but the reason for this thickening in dogs is unclear. A prospective study was undertaken to assess the degree and frequency of patellar ligament desmopathy in 25 consecutive cases undergoing tibial tuberosity advancement (TTA). OBJECTIVES: To determine the incidence of patellar ligament thickening following TTA. METHODS: Consecutive cases undergoing TTA had ultrasonographic and radiographic measurements performed of the patellar ligament, at multiple positions on the ligament. This was performed at the time of surgery, and at six weeks and six months (ultrasound only) following surgery. The radiographic measurements were performed by two reviewers who were blinded to the timeframe of each image. RESULTS: There was great variation in both the incidence and degree of thickening of the ligament. Fifty percent of the cases showed no changes in the thickness of the patellar ligament. A clinical pain response was not associated with patellar ligament thickening. No statistically significant variables which predicted the development of patellar ligament thickening were identified . CLINICAL SIGNIFICANCE: The presence of signs of patellar ligament thickening is of questionable clinical significance and is probably an incidental finding.

Cranial tibial plating in the management of failed tibial tuberosity advancement in four large breed dogs.

The management of failed surgical procedures involving osteotomy for tibial tuberosity advancement can be demanding due to the limited available bone stock, which must be large enough to counteract the powerful proximal and cranial distractive forces exerted by the quadriceps mechanism. Initial mode of failure may be related to implant failure, fracture of the tibial tuberosity, or a combination of both. The complications and management of the cases reported here were all associated with avulsion fracture of the tibial tuberosity following tibial tuberosity advancement. In all cases, a cranial tibial dynamic compression plate was applied to reduce the fractures and stabilize the osteotomy. No further major complications associated with the implants or fracture occurred. Radiographic evidence of progression of fracture healing was documented in all four cases at the six to eight-week postoperative follow-up. Long-term follow-up information was available for three out of four cases at nine to 23 months after surgery by telephone interview and validated owner questionnaires. Owners reported return to normal exercise with intermittent lameness occurring in two of the three cases. The authors concluded that this technique offers an alternative technique for the management of such fractures, in particular in large breed dogs where sufficient tibial tuberosity bone stock remains.

Comparison of forced-air warming systems with lower body blankets using a copper manikin of the human body.

BACKGROUND: Forced-air warming has gained high acceptance as a measure for the prevention of intraoperative hypothermia. However, data on heat transfer with lower body blankets are not yet available. This study was conducted to determine the heat transfer efficacy of six complete lower body warming systems. METHODS: Heat transfer of forced-air warmers can be described as follows:[1]Qdot;=h.DeltaT.A where Qdot; = heat transfer [W], h = heat exchange coefficient [W m-2 degrees C-1], DeltaT = temperature gradient between blanket and surface [ degrees C], A = covered area [m2]. We tested the following forced-air warmers in a previously validated copper manikin of the human body: (1) Bair Hugger and lower body blanket (Augustine Medical Inc., Eden Prairie, MN); (2) Thermacare and lower body blanket (Gaymar Industries, Orchard Park, NY); (3) WarmAir and lower body blanket (Cincinnati Sub-Zero Products, Cincinnati, OH); (4) Warm-Gard(R) and lower body blanket (Luis Gibeck AB, Upplands Väsby, Sweden); (5) Warm-Gard and reusable lower body blanket (Luis Gibeck AB); and (6) WarmTouch and lower body blanket (Mallinckrodt Medical Inc., St. Luis, MO). Heat flux and surface temperature were measured with 16 calibrated heat flux transducers. Blanket temperature was measured using 16 thermocouples. DeltaT was varied between -10 and +10 degrees C and h was determined by a linear regression analysis as the slope of DeltaT vs. heat flux. Mean DeltaT was determined for surface temperatures between 36 and 38 degrees C, because similar mean skin temperatures have been found in volunteers. The area covered by the blankets was estimated to be 0.54 m2. RESULTS: Heat transfer from the blanket to the manikin was different for surface temperatures between 36 degrees C and 38 degrees C. At a surface temperature of 36 degrees C the heat transfer was higher (between 13.4 W to 18.3 W) than at surface temperatures of 38 degrees C (8-11.5 W). The highest heat transfer was delivered by the Thermacare system (8.3-18.3 W), the lowest heat transfer was delivered by the Warm-Gard system with the single use blanket (8-13.4 W). The heat exchange coefficient varied between 12.5 W m-2 degrees C-1 and 30.8 W m-2 degrees C-1, mean DeltaT varied between 1.04 degrees C and 2.48 degrees C for surface temperatures of 36 degrees C and between 0.50 degrees C and 1.63 degrees C for surface temperatures of 38 degrees C. CONCLUSION: No relevant differences in heat transfer of lower body blankets were found between the different forced-air warming systems tested. Heat transfer was lower than heat transfer by upper body blankets tested in a previous study. However, forced-air warming systems with lower body blankets are still more effective than forced-air warming systems with upper body blankets in the prevention of perioperative hypothermia, because they cover a larger area of the body surface.

