Biopsychosocial complexity in patients scheduled for elective TKA surgery: A feasibility pilot study with the INTERMED self-assessment questionnaire.

OBJECTIVE: Primary aim; to determine the feasibility of implementation of the INTERMED Self-Assessment (IM-SA) in adult patients scheduled for total knee arthroplasty (TKA). Secondary aim; to measure biopsychosocial complexity, referral to psychiatry or psychology in cases of complexity and to gain insight into the relation between biopsychosocial complexity and length of stay (LOS), method of discharge (MOD) and polypharmacy. METHODS: A feasibility study was conducted with 76 participants in a general hospital in the Netherlands. Feasibility was determined by the number of completed questionnaires, time spent completing the questionnaire and the attitude of staff and patients towards the IM-SA. A cut off point ≥19 on the IM-SA was used to determine the prevalence of biopsychosocial complexity. A case file study was performed to check if referral to psychiatry or psychology had taken place. The Spearman's Rank Correlation Coefficient or Phi was used to determine if there was a relation between biopsychosocial complexity and LOS, MOD and polypharmacy. RESULTS: All participants completed the IM-SA. The average time spent completing the questionnaire was 11.46 min (SD 5.74). The attitude towards the IM-SA was positive. The prevalence of biopsychosocial complexity was 11.84%. Referral to psychiatry or psychology did not take place. There was no relation between complexity and LOS (Spearman's rho (r) = 0.079, p = 0.499, MOD (Phi = 0.169, p = 0.173) and polypharmacy (Phi = 0.007, p = 0.953). CONCLUSION: Biopsychosocial complexity can be identified in TKA patients during the pre-operative phase by using the IM-SA. Implementation of the IM-SA in a Dutch general hospital is feasible.

Transformative effect of a Humanitarian Program for individuals affected by rare diseases: building support systems and creating local expertise.

Rare diseases affect > 400 million people globally with a disproportionate burden falling on children, resulting in high morbidity and mortality rates. Affected individuals in some under-resourced countries have limited access to expert care or treatments; moreover, they suffer long diagnostic journeys during which debilitating and life-threatening complications occur. Lysosomal storage disorders (LSD) are prototype rare diseases due, in the main, to inherited deficiencies of lysosomal enzymes/transporters that affect up to 1 in 5000 newborns. Recognizing the need to provide treatment access to people with LSDs everywhere, a collaborative partnership was pioneered and set up 30 years ago. Partnering with local authorities, non-government organizations across six continents, local as well as international experts, a robust, sustainable Humanitarian Program emerged that now represents the most enduring charitable access program for LSD treatment. Here we present the history, process, lasting beneficial effect of the program to develop healthcare systems and infrastructures, and the lessons learned from addressing major unmet needs for LSDs.

Recommendations on how to provide cardiac rehabilitation services during the COVID-19 pandemic.

The ongoing coronavirus disease 2019 (COVID-19) crisis is having a large impact on acute and chronic cardiac care. Due to public health measures and the reorganisation of outpatient cardiac care, traditional centre-based cardiac rehabilitation is currently almost impossible. In addition, public health measures are having a potentially negative impact on lifestyle behaviour and general well-being. Therefore, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for the provision of cardiac rehabilitation during the COVID-19 pandemic, by using telerehabilitation programmes without face-to-face contact based on current guidelines supplemented with new insights and experiences.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation.

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Loss to follow-up among infants in a study of isoniazid prophylaxis (P1041) in South Africa.

OBJECTIVE: To assess risk factors for loss to follow-up (LFU) from the IMPAACT P1041 study, an isoniazid (INH) prophylaxis study conducted in southern Africa. DESIGN: Infants in two cohorts, human immunodeficiency virus-infected (HIV+) and HIV-exposed but non-infected (HIV-), were randomized to INH or placebo for 96 weeks. LFU was evaluated at week 96. RESULTS: Of 1351 infants, 12.9% were LFU (10.4% HIV+, 14.7% HIV-); 65% of the HIV+ cohort was asymptomatic. Among HIV+ infants, large household size (>6 vs. <4 members, P = 0.035) and presence of an elder (≥55 years, P = 0.05) were associated with better retention. Although attenuated in adjusted analysis, these associations held among HIV- infants. Among HIV- infants, having a younger mother increased the risk (P = 0.008) and maternal history of TB reduced the risk of LFU, the latter by nearly 70% (P = 0.048 univariate, 0.09 adjusted). LFU was largely due to inability to contact the participant (58% HIV+, 30% HIV-), and inability to attend the clinic and withdrawal of consent (HIV-). CONCLUSIONS: Household support was an important factor in participant retention, particularly for the non-HIV-infected cohort, as young maternal age was a risk factor for LFU. Retaining study participants from this mobile population can be challenging and may warrant additional support.

