[Decisive factors for an accomplished clinical claims and risk management]. / Entscheidende Faktoren des gelingenden klinischen Schaden- und Risikomanagements.

Damage to health caused by complications and errors is part of the reality of medical treatment. In order to avoid further negative consequences in the event of legal claims as a result of excessive processing times or unjustified refusals, a good cooperation between the physician and claims management in the clinic and the legal processor in liability insurance is required. In order to avoid false assumptions in claims processing, a critical analysis of the facts of the case is necessary. In addition, findings from claims management must be recorded and effectively implemented in the clinical practice.

The effect of peer review on mortality rates.

OBJECTIVE: Lowering of mortality rates in hospitals with mortality rates higher than accepted reference values for acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia, stroke, mechanical ventilation (MV) and colorectal surgery by using an external peer review process that identifies areas requiring rectification and implements protocols directed at improving these areas. DESIGN: Retrospective, observational, quality management study using administrative data to compare in-hospital mortality rates (pre and post an external peer review process that included adoption of improvement protocols) with reference values. SETTING: German general hospitals of a large, private group. PARTICIPANTS: Hospitals with mortality rates higher than reference values. INTERVENTIONS: Peer review of medical records by experienced, outside physicians triggered by in-hospital mortality rates higher than expected. Inadequacies were identified, improvement protocols enforced and mortality rates subsequently re-examined. MAIN OUTCOME MEASURES: Mortality rates 1 year before and 1 year after peer review and protocol use. RESULTS: For AMI, CHF, pneumonia, stroke, MV and colorectal surgery, the mortality rates 1 year post-peer review were significantly decreased as compared to pre-peer review mortality rates. The standardized mortality ratio for all of the above diagnoses was 1.45, 1 year before peer review, and 0.97, 1 year after peer review. The absolute risk reduction of 7.3% translates into 710 deaths in this population which could have been prevented. CONCLUSIONS: Peer review triggered and conducted in the manner described here is associated with a significant lowering of in-hospital mortality rates in hospitals that previously had higher than expected mortality rates.

Preoperative administration of etoricoxib in patients undergoing hip replacement causes inhibition of inflammatory mediators and pain relief.

OBJECTIVE: Administering cyclooxygenase-2 inhibitors preoperatively appears attractive since these drugs reduce post-operative pain, but do not increase the risk of post-operative bleeds, asthmatic attacks and stress-related gastrointestinal ulcers. In a former investigation, we could show that post-operative administration of etoricoxib reduces prostaglandin production in wound fluid, but the onset of action is variable due to delayed post-operative absorption. METHODS: In this study, we investigated the preoperative administration of etoricoxib in patients undergoing hip replacement. They received 120 mg etoricoxib or placebo 2 h before surgery and 1 day after in a double-blinded, randomized, parallel group design. RESULTS: A total of 11 patients were randomized (placebo n = 5; verum n = 6). We found high and constant levels of the drug in blood, central nervous system and wound fluid already at the end of surgery (t(max) < 2 h). This was accompanied by inhibition of prostaglandin production in the wound tissue (treatment p < 0.05), suppression of interleukin 6 increase in plasma (treatment p < 0.01), and - despite existing standard pain relief procedures - higher satisfaction with analgesics (time vs. treatment p < 0.05) and less demand for opioids (treatment p < 0.01) and intrathecal bupivacaine (treatment p = 0.05) administration. CONCLUSION: Administration of etoricoxib 2 h before surgery allows for an effective drug concentration in critical tissues, a reduction of the production of pro-inflammatory mediators and for better pain relief.

[Implant-related fractures of the femoral neck cone adapter of a modular short-stem hip prosthesis - patient management and operative technique]. / Implantatbedingte Brüche des Schenkelhals-Konusadapters einer modularen Kurzschaft-Hüftendoprothese - Patientenmanagement und OP-Technik.

