Supplementary orthopaedic screening for children and adolescents to prevent permanent skeletal deformities - protocol for the "OrthoKids" study.

BACKGROUND: Skeletal deformities (SD) in children and adolescents can lead to arthritic conditions, impairment of quality of life, and high treatment costs in the long term. However, comprehensive data on the prevalence of SDs in children and adolescents are limited and it remains therefore unclear whether there is a healthcare gap. "OrthoKids" is a project that addresses this evidence gap by implementing an orthopaedic screening for children and adolescents that supplements existing detection examinations within statutory standard care in Germany. OBJECTIVE: To detect SDs so that they can be treated as needed at an early stage. METHODS: The implementation of the supplementary orthopaedic screening will be evaluated through an exploratory cohort study that is set up in the German state Baden-Wuerttemberg. 20,000 children and adolescents aged 10 to 14 years will be recruited as a prospective cohort. A retrospective control cohort will be formed based on claims data provided by two cooperating statutory health insurances (SHIs). Participating children and adolescents receive a one-time orthopaedic screening. If at least one SD is diagnosed, treatment will be provided as part of the statutory standard care. Within the scope of the project, a follow-up examination will be performed after one year. An IT-platform will complement the study. The primary outcome measure is the point prevalence of scoliosis, genu varum/valgum, hip dysplasia, and flat feet. Secondary outcome measures are (i) the point prevalence of further less common SDs, (ii) health-related quality of life (HRQoL), (iii) sports ability based on activity (physical/athletic), physical constraints, and (sports) injuries, as well as (iv) monetary consequences of the orthopaedic screenings' implementation. Implementation determinants will be evaluated, too. DISCUSSION: If the supplementary orthopaedic screening proves to be viable, it could be considered as a supplementary examination for children and adolescents within the frame of SHI in Germany. This could relieve the burden of disease among children and adolescents with SDs. In addition, it could disburden SHIs in the medium to long term. TRIAL REGISTRATION: The OrthoKids study was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 26th July 2022 under the number 00029057.

Secondary prevention of minor trauma fractures: the effects of a tailored intervention-an observational study.

INTRODUCTION: Minor trauma fractures (MTF) in the elderly are associated with an increase in mortality, morbidity, and the risk of subsequent fractures. Often, these patients who sustain MTF have an underlying bone disease, such as osteopenia or osteoporosis. Osteoporosis is known to be underdiagnosed and undertreated, and adequate treatment is essential to reduce the occurrence of MTFs. At our hospital, this has led to the implementation of Osteofit, a patient-education-based intervention targeted at improving screening and prevention of osteoporosis, with the goal to reduce the rate of subsequent MTF. OBJECTIVE: The aim of this study was to assess the efficacy of Osteofit in improving osteoporosis screening and treatment in patients after an initial MTF episode. METHODS: The study is a prospective, single-center, cohort study of MTF patients aged 50 years or older. A standardized questionnaire and telephone interview were used to collect 1-year follow-up data. The primary outcome was the rate of patients undergoing Dual X-ray Absorptiometry (DXA) scanning. Secondary outcomes were the rate of patients with a diagnosis of osteoporosis or osteopenia, the rate of patients treated with anti-osteoporotic medication, and the rate of patients with a subsequent fracture. DXA scanning rate, the prevalence of a diagnosis (osteoporosis/osteopenia), and data on medical treatment for osteoporosis were compared to the results of a previous study in the same hospital, published in 2004. RESULTS: Between 2012 and 2015, 411 of 823 eligible patients consented to participate and were included in this study. The mean age was 72 ± 9.3 years. Sixty-three percent (63.3%, n = 252) of the patients received a DXA scan, compared to 12.6% reported in our previous study. Of all patients who received a DXA scan, 199 (82.9%) were diagnosed with osteoporosis or osteopenia. A total of 95 patients (23.1%) received specific medical treatment for osteoporosis and 59.8% reported the intake of any unspecific medication (vitamin D, calcium, or both). Fifteen patients (3.9%) had a subsequent fracture as a result of a minor trauma fall. CONCLUSION: The implementation of a MTF secondary prevention program with dedicated health professionals improved the rate of patients who underwent DXA screening by fivefold. Despite this improvement, DXA screening was missed in over a third of patients, with only 23% of eligible patients receiving specific medical treatment for osteoporosis at 1-year follow-up. Consequently, this tailored intervention is a promising first step in improving geriatric fracture care. However, further work to improve the rate of osteoporosis screening and medical treatment initiation for the long-term prevention of subsequent MTF is recommended. We believe osteoporosis screening and adequate osteoporosis medication should be integrated as standard procedure in the aftercare of MTF. LEVEL OF EVIDENCE: II.