Juxta-articular myxoma of the knee in a 5-year-old boy: a case report and review of the literature (2009: 12b).

Juxta-articular myxoma (JAM) is a relatively rare variant of myxoma that occurs in the vicinity of large joints. It is composed of fibroblast-like cells that produce an excessive amount of glycosaminoglycans rich in hyaluronic acid. The peak incidence is between the 3rd and 5th decades of life. In this report we describe an extremely rare case of JAM in the knee of a 5-year-old child. The clinical presentation, radiological features and histopathologic findings are described, and the relevant literature is reviewed.

The versatility of progress testing assessed in an international context: a start for benchmarking global standardization?

Sharing and collaboration relating to progress testing already takes place on a national level and allows for quality control and comparisons of the participating institutions. This study explores the possibilities of international sharing of the progress test after correction for cultural bias and translation problems. Three progress tests were reviewed and administered to 3043 Pretoria and 3001 Maastricht medical students. In total, 16% of the items were potentially biased and removed from the test items administered to the Pretoria students (9% due to translation problems; 7% due to cultural differences). Of the three clusters (basic, clinical and social sciences) the social sciences contained most bias (32%), basic sciences least (11%). The differences that were found, comparing the student results of both schools, seem a reflection of the deliberate accentuations that both curricula pursue. The results suggest that the progress test methodology provides a versatile instrument that can be used to assess medical schools across the world. Sharing of test material is a viable strategy and test outcomes are interesting and can be used in international quality control.

Effect of nematode burden as assessed by means of faecal egg counts on body condition in goats farmed under resource-poor conditions in South Africa.

A longitudinal study was conducted of the nematode faecal egg counts (FECs) and body condition scores (BCSs) of goats of resource-poor farmers at Rust de Winter, Gauteng Province, Impendle, KwaZulu-Natal Province, and Kraaipan, North-West Province, South Africa. Periods of higher FECs occurred from December/January to March/April at Rust de Winter and at Impendle and from January to March at Kraaipan. Seasonal variations in body condition were evident in the goats at Impendle with the animals showing lower BCSs from June to October. The goats at Rust de Winter and at Kraaipan did not show clear seasonal variations, although the goats at Rust de Winter showed lower BCSs from mid-July to early December. The BCSs for Rust de Winter where the animals were grazed on a private farm were generally higher than those of the other sites, where communal grazing is practised.

Incidence of Haemonchus spp. and effect on haematocrit and eye colour in goats farmed under resource-poor conditions in South Africa.

The diversity and predominance of nematode genera in goats of resource-poor farmers at Rust de Winter, Gauteng Province, Impendle, KwaZulu-Natal Province, and Kraaipan, North-West Province, South Africa, was determined by means of a longitudinal study of the nematode faecal egg counts (FECs) and differential third-stage nematode larvae. The animals were bled for haematocrit determination and scored for pallor of ocular mucous membranes using the FAMACHA( Copyright) method, an assay for clinical evaluation of anaemia caused by Haemonchus spp. Animals considered to be in danger of dying from anaemia caused by haemonchosis were selectively treated with an anthelmintic. Lower haematocrit values were registered during periods of heavier Haemonchus infection, which occurred from December/January to March for Rust de Winter; from December to March/April for Impendle; and from November/December to February or April for Kraaipan. There was agreement too between the lower haematocrits and paler mucous membranes scored according to the FAMACHA( Copyright) method. The use of this system may be recommended as part of an integrated approach to worm control in goats kept in the resource-poor areas studied.

Haemonchus spp. in sheep farmed under resource-poor conditions in South Africa--effect on haematocrit, conjunctival mucous membrane colour and body condition.

A longitudinal study was conducted on the differential faecal egg counts, haematocrits and body condition scores of sheep belonging to resource-poor farmers at Rust de Winter, Gauteng province, and Kraaipan, North West Province, South Africa. The animals were scored for level of anaemia using the FAMACHA method, an assay for the clinical evaluation of anaemia caused by Haemonchus spp. Periods of higher Haemonchus egg counts occurred from October to March for sheep at Rust de Winter and from September/October to February or April for sheep at Kraaipan. Lower haematocrit values were registered during these periods as was a higher incidence of anaemic conjunctival mucous membrane colour scores compared to the period April to September. No clear relationship between the faecal egg counts and the body condition scores was evident. Although wider application of the FAMACHA system in sheep raised by resource-poor farmers should be investigated, the present study indicates that this method may certainly prove to be a valuable worm control strategy for such livestock owners.