AIM: In cases of unexpected and implant-related mechanical failures, optimal surgical treatment and provident information for the patients are mandatory. We describe the surgical method to revise the hip stem after fracture of the modular cone adapter of a short-stem hip prosthesis and the management of and information for all patients who have received a fracture-prone implant. METHOD: We present two out of four cases in a series of fractures of the femoral neck cone adapter of a modular short-stem hip prosthesis. The patients in our hospital were male, aged 69 and 52 years with a body weight of 73 and 88 kg. Implant failures occurred 18 and 20 months after the index THA. RESULTS: Using special instruments available at short notice, the revision operation can be carried out with a primary implant (case 2) with reasonable technical expenditure, unless pathological-anatomic reasons do not allow it (case 1 with varus-flexion deformity and a rotational deviation that required a revision long-stem with combined correction osteotomy). Once the implants were fully integrated and tightly secured to the bone, they were loosened with flexible thin chisels. Drilling a hole and a thread into the fractured cone adapter allows the connection of a removal instrument for implant extraction. The clinical and radiological examination showed good results with an HSS of 100 points at 24 months follow-up. Our institution decided to inform all 54 patients who had received the failure-prone implant device. The provision of advice to the patients at risk proved to be effective. CONCLUSIONS: When using new implants and procedures, the surgeons must inform the patients of hitherto unknown risks. The recipients of a failure-prone implant must be provided with comprehensive information. It is advisable for both the clinic and the manufacturer to contact the patients and advise them on how to cope with the situation. In most cases, the revision operation of the stem component can be performed with a primary implant without significant additional bone loss.

Molecular signatures and new candidates to target the pathogenesis of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic, inflammatory joint disease of unknown etiology and pronounced interpatient heterogeneity. To characterize RA at the molecular level and to uncover pathomechanisms, we performed genome-wide gene expression analysis. We identified a set of 1,054 genes significantly deregulated in pair-wise comparisons between RA and osteoarthritis (OA) patients, RA and normal donors (ND), or OA and ND. Correlation analysis revealed gene sets regulated identically in all three groups. As a prominent example secreted phosphoprotein 1 (SPP1) was identified to be significantly upregulated in RA compared with both OA and ND. SPP1 expression was found to correlate with genes expressed during an inflammatory response, T-cell activation and apoptosis, suggesting common underlying regulatory networks. A subclassification of RA patients was achieved on the basis of proteoglycan 4 (PRG4) expression, distinguishing PRG4 high and low expressors and reflecting the heterogeneity of the disease. In addition, we found that low PRG4 expression was associated with a more aggressive disease stage, which is in accordance with PRG4 loss-of-function mutations causing camptodactyly-arthropathy-coxa vara-pericarditis syndrome. Altogether we provide evidence for molecular signatures of RA and RA subclasses, sets of new candidate genes as well as for candidate gene networks, which extend our understanding of disease mechanisms and may lead to an improved diagnosis.

[Partial physeal growth arrest with increasing genu varum deformity caused by a cortical enchondroma--a case report]. / Partielle epiphyseale Brückenbildung mit zunehmendem Genu varum bei kortikalem Enchondrom--ein Fallbericht.

INTRODUCTION: Trauma or infectious diseases can cause destruction of the epiphyseal region of the knee with premature partial bridging of the physis and deviation of length and axis. There is only little information about tumorous lesions as pathogenetic factor for these deviations. We have been searching for an approach to take advantage of the particular growth potential in order to avoid further complex procedures. METHOD: We report the case of a 6-year-old girl with progredient varus deformity of the left knee and reduction of walking distance. The X-ray and MRI investigations have shown a benign lesion like osteofibroma of the mediodistal femur with an affection of the medial physis. Because of the early and rapidly progredient deformity we planned an operative intervention, including the following two steps: 1) resection of the benign lesion and arthroscopically assisted resection of the bony bar with fat-patch interposition; 2) lateral hemiepiphyseodesis with an eight-plate. The histological examination revealed a cortical enchondroma, which had caused the above-mentioned growth disturbance. During follow-up (clinical and radiological examinations every 3 months) we saw a nearly normal growth of the mediodistal femoral physis with consecutive correction of the axial deviation. RESULTS: With surgical intervention (resection and temporary lateral hemiepiphyseodesis) we achieved a complete deformity correction in reference to the opposite side within one year post operation. Removal of the eight-plate has already been accomplished. Follow-up will be continued until completion of growth. CONCLUSION: In cases of rare partial bridging of the physis induced by a benign bone tumour one can achieve early correction of axial deviation during growth with resection, interposition of a fat patch and temporary hemiepiphyseodesis. With the help of such a procedure it is possible to prevent further progression of a pre-existing deformity and later aggressive surgical intervention.