[Recommendations for the Stepwise Occupational Reintegration: Can the Characteristic of the Patients Explain the Differences Between the Rehabilitation Centers?]. / Nachsorgeempfehlungen zur stufenweisen Wiedereingliederung: Inwieweit erklären Rehabilitandenmerkmale die bestehenden Unterschiede zwischen den Einrichtungen?

BACKGROUND: The first step to initiate a stepwise occupational reintegration (SOR) is the recommendation of the rehabilitation centers. Therefore rehabilitation centers have a significant impact on the use of SOR. There is evidence that the recommendation rate between the rehabilitation centers differs clearly. The present survey therefore analyses in detail the differences of the recommendation rate and examines which patient-related factors could explain the differences. METHODS: This study is based on analysis of routine data provided by the German pension insurance in Baden-Württemberg (Rehabilitationsstatistikdatenbasis 2013; RSD). In the analyses rehabilitation measures were included if they were conducted by employed patients (18-64 years) with a muscular-skeletal system disease or a disorder of the connective tissue. Logistic regression models were performed to explain the differences in the recommendation rate of the rehabilitation centers. RESULTS: The data of 134 853 rehabilitation measures out of 32 rehabilitation centers were available. The recommendation rate differed between the rehabilitation centers from 1.36-18.53%. The logistic regression analysis showed that the period of working incapacity 12 month before the rehabilitation and the working capacity on the current job were the most important predictors for the recommendation of a SOR by the rehabilitation centers. Also the rehabilitation centers themselves have an important influence. DISCUSSION: The results of this survey indicate that the characteristic of the patients is an important factor for the recommendation of SOR. Additionally the rehabilitation centers themselves have an influence on the recommendation of SOR. The results point to the fact that the rehabilitation centers use different criteria by making a recommendation.

[Bilateral Instability of the Interphalangeal Articulation of the Thumb in Hajdu-Cheney Syndrome]. / Instabilität der Daumenendgelenke beidseits bei Hajdu-Cheney-Syndrom.

We present the case of a 52-year-old lady suffering from Hajdu-Cheney syndrome, a rare hereditary disease, which was referred to our clinic on the basis of progressive instability of the interpalangeal articulations of both thumbs. Even if acroosteolysis of the distal phalangeal bones is typical for this disease, to the best of our knowledge the interphalangeal instability has not been described before.

[The User Survey on the Revision of the Classification of Therapeutic Procedures]. / Die Anwenderbefragung zur Aktualisierung der Klassifikation therapeutischer Leistungen (KTL).

INTRODUCTION: An extensive user survey was conducted in the context of updating the Classification of Therapeutic Procedures (KTL 2015). This paper reflects the results of the user survey and raises critical discussion points. METHODS: The user survey was sent to all rehabilitation centers contracted by the German pension insurance as well as professional associations. The user survey was available both as a paper questionnaire and as an online version. The feedback of the user survey provided an important basis for the revision of the KTL. RESULT: The survey yielded 1,868 suggestions from 360 users. Most of them related to chapters E ("occupational therapy, work therapy, other functional therapy") and C ("information, motivation, training"). The change from German diplomas to the international Bachelor's and Master's degrees, and the inclusion of diagnostic and work-related procedures were the main focus of the user feedback. CONCLUSION: For the revision of the KTL, the user survey provided valuable information. Only by the inclusion of practitioners can the KTL meet the requirements of realistic and comprehensive acquisition of data on therapeutic procedures also in future.

Altered emotionality and neuronal excitability in mice lacking KCTD12, an auxiliary subunit of GABAB receptors associated with mood disorders.