Acetabular revision with impacted grafting and a reinforcement ring: 42 patients followed for a mean of 10 years.

We analyzed the outcome of 42 cemented cup revisions (40 patients) with morselized bone grafts and a reinforcement ring after median 10 (7-16) years. The acetabular component migrated a mean of 7 (5-8) mm in 5 hips. The migration stopped after 2 years except in 1 hip, the only one revised because of mechanical loosening. 3 other hips were revised because of infection. Among the other 38 hips (36 patients), the Merle d'Aubigné score increased from 9 to 15 points.

Testing for clinical anaemia caused by Haemonchus spp. in goats farmed under resource-poor conditions in South Africa using an eye colour chart developed for sheep.

A novel clinical assay for the assessment and subsequent treatment of Haemonchus infection in sheep to slow down the development of anthelmintic resistance--the FAMACHA system--has been developed, tested and validated in South Africa. The system is based on a colour chart with five colour categories depicting varying degrees of anaemia that are compared with the colour of the mucous membranes of the eyes of sheep. The animal is then scored from severely anaemic (pale) through anaemic to non-anaemic (red) and those animals considered in danger of succumbing to the effects of haemonchosis are treated. This method was tested in goats farmed under resource-poor conditions in South Africa. Analyses in goats performed during the summers of 1998/1999 and 1999/2000 show a test sensitivity of 76 and 85%, respectively, meaning that the system may be used to identify correctly 76-85% of those animals in need of treatment with an anthelmintic. However, the test specificity remains low at 52-55%. This means that a large proportion of those animals that would not require treatment would in fact be treated. However, when the use of the FAMACHA system is compared with conventional dosing practices where all the animals are treated, using the FAMACHA system would result in a large proportion of the animals being left untreated. The untreated animals are then able to deposit the eggs of anthelmintic-susceptible worms on the pasture, while the treated ones should pass very few ova, given an effective anthelmintic. This maintains a reservoir of susceptible larvae in refugia, and should slow down the development of anthelmintic resistance. The validation of the FAMACHA system for goats for use by resource-poor farmers, which this paper describes, may have wide application in the tropics and subtropics of sub-Saharan Africa and elsewhere.

The effect of frog pressure and downward vertical load on hoof wall weight-bearing and third phalanx displacement in the horse--an in vitro study.

A shoe was designed to combine the advantages of a reverse shoe and an adjustable heart bar shoe in the treatment of chronic laminitis. This reverse even frog pressure (REFP) shoe applies pressure uniformly over a large area of the frog solar surface. Pressure is applied vertically upward parallel to the solar surface of the frog and can be increased or decreased as required. Five clinically healthy horses were humanely euthanased and their dismembered forelimbs used in an in vitro study. Frog pressure was measured by strain gauges applied to the ground surface of the carrying tab portion of the shoe. A linear variable distance transducer (LVDT) was inserted into a hole drilled in the dorsal hoof wall. The LVDT measured movement of the third phalanx (P3) in a dorsopalmar plane relative to the dorsal hoof wall. The vertical component of hoof wall compression was measured by means of unidirectional strain gauges attached to the toe, quarter and heel of the medial hoof wall of each specimen. The entire limb was mounted vertically in a tensile testing machine and submitted to vertical downward compressive forces of 0 to 2,500 N at a rate of 5 cm/minute. The effects of increasing frog pressure on hoof wall weight-bearing and third phalanx movement within the hoof were determined. Each specimen was tested with the shoe under the following conditions: zero frog pressure; frog pressure used to treat clinical cases of chronic laminitis (7 N-cm); frog pressure clinically painful to the horse as determined prior to euthanasia; frog pressure just alleviating this pain. The specimens were also tested after shoe removal. Total weight-bearing on the hoof wall at zero frog pressure was used as the basis for comparison. Pain-causing and pain-alleviating frog pressures decreased total weight-bearing on the hoof wall (P < 0.05). Frog pressure of 7 N-cm had no statistically significant effect on hoof wall weight-bearing although there was a trend for it to decrease as load increased. Before loading, the pain-causing and pain-alleviating frog pressures resulted in a palmar movement of P3 relative to the dorsal hoof wall compared to the position of P3 at zero frog pressure (P < 0.05). This difference remained statistically significant up to 1300 N load. At higher loads, the position of P3 did not differ significantly for the different frog pressures applied. It is concluded that increased frogpressure using the REFP shoe decreases total hoof wall weight-bearing and causes palmar movement of P3 at low weight-bearing loads. Without a shoe the toe and quarter hoof wall compression remained more constant and less in magnitude, than with a shoe.