Comparison of forced-air warming systems with upper body blankets using a copper manikin of the human body.

BACKGROUND: Forced-air warming with upper body blankets has gained high acceptance as a measure for the prevention of intraoperative hypothermia. However, data on heat transfer with upper body blankets are not yet available. This study was conducted to determine the heat transfer efficacy of eight complete upper body warming systems and to gain more insight into the principles of forced-air warming. METHODS: Heat transfer of forced-air warmers can be described as follows: Qdot;=h. DeltaT. A, where Qdot;= heat flux [W], h=heat exchange coefficient [W m-2 degrees C-1], DeltaT=temperature gradient between the blanket and surface [ degrees C], and A=covered area [m2]. We tested eight different forced-air warming systems: (1) Bair Hugger and upper body blanket (Augustine Medical Inc. Eden Prairie, MN); (2) Thermacare and upper body blanket (Gaymar Industries, Orchard Park, NY); (3) Thermacare (Gaymar Industries) with reusable Optisan upper body blanket (Willy Rüsch AG, Kernen, Germany); (4) WarmAir and upper body blanket (Cincinnati Sub-Zero Products, Cincinnati, OH); (5) Warm-Gard and single use upper body blanket (Luis Gibeck AB, Upplands Väsby, Sweden); (6) Warm-Gard and reusable upper body blanket (Luis Gibeck AB); (7) WarmTouch and CareDrape upper body blanket (Mallinckrodt Medical Inc., St. Luis, MO); and (8) WarmTouch and reusable MultiCover trade mark upper body blanket (Mallinckrodt Medical Inc.) on a previously validated copper manikin of the human body. Heat flux and surface temperature were measured with 11 calibrated heat flux transducers. Blanket temperature was measured using 11 thermocouples. The temperature gradient between the blanket and surface (DeltaT) was varied between -8 and +8 degrees C, and h was determined by linear regression analysis as the slope of DeltaT vs. heat flux. Mean DeltaT was determined for surface temperatures between 36 and 38 degrees C, as similar mean skin surface temperatures have been found in volunteers. The covered area was estimated to be 0.35 m2. RESULTS: Total heat flow from the blanket to the manikin was different for surface temperatures between 36 and 38 degrees C. At a surface temperature of 36 degrees C the heat flows were higher (4-26.6 W) than at surface temperatures of 38 degrees C (2.6-18.1 W). The highest total heat flow was delivered by the WarmTouch trade mark system with the CareDrape trade mark upper body blanket (18.1-26.6 W). The lowest total heat flow was delivered by the Warm-Gard system with the single use upper body blanket (2.6-4 W). The heat exchange coefficient varied between 15.1 and 36.2 W m-2 degrees C-1, and mean DeltaT varied between 0.5 and 3.3 degrees C. CONCLUSION: We found total heat flows of 2.6-26.6 W by forced-air warming systems with upper body blankets. However, the changes in heat balance by forced-air warming systems with upper body blankets are larger, as these systems are not only transferring heat to the body but are also reducing heat losses from the covered area to zero. Converting heat losses of approximately 37.8 W to heat gain, results in a 40.4-64.4 W change in heat balance. The differences between the systems result from different heat exchange coefficients and different mean temperature gradients. However, the combination of a high heat exchange coefficient with a high mean temperature gradient is rare. This fact offers some possibility to improve these systems.

Clinical experiences with low-molecular weight heparins in pediatric patients.