Gamma-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the brain, is fundamental to brain function and implicated in the pathophysiology of several neuropsychiatric disorders. GABA activates G-protein-coupled GABAB receptors comprising principal GABAB1 and GABAB2 subunits as well as auxiliary KCTD8, 12, 12b and 16 subunits. The KCTD12 gene has been associated with bipolar disorder, major depressive disorder and schizophrenia. Here we compare Kctd12 null mutant (Kctd12(-/-)) and heterozygous (Kctd12(+/-)) with wild-type (WT) littermate mice to determine whether lack of or reduced KCTD12 expression leads to phenotypes that, extrapolating to human, could constitute endophenotypes for neuropsychiatric disorders with which KCTD12 is associated. Kctd12(-/-) mice exhibited increased fear learning but not increased memory of a discrete auditory-conditioned stimulus. Kctd12(+/-) mice showed increased activity during the inactive (light) phase of the circadian cycle relative to WT and Kctd12(-/-) mice. Electrophysiological recordings from hippocampal slices, a region of high Kctd12 expression, revealed an increased intrinsic excitability of pyramidal neurons in Kctd12(-/-) and Kctd12(+/-) mice. This is the first direct evidence for involvement of KCTD12 in determining phenotypes of emotionality, behavioral activity and neuronal excitability. This study provides empirical support for the polymorphism and expression evidence that KCTD12 confers risk for and is associated with neuropsychiatric disorders.

[Quality assurance in outpatient neurological rehabilitation: measuring the effects of rehabilitation with the competency rating scale]. / Qualitätssicherung in der ambulanten neurologischen Rehabilitation: Messung der Rehabilitationseffekte mit der Marburger Kompetenz Skala.

BACKGROUND: So far, there are only few studies concerning the outcome of outpatient neurological rehabilitation in Germany. Considering the statutory obligations of quality assurance there is an urgent need of appropriate instruments to assess the rehabilitation outcome. The aim of this study was to assess the appropriateness of the Competency Rating Scale (CRS), which was used to measure rehabilitation outcome, and to collect data of the effects of outpatient neurological rehabilitation as a measure of rehabilitation outcome. METHODS: The basis of this study was data collected between 2008 and 2011. During that period the data of all patients of an outpatient neurological rehabilitation center were consecutively collected. There were no exclusion criteria. To measure rehabilitation outcome patients' self ratings with the CRS were used. To check the appropriateness of the CRS the dropout rate and the missing values were analysed. In addition, the patients' self ratings were compared with the data of a near relative rating with the CRS. RESULTS: On examining the entire group of patients, statistically significant improvements over time were found in the motor as well as in the cognitive-psychosocial areas. The analysis of the data with regard to the appropriateness of the CRS showed considerable ceiling effects and a high dropout rate. Differences between the self and the near relative ratings could be detected. CONCLUSION: For the overall group of patients positive effects of outpatient neurological rehabilitation can be proven. The assessment instrument used in this study is only partially suitable for assessing the outcome of outpatient neurological rehabilitation. The comparison of self and near relative ratings can systematically be used in the therapy process.

[Degenerative rupture of the hip abductors. Missed diagnosis with therapy-resistant trochanteric pain of the hips and positive Trendelenburg sign in elderly patients]. / Degenerative Ruptur der Hüftabduktoren. Verpasste Diagnose bei therapieresistenter Periarthropathie der Hüfte und positivem Trendelenburg-Zeichen des älteren Patienten.