[Prevalence of musculoskeletal complaints and self-reported joint osteoarthritis in the population of Herne : a telephone survey]. / Prävalenz von muskuloskelettalen Beschwerden und selbstberichteter Gelenkarthrose in der Herner Bevölkerung : Ein Telefon-Survey.

BACKGROUND: Musculoskeletal pain is among the most common symptoms in the population and osteoarthritis is the most important underlying disease. Due to demographic changes, an increase in problems with arthritis is to be expected. To assess the impact on individuals affected and the community, data on the prevalence of musculoskeletal pain and osteoarthritis are essential. METHODS: We performed a telephone survey in a sample of 1,270 inhabitants of the City of Herne, Germany, aged 40 years and older. Participants were asked to give their experience on musculoskeletal pain at the time of the questionnaire and during the last 4 weeks and 12 months. Further questions were whether the knee or hip were the site of most severe pain and if osteoarthritis was ever diagnosed by a physician. Standardized prevalences are reported according to age. RESULTS: A total of 862 (67.9%) persons participated and participants were significantly older and more often female. Musculoskeletal pain on the day of the questionnaire, during the past 4 weeks and the past 12 months was reported in 37.4%, 53.0% and 60.0%, respectively. The knee and hip were predominantly affected in 35.9% and 16.1%, respectively and 26.2% reported that a physician had previously diagnosed osteoarthritis. The prevalences were related to age and gender. CONCLUSIONS: Musculoskeletal pain and osteoarthritis affect an important part of the adult urban population. We found associations between self-reported musculoskeletal pain, osteoarthritis, age and gender. Further studies should evaluate the interference of pain with activities of daily living as well as the use of health services by affected patients.

Topical diclofenac and its role in pain and inflammation: an evidence-based review.

OBJECTIVE: Topical diclofenac is widely used in the treatment of pain and inflammation. This comprehensive review assesses the safety and efficacy of topical diclofenac in a range of painful and inflammatory disorders. METHODS: Double-blind, randomized, placebo- or active-controlled trials (RCT) evaluating topical diclofenac in soft-tissue injuries, soft-tissue rheumatic disorders and osteoarthritis were identified through detailed literature searches. In addition, non-RCT evidence from publications evaluating the pharmacologic characteristics of topical diclofenac were also included in this review to obtain a more complete picture of the drug's profile, its efficacy and safety. RESULTS: Studies demonstrate that the drug preferentially distributes to the target tissues in sufficient concentrations to produce a therapeutic effect. A total of 19 double-blind RCTs in more than 3000 patients, supported by single-blind or open trials, consistently show that topical diclofenac significantly reduces pain and inflammation in acute and chronic conditions compared with placebo and is comparable to other topical non-steroidal anti-inflammatory drugs (NSAIDs) and some oral NSAIDs (diclofenac, ibuprofen, naproxen). Improvements have also been observed in patients' functional capacity and mobility. Topical diclofenac is well tolerated, resulting mostly in mild, easily resolved local skin irritation, and is associated with fewer side-effects than other topical NSAIDs and a lower rate of gastrointestinal complications than oral NSAIDs (diclofenac, ibuprofen, naproxen). CONCLUSION: This evidence-based review shows topical diclofenac to be an effective and well tolerated treatment in painful and inflammatory conditions, at least in the short-term. However, only published RCT studies have been included in this analysis, which may exclude some interesting data from non-RCT studies. Future trials of topical diclofenac need to be of longer duration, be better reported and consider a broader spectrum of acute and chronic pain indications.

[Imaging of osteoarthritis of the peripheral joints]. / Bildgebung bei der Arthrose peripherer Gelenke.