The courses of 79 children (2 weeks to 19 years old) treated with two different low-molecular weight heparins (LMWHs)--nadroparin (n=66) and enoxaparin (n=13)--were retrospectively analysed. In 62 patients, LMWHs were given for short-term prophylaxis (1-2 weeks) during immobilization after surgery or trauma. Thirteen children with thromboembolic events received long-term prophylaxis with LMWHs for 2-18 months--six after thrombolytic therapy and seven after therapy with unfractionated heparin (UFH). Because of thromboembolic events, four patients were initially treated with LMWHs. In all patients with short-term prophylaxis, no thrombosis occurred. After thrombolytic therapy, three children had no reocclusion, two had no thrombus apposition and one had complete recanalization. In the seven patients treated with LMWHs after UFH, four had no reocclusion, two had recanalization and one had reocclusion. In all patients receiving LMWHs for initial treatment of thrombosis, no thrombus apposition, but also no recanalization, occurred. For short-term prophylaxis, nadroparin was used independent of the body weight and without determination of anti-factor Xa (anti-FXa) activity. Long-term prophylaxis was given mainly as doses of 45-100 anti-FXa U/kg resulting in anti-FXa activities between 0.2 and 0.4 U/ml. For treatment of thrombosis, doses of 200-300 anti-FXa U/kg corresponded to 0.5-1.0 anti-FXa U/ml. Side effects--slight gastrointestinal bleeding and temporary reversible hair loss--were seen in two patients. In conclusion, LMWHs proved to be efficacious and safe especially in prophylaxis of thromboembolic events in children.

[Late complications after transcatheter closure of atrial septal defect]. / Spätkomplikation nach katheterinterventionellem Vorhofseptumdefektverschluss.

The transcatheter closure of atrial septal defects is generally accepted as an alternative to surgical therapy in selected patients. Potential complications of these devices are a matter of concern, as well as the very complicated implantation technique required for some systems. We report on a 17 year old patient in whom embolization of a fractured umbrella arm into a peripheral branch of the left pulmonary artery occurred. A 35 mm-ASDOS-Device (protected trademark of the Dr. Osypka GmbH/Grenzach-Wyhlen, Germany) had been implanted 4 years ago. The perfusion scintigraphy of the left lung showed normal pulmonary blood flow. Echocardiography failed to demonstrate instability of the double-umbrella device. The patient was always free of any symptoms. Due to the permanent stresses between device and heart, late fractures of the device and embolizations of fragments are possible. It can be concluded that patients who underwent transcatheter closure of an ASD require lifelong follow-up.

Costs of tuberculosis for households and health care providers in Dar es Salaam, Tanzania.

OBJECTIVE: To assess the costs of tuberculosis at household level in Dar es Salaam and to compare them with the provider costs of the national tuberculosis control programme. DESIGN: Tuberculosis patients were found by active case searching within a routine census in three areas of Dar es Salaam, and by examining records for residents already receiving treatment. Costs at household level were evaluated through a cross-sectional household survey. RESULTS: One hundred and ninety-one tuberculosis cases were included in the survey. With treatment periods of 8 to 12 months, extrapolated average costs of a period of illness to patients and their families were as follows: US 2 dollars for examination and laboratory costs, between US 17 dollars and US 50 dollars for consultation and drugs, less than US 1 dollar for hospitalization and between US 13 dollars and US 20 dollars for transport. The analysis revealed high costs due to inability to work, ranging from US 154 dollars to US 1384 dollars. These data were compared with the operation costs of the tuberculosis programme and proved to comprise 68% to 94% of total costs. CONCLUSIONS: For patients and their families, tuberculosis implies three main types of cost: drugs, transportation and, most importantly, financial loss due to inability to work. They represent around two thirds of total cost and are a high economic burden for households, in particular those with a low-income. While assessing tuberculosis control strategies such as direct case finding at home, it is therefore important to also include costs incurred at household level.

Decentralization and central and regional coordination of health services: the case of Switzerland.

As part of reforms in the health care delivery sector, decentralization is currently promoted in many countries as a means to improve performance and outcomes of national health care systems. Switzerland is an example of a country with a long-standing tradition of decentralized organization for many purposes, including health care delivery. Apart from the few aspects where the responsibility is at the federal level, it is the task of the 26 cantons to organize the provision of health services for the population of around 7 million people. This permits the system to be responsive to local priorities and interest as well as to new developments in medical and public health know-how. However, the increasing and complex difficulties of most health care delivery systems raise questions about the need for mechanisms for coordination at federal level, as well as about the equity and the effectiveness of the decentralized approach. The Swiss case shows that in a strongly decentralized system, health policy and strategy elaboration, as well as coordination mechanisms among the regional components of the system, are very hard to establish. This situation may lead to strong regional inequities in the financing of health care as well as to differences in the distribution of financial, human and material inputs into the health system. The study of the Swiss health system reveals also that, within a decentralized framework, the promotion of cost-effective interventions through a well-balanced approach towards promotional, preventive and curative services, or towards ambulatory and hospital care, is difficult to achieve, as agreements between relatively autonomous regions are difficult to obtain. Therefore, a decentralized system is not necessarily the most equitable and cost-effective way to deliver health care.

Episiotomy in Burkina Faso.