The cases of four elderly patients with persistent trochanteric pain and tears of the gluteus medius and/or gluteus minimus tendons detected in magnetic resonance imaging (MRI) are presented. There was no history of local trauma in any patient but three patients had a positive Trendelenburg sign. Magnetic resonance imaging showed either an obvious discontinuity of the affected tendon or an increased T2 signal above, or less specifically lateral to the greater trochanter. The presence of an elongated tendon on MRI is most likely indicative of a partial rupture of the tendon. Pain and local tenderness over the lateral aspect of the hip in clinical examination is commonly attributed to trochanteric bursitis or trochanteric pain syndrome. Partial or complete tears of the gluteus medius and/or gluteus minimus tendons are thought to represent an unusual finding. However, the true incidence and the clinical significance of hip abductor degeneration and rupture remain to be determined. More studies are needed to examine the prevalence of ruptures in asymptomatic patients, to evaluate the subsequent risk for developing osteoarthritis of the hip (caused by impaired protective reflexes originating from proprioceptive nerve endings in muscle spindles) and to determine the risk for falls related to weakness of hip abduction. Furthermore, no data exist regarding the success rate of conservative treatment. Tears of the gluteus medius and minimus tendons in the elderly population are likely to be a more common cause of pain in the greater trochanteric region than previously thought. In patients who do not respond to conservative treatment, weakness of hip abduction (positive Trendelenburg sign) and new limping should point to the possibility of hip abductor ruptures. The most useful examination technique for diagnosis is MRI.

[Symptoms and cognition in geriatric schizophrenia]. / Symptomatik und Kognition bei Schizophrenie im Alter.

From the first manifestation of schizophrenic psychosis onwards numerous psychopathological symptoms and cognitive impairments occur, which are affected by age and the aging process. Clinical trials report a pronounced incidence of positive symptoms in late-onset schizophrenia. Negative symptoms are often observed in chronic-course psychosis, but occur infrequently in late-onset-schizophrenia. With respect to cognitive performance neuropsychological studies have shown a decrease in the test performance of permanently hospitalised patients with chronic schizophrenia as age and illness duration increased. Comparative studies of early and late-onset patients in most cases have reported no differing profiles of cognitive performance. Some investigators propose that late-onset schizophrenia may be a prodromal symptom of dementia. However, current studies show that late-onset schizophrenia is basically comparable to its early-onset counterpart. The manifestation in youth and early adulthood may be prevented by specific protective factors until aging-related parameters lead to the onset of symptoms during late life.

Dynamics of red blood cells and vesicles in microchannels of oscillating width.

We have studied the dynamics of red blood cells and fluid lipid vesicles in hydrodynamic flow fields created by microchannels with periodically varying channel width. For red blood cells we find a transition from a regime with oscillating tilt angle and fixed shape to a regime with oscillating shape with increasing flow velocity. We have determined the crossover to occur at a critical ratio L(y)/v(m) ≈ 2.2 × 10⁻³ s with channel width L(y) and red blood cell velocity v(m). These oscillations are superposed by shape transitions from a discocyte to a slipper shape at low velocities and a slipper to parachute transition at high flow velocities.

Surface acoustic wave actuated cell sorting (SAWACS).

We describe a novel microfluidic cell sorter which operates in continuous flow at high sorting rates. The device is based on a surface acoustic wave cell-sorting scheme and combines many advantages of fluorescence activated cell sorting (FACS) and fluorescence activated droplet sorting (FADS) in microfluidic channels. It is fully integrated on a PDMS device, and allows fast electronic control of cell diversion. We direct cells by acoustic streaming excited by a surface acoustic wave which deflects the fluid independently of the contrast in material properties of deflected objects and the continuous phase; thus the device underlying principle works without additional enhancement of the sorting by prior labelling of the cells with responsive markers such as magnetic or polarizable beads. Single cells are sorted directly from bulk media at rates as fast as several kHz without prior encapsulation into liquid droplet compartments as in traditional FACS. We have successfully directed HaCaT cells (human keratinocytes), fibroblasts from mice and MV3 melanoma cells. The low shear forces of this sorting method ensure that cells survive after sorting.

Induction of complete and sustained remission of rheumatoid pachymeningitis by rituximab.

Aseptic pachymeningitis is a rare and serious complication of rheumatoid arthritis (RA). Herein, we describe a patient with rheumatoid factor-positive and anti-cyclic citrullinated peptide-positive RA who experienced a focal seizure, with aphasia and convulsions of the right side of the body. The findings of magnetic resonance imaging and histologic analysis led to a diagnosis of rheumatoid pachymeningitis. Because the patient had a large number of CD20-expressing B lymphocytes, therapy with rituximab was started and has resulted in complete and sustained remission of both the pachymeningitis and the RA for >2 years. Despite a decrease in immunoglobulins, the patient has remained free of infections, which illustrates the favorable outcome that can result from therapeutic B cell depletion in this potentially lethal manifestation of RA.