Nerve injury after hip arthroplasty. 5/600 cases after uncemented hip replacement, anterolateral approach versus direct lateral approach.

In 600 consecutive uncemented total hip replacements, 2 surgical approaches were used: the direct lateral Hardinge approach in supine position (group I: 241 cases) or in a lateral position (group II: 280 cases) and the anterolateral Watson-Jones approach in supine position (group III: 79 cases). 5 patients had clinically evident peripheral nerve injuries confirmed with EMG: none in group I, 1 lesion of the nervus ischiadicus and nervus femoralis in group II and 4 nervus femoralis lesions in group III, of which 1 was combined with an obturator nerve injury. The nerve injuries were evaluated with EMG. All 4 nervus femoralis lesions recovered spontaneously, but the one patients in group II had a persistent palsy of the peroneal nerve. The anatomical basis for the higher prevalence of nervus femoralis lesions in the anterolateral Watson-Jones approach is described.

Speech production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult.

Profoundly deaf cochlear implant users provide an interesting population in which to assess the role of distorted auditory feedback in speech, since their electrically stimulated hearing is significantly different from normal hearing. The aim of the study was to evaluate, by means of spectrographic and listener analyses, the speech production changes in a postlingually deafened adult with the use of a multichannel cochlear implant over time, compared to that of hearing aids as well as no-amplification. The results indicated significant improvements in the use of suprasegmental speech features as well in the production of specific segmental features of speech.

Lyme carditis: clinical characteristics of 105 cases.

105 North American and European cases of Lyme carditis, being documented and in part published in the period 1977-1990, are reviewed and compared. The male: female ratio was 3:1, as well in Europe as in the USA. Transient atrioventricular block is the most frequent manifestation of Lyme carditis, with a remarkable similarity in the frequency of complete AV block and attending neurological illness in Europe and the USA. The distribution of (maximal observed) atrioventricular block in all patients existed of 49% third degree, 16% second degree and 12% first degree. Data of electrophysiological studies show that affection of the cardiac conduction system can be local or very diffuse. Other manifestations like rhythm disturbances, (myo)pericarditis and heart failure were less striking and have a less similar frequency in the European and American cases. Medicational therapy seems not to be an unconditional requirement for recovery of Lyme carditis itself, but cannot be withheld because of the proven beneficial effects of antibiotic therapy in other manifestations of Lyme borreliosis. Temporary pacemakers are frequently inserted, but pacemaker implantation is rarely needed. The overall prognosis of Lyme carditis seems to be good, although delayed recovery has been described and possible late manifestations have been suggested.

Range of atrioventricular conduction disturbances in Lyme borreliosis: a report of four cases and review of other published reports.

Four patients with Lyme borreliosis had atrioventricular conduction disturbances. All four were positive for specific antibodies against Borrelia burgdorferi measured by indirect immunofluorescence tests. Biopsy specimens, which were obtained in three patients, showed band-like infiltrates of plasma cells and lymphocytes in the endocardium. There was diffuse infiltration of the interstitium of the myocardium by lymphocytes, plasma cells, and macrophages. In two patients single fibre necrosis was seen in the myocardium. Biopsy specimens of the heart showed spirochetes in all three patients and serial sections stained by the Bosma-Steiner technique showed that they resembled Borrelia burgdorferi. At follow up one patient had persistent complete atrioventricular block, despite treatment with antibiotics and corticosteroid, and a permanent pacemaker was implanted.

Demonstration of spirochetes in cardiac biopsies of patients with Lyme disease.

Cardiac involvement occurring early in Borrelia burgdorferi infection is a clinical manifestation of human Lyme disease. Therefore, two patients with acute complete atrioventricular heart blocks and unexplained recurrent dizziness were studied. Both patients had significantly elevated serum titers of IgM and IgG antibodies to B. burgdorferi. Right ventricular subendocardial biopsies showed dense infiltrates consisting of lymphocytes and plasma cells. Silver staining revealed spirochetes characteristic of B. burgdorferi near and in the infiltrates, between the muscle fibers, and in the endocardium. One patient responded to penicillin; the other did not, necessitating installation of a pacemaker. Thus, permanent heart damage may result from cardiac involvement in Lyme disease.

Transient complete AV block in Lyme disease. Electrophysiologic observations.

The findings in a patient with complete AV block and intra-atrial conduction disturbances due to Lyme disease are presented. The electrocardiographic follow-up and serial EP findings suggest that complete AV block in Lyme disease may signify a more extensive affection of the AV conduction system (with eventually attendant intra-atrial conduction disturbances) than described in earlier reports. An almost complete resolution of the considerable damage to the conduction system occurred within two weeks.