Episiotomy is a common obstetric intervention in many countries of the world, although little is known about rates in African countries. In recent years, the effectiveness of routine episiotomy to prevent severe tears and neonatal asphyxia has been questioned, and evidence shows that the procedure results in considerable maternal morbidity. This study estimates episiotomy rates in Burkina Faso. A high proportion of primigravidae (46%) received an episiotomy when trained midwives attended the delivery; a level which indicates the procedure has to be regarded as routine practice. The episiotomy rate was lower (26%) in primigravidae delivered by auxillary midwives. This proportion is closer to recommended selective approaches derived from good research summaries. The tear rate in women assisted by midwife and auxiliary staff was similar, suggesting that women tear even when the procedure is performed. These results indicate that obstetricians and midwives in Burkina Faso should critically appraise whether routine episiotomy should be abandoned. The introduction of a labour chart is a good vehicle to introduce a policy on avoiding episiotomies.

Utilisation of government and private health services in Dar es Salaam.

Following the liberalisation of medical practice in Tanzania since the early 1990's, and the introduction of user fees in public hospitals in 1993, a household survey evaluated utilisation of health care in Dar es Salaam. A sample of 6,589 inhabitants was interviewed in April 1995 by means of a two-stage cluster sampling technique. Of the respondents, 32% reported some use of health care within the previous two weeks. Among these respondents, 35% had used government health services, 41% had used private services and self-treatment was chosen by 27%. The user patterns identified reveal that adults aged 15-49 years used government health service least often. Use of government services clearly decreased as the level of education, socioeconomic class and wealth status of the zone of residence of the ill person increased. Conversely in the study sample, there was an apparent tendency for people with a high level of education or belonging to a rich socio-economic class to use private facilities more often. The data also indicate that already after two years the private sector plays an important role in providing medical care and that a two-tier system of health care delivery is developing. In order to render the private sector complementary to public services, there is need for a coherent policy on legislation, development, regulation and control of private sector health services as well as a monitoring system to reinforce the policies.

[Sexuality and AIDS. KAPB study accomplished in 1989 in a school environment in Ouagadougou (Burkina Faso)]. / Sexualité et SIDA. Etude CAPC réalisée en 1989 en milieu scolaire à Ouagadougou (Burkina Faso).

AIDS is nowadays one of the major problems of public health in Burkina Faso. In order to get informations on pupils' sexual behaviour and knowledge about AIDS, we conducted a study on a representative sample from secondary schools' students in Ouagadougou (n = 466). The mean age was 18.2 years old; 48.7% among these pupils declared to have had least one sexual intercourse. The mean age of the first intercourse was 16.3 years old. For them, media was the main information source on AIDS (72.1%), whereas schools were not named. 58.4% mentioned condom as a mean of prevention and 64.1% among males who have had a sexual experience used condom. Although they were afraid of AIDS the school students asked did not think they were likely to contract the illness; but they pointed out the prostitutes as a risk behaviour group. These results are discussed according to the gravity of AIDS. So, the risky sexual behaviour, due to ignorance and/or thoughtlessness, endanger this youth and challenge all actors.

Quality of primary outpatient services in Dar-es-Salaam: a comparison of government and voluntary providers.

This study aimed to test whether voluntary agencies provide care of better quality than that provided by government with respect to primary curative outpatient services in Dar-es-Salaam. All non-government primary services were included, and government primary facilities were randomly sampled within the three districts of the city. Details of consultations were recorded and assessed by a panel who classed consultations as adequate, inadequate but serious consequences unlikely, and consultations where deficiencies in the care could have serious consequences. Interpersonal conduct was assessed and exit interviews were conducted. The study found that government registers of non-government 'voluntary' providers actually contained a high proportion of for-profit private providers. Comparisons between facilities showed that care was better overall at voluntary providers, but that there was a high level of inadequate care at both government and non-government providers.

The right objectives in health care planning.

In Dar es Salaam, United Republic of Tanzania, the traditional epidemiological approach to health service planning has been superseded by a process-oriented approach. The implications for managers are discussed below.

PIP: Health planning in Tanzania has been based upon epidemiological considerations, with population needs for health services expressed in terms of health status and disease profiles. In 1989, however, a project was launched with Tanzanian and Swiss government funding to improve the physical and functional status of the public health system in Dar es Salaam. The aims were to strengthen management capacities at the city and district levels, to rehabilitate the health service infrastructure, which had deteriorated since the early 1980s because of reduced resources and population growth, and to develop a health care strategy for the city. A process-oriented approach to health service planning is now in place in Dar es Salaam. Selected indicators are not epidemiological, but are pragmatic process markers intended to allow targets to be set which can easily be monitored. These changes are seen as a step toward improving service delivery.