Probing the Kondo density of states in a three-terminal quantum ring.

We have measured the Kondo effect in a quantum ring connected to three terminals. In this configuration nonlinear transport measurements allow us to check which lead contributes to the Kondo density of states (DOS) and which does not. The ring geometry allows a fine-tuning of the coupling to each lead through the Aharonov-Bohm effect via application of a magnetic field. When the ring is connected to two strongly and one weakly coupled leads, conductance through the weakly coupled lead provides a direct measurement of the DOS in the Kondo regime. By applying a bias between the two strongly coupled leads, we demonstrate directly the splitting of the out-of-equilibrium Kondo DOS.

Education in end-of-life care: bridging disciplinary and institutional boundaries.

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

Are living beings in the state of self-organized criticality? A new interpretation of data on work incapacity due to low back pain.

Using data published elsewhere I demonstrate in this paper that the frequency distribution of the duration of work incapacity from low back pain follows a power law. Power laws are not common in medicine and the question arises why we can find one here. The peculiarity of the data considered here is that they embrace not only the passive reaction but also the whole spectrum of possible active responses of a living being to a disturbance. For the duration of sick leave due to low back pain is not only influenced by the defect a person is affected by, but even more dependent on how he or she copes with it. Coping comprises a broad range of possibilities from denial of the disability to its aggravation, from therapy to malingering. In contrast to the scientific ideal none of these faculties has been excluded in the data used here. They concern the whole living being. Power laws are typical for systems in the state of self-organized criticality. The system involved in the case of low back pain is the whole living human being with all its possibilities to react and to respond. Thus, my findings support empirically the hypothesis that living beings are in the state of self-organized criticality.

Ketamine-induced deficits in auditory and visual context-dependent processing in healthy volunteers: implications for models of cognitive deficits in schizophrenia.

BACKGROUND: In patients with schizophrenia, deficient generation of mismatch negativity (MMN)-an event-related potential (ERP) indexing auditory sensory ("echoic") memory-and a selective increase of "context dependent" ("BX") errors in the "A-X" version of the Continuous Performance Test (AX-CPT) indicate an impaired ability to form and use transient memory traces. Animal and human studies implicate deficient N-methyl-D-aspartate receptor (NMDAR) functioning in such abnormalities. In this study, effects of the NMDAR antagonists ketamine on MMN generation and AX-CPT performance were investigated in healthy volunteers to test the hypothesis that NMDARs are critically involved in human MMN generation, and to assess the nature of ketamine-induced deficits in AX-CPT performance. METHODS: In a single-blind placebo-controlled study, 20 healthy volunteers underwent an infusion with subanesthetic doses of ketamine. The MMN-to-pitch and MMN-to-duration deviants were obtained while subjects performed an AX-CPT. RESULTS: Ketamine significantly decreased the peak amplitudes of the MMN-to-pitch and MMN-to-duration deviants by 27% and 21%, respectively. It induced performance deficits in the AX-CPT characterized by decreased hit rates and specific increases of errors (BX errors), reflecting a failure to form and use transient memory traces of task relevant information. CONCLUSIONS: The NMDARs are critically involved in human MMN generation. Deficient MMN in schizophrenia thus suggests deficits in NMDAR-related neurotransmission. N-methyl-D-aspartate receptor dysfunction may also contribute to the impairment of patients with schizophrenia in forming and using transient memory traces in more complex tasks, such as the AX-CPT. Thus, NMDAR-related dysfunction may underlie deficits in transient memory at different levels of information processing in schizophrenia. Arch Gen Psychiatry. 2000;57:1139-1147.

Management of irregular astigmatism.