Pain and loss of function are the clinical signs of osteoarthritis (OA). Conventional x-rays confirm the diagnosis or provide important hints for differential diagnosis. In the natural course of OA, x-rays are performed at longer intervals when pain increases or therapy is without effect, especially if more invasive therapies, or even surgery, becomes necessary. The advantages of x-rays are worldwide availability, cost effectiveness, very long experience with this imaging method and the possibility of storing the images for long periods of time. The typical findings of OA can be detected only roughly by quantitative methods. In many patients, grading of OA does not correlate well with the clinical symptoms. X-ray changes are part of the American College of Rheumatology (ACR) classification criteria for OA of the hand, hip and knee. Ordinary s-rays can depicting bone with a higher local resolution than any other imaging technique. Soft tissues and cartilage can be visualized only indirectly. In OA, ultrasound is the method to depict intra-articular effusion at an early stage. Osteophytes or the degree of synovitis are also visible. Concomitant changes in tendons, bursae or cartilage, such as structures in the hip, shoulder and knee, can be evaluated. MRI is an appropriate tool for describing changes in cartilage volume and concomitant soft-tissue alterations. For qualitative cartilage imaging, MRI has, to date, not been fully validated. Bone scans (bone scintigraphy) allow the differentiation of inflammatory from degenerative joint affections and may add information on the activity of the subchondral bone, which may develop to a prognostic marker of OA. This survey represents recommendations of the Commission "Imaging Techniques" of the German Rheumatology Society regarding the technical and individual conditions, indications, practical guidance and the typical findings of imaging in OA.

Effect of field of view on the levitation illusion.

Supine subjects inside a furnished room in which both they and the room are pitched 90 degrees backwards may experience themselves and the room as upright relative to gravity. This effect is known as the levitation illusion because observers report that their arms feel weightless when extended, and objects hanging in the room seem to "levitate". This illusion is an extreme example of a visually induced illusion of static tilt. Visually induced tilt illusions are commonly experienced in wide-screen movie theatres, flight simulators, and immersive virtual reality systems. For technical reasons an observer's field of view is often constrained in these environments. No studies have documented the effect of field-of-view (FOV) restriction on the incidence of the levitation illusion. Preliminary findings suggest that when concurrently manipulating the FOV and observer position within an environment, the incidence of levitation illusions depends not only on the field of view but also on the visible scene content.

Gravity and perceptual stability during translational head movement on earth and in microgravity.

We measured the amount of visual movement judged consistent with translational head movement under normal and microgravity conditions. Subjects wore a virtual reality helmet in which the ratio of the movement of the world to the movement of the head (visual gain) was variable. Using the method of adjustment under normal gravity 10 subjects adjusted the visual gain until the visual world appeared stable during head movements that were either parallel or orthogonal to gravity. Using the method of constant stimuli under normal gravity, seven subjects moved their heads and judged whether the virtual world appeared to move "with" or "against" their movement for several visual gains. One subject repeated the constant stimuli judgements in microgravity during parabolic flight. The accuracy of judgements appeared unaffected by the direction or absence of gravity. Only the variability appeared affected by the absence of gravity. These results are discussed in relation to discomfort during head movements in microgravity.

The relative role of visual and non-visual cues in determining the perceived direction of "up": experiments in parabolic flight.

In order to measure the perceived direction of "up", subjects judged the three-dimensional shape of disks shaded to be compatible with illumination from particular directions. By finding which shaded disk appeared most convex, we were able to infer the perceived direction of illumination. This provides an indirect measure of the subject's perception of the direction of "up". The different cues contributing to this percept were separated by varying the orientation of the subject and the orientation of the visual background relative to gravity. We also measured the effect of decreasing or increasing gravity by making these shape judgements throughout all the phases of parabolic flight (0 g, 2 g and 1 g during level flight). The perceived up direction was modeled by a simple vector sum of "up" defined by vision, the body and gravity. In this model, the weighting of the visual cue became negligible under microgravity and hypergravity conditions.

Efficacy of lumiracoxib in osteoarthritis: a review of nine studies.

Lumiracoxib is a cyclooxygenase-2 selective inhibitor in development for the treatment of osteoarthritis (OA), rheumatoid arthritis and acute pain. We reviewed nine clinical studies of 1-52 weeks' duration demonstrating the efficacy of lumiracoxib in OA. Male and female patients aged > or = 18 years with primary OA of the hand, hip or knee received lumiracoxib, placebo or active comparators (diclofenac, celecoxib or rofecoxib). Lumiracoxib provided consistent reductions in OA pain intensity and improvements in the patient's global assessment of disease activity and functional status (assessed using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire or the Australian/Canadian OA Hand Index). These results were superior to placebo and similar to the active comparators tested. In addition, lumiracoxib was consistently superior to placebo and generally similar to active comparators in terms of the new Outcome Measures in Clinical Trials and Osteoarthritis Research Society International criteria. These were used to provide a single measure of response to treatment, taking into account pain, the patient's global assessment of disease activity and functional status.