Using a liberal definition of corneal irregularity, modern videokeratoscopy may define approximately 40% of normal corneas with a toric refractive error as possessing primary irregular astigmatism. The causes of secondary forms of irregular astigmatism include corneal surgery, trauma, dystrophies, and infections. Internal refractive surface and media irregularity or noncorneal astigmatism (ocular residual astigmatism) contribute to irregular astigmatism of the entire refractive path of which crystaline lenticular astigmatism is usually the principal contributing component. Treatment options have increased in recent years, particularly, though not exclusively, through the advent of tailored corneal excimer laser ablations. However, discussion continues concerning the systematic approach necessary to enable treatment to achieve an optimal optical surface for the eye. Discussion also continues as to what constitutes the optimal corneal shape. Some refractive procedures may increase higher order aberrations in the attempt to neutralize refractive astigmatism. The way to further refinement of the commonly performed refractive techniques will ultimately lie in the integrated inclusion of a trio of technologies: topographic analysis of the corneal surface, wavefront analysis of ocular refractive aberrations, and vector planning to enable the appropriate balance in emphasis between these two diagnostic modalities. For the uncommon, irregularly roughened corneas, the ablatable polymer techniques show some promise.

Characteristics and prognosis of myocardial infarction in patients with normal coronary arteries.

STUDY OBJECTIVES: Myocardial infarction with angiographically normal coronary arteries (MINC) is a life-threatening event with many open questions for physicians and patients. There are little data concerning the prognosis for patients with MINC. DESIGN: Retrospective follow-up study. SETTING: Tertiary referral center. PATIENTS: Patients with MINC were investigated and compared to age- and sex-matched control subjects with myocardial infarction due to coronary artery disease (CAD). The patients were examined clinically using stress exercise and hyperventilation tests. Migraine and Raynaud's symptoms were determined by means of a standardized questionnaire. Serum lipoproteins; the seroprevalence of cytomegalovirus, Helicobacter pylori, and Chlamydia pneumoniae infections; and the most frequent causes of thrombophilia were assessed. MEASUREMENTS AND RESULTS: From > 4,300 angiographies that were performed between 1989 and 1996, 21 patients with MINC were identified. The mean +/- SD patient age at the time of myocardial infarction was 42 +/- 7.5 years. When compared to control subjects (n = 21), patients with MINC had fewer risk factors for CAD. In contrast, MINC patients had more frequent febrile reactions prior to myocardial infarction (six patients vs zero patients; p < 0.05), and the migraine score was significantly higher (7.1 +/- 6.3 vs 2.2 +/- 4.1; p < 0.01). The seroprevalence of antibodies against cytomegalovirus, C pneumoniae, and H pylori tended to be higher in patients with MINC and CAD as compared to matched healthy control subjects. Three patients with MINC vs none with CAD had coagulopathy. During follow-up (53 +/- 37 months), no major cardiac event occurred in the MINC group; no patients with MINC vs nine with CAD (p = 0.0001) underwent repeated angiography. CONCLUSION: High migraine score and prior febrile infection together with a lower cardiovascular risk profile are compatible with an inflammatory and a vasomotor component in the pathophysiology of the acute coronary event in MINC patients. The prognosis for these patients is excellent.

Comparison of ender nails, dynamic hip screws, and Gamma nails in the treatment of peritrochanteric femoral fractures.

Three hundred seventy-six patients with peritrochanteric fractures treated over a 10-year period were reviewed. In 85 patients treated with Ender nailing, the most frequent complications were leg shortening (34), external rotation failure (21), and postoperative distal gliding of the nails (7). In 183 patients treated with dynamic hip screws or a 95 degree condylar or a 130 degree blade plate, 3 presented with infection, 5 with instability, and 4 with femoral head necrosis. In 105 patients treated with Gamma nailing, the most serious complications were infections (3), inward rotation failure (2), postoperative bleeding at the insertion site (2), and shaft fracture (1). Because of its inherent instability, Ender nailing is no longer used. The implantation technique for the dynamic hip screw is safer and simpler than the various models of the ASIF blade plate. However, the dynamic hip screw has been superseded by the Gamma nail because of its absolute stability. In the beginning, Gamma nailing was technically more demanding with a higher number of intraoperative complications. In this study, the number of malalignments did not differ significantly between the dynamic hip screw (14) and the Gamma nail (11), but was high with Ender nailing (56).