Childhood tuberculosis in an urban population in South Africa: burden and risk factor.

AIM: To study the epidemiology of childhood tuberculosis (TB) in a developing country. SETTING: Two urban communities of Cape Town, South Africa with a TB case notification rate of 1149/100 000. DESIGN: Retrospective descriptive study using the national population census (1991), 10 year official TB notification records, and a geographical information system. RESULTS: The case notification rate of TB in children 0-5 years old was 3588 cases/100 000 children aged 0-5 years, 3.5 times the case notification rate in adults. Children (0-14 years) accounted for 39% of the total case load. Childhood TB case notification rate correlated with parental education (r = -0.64), annual household income (r = -0.6), and crowding (r = 0.32). CONCLUSION: Children, especially those living in poor socioeconomic conditions, form an important epidemiological group and account for a notable proportion of the morbidity caused by TB. Efforts to improve TB control must therefore not only target adults (case detection and cure of infectious cases) but also children (screening of child contacts of adult cases) and the socioeconomic living conditions.

[The pivot-shift test in relation to hip position and lower leg rotation. A clinical analysis]. / Der Pivot-shift-Test in Abhängigkeit von Hüftstellung und Unterschenkelrotation. Eine klinische Analyse.

In a prospective clinical study conducted on 50 patients with isolated insufficiency of the anterior cruciate ligament (ACL), we investigated the triggering of pivot shift as a function of the position of the hip joint and the rotational position of lower leg; the results were compared with those yielded by the Lachman test. The pivot shift phenomenon was found to be more readily triggered when the hip was abducted, and especially when the investigator had specified external rotation of the lower leg at the same time. Our results show that this modification of the classic pivot shift test can fill a diagnostic gap in the clinical investigation. The pivot shift test with hip abduction and external rotation of the lower leg is a valuable alternative test for the diagnosis of ACL insufficiency.

The use of a geographical information system (GIS) to evaluate the distribution of tuberculosis in a high-incidence community.

OBJECTIVE: To determine the geographical distribution of tuberculosis in the two Western Cape suburbs with the highest reported incidence of tuberculosis. DESIGN: Descriptive illustrative study. SETTING: Two adjacent Western Cape suburbs covering 2.42 km2 with a population of 34,294 and a reported tuberculosis incidence of > 1,000/100,000. SUBJECTS: All patients notified as having tuberculosis over a 10-year period (1985-1994). INTERVENTIONS: None OUTCOME MEASURE: The geographical distribution of the cases was determined using a geographical information system (GIS) and the National Population Census (1991). RESULTS: One thousand eight hundred and thirty-five of the 5,345 dwelling units (34.3%) housed at least 1 case of tuberculosis during the past decade and in 483 houses 3 or more cases occurred. These cases were distributed unevenly through the community, with the tuberculosis incidence per enumerator subdistrict (ESD) varying from 78 to 3,150/100,000 population. CONCLUSION: In a small area with a high incidence of tuberculosis, the cases are spread unevenly through the community and there are certain houses where tuberculosis occurs repeatedly. This information should be used to direct health services to concentrate on certain high-risk areas.

[Overview, analysis and evaluation of the 1995 public health structural law and the federal social care law from the viewpoint of the trauma surgery department of a university clinic. Measures for preparation of a new reimbursement system and documentation requirements]. / Uberblick, Analyse und Bewertung des Gesundheitsstrukturgesetzes und der Bundespflegesatzverordnung 1995 aus der Sicht der Unfallchirurgischen Abteilung eines Universitätsklinikums. Massnahmen zur Vorbereitung der neuen Entgeltsysteme und Dokumentationspflichten.

All doctors in Germany are required to cooperate in the implementation of the health system reform and the new system for reimbursement of the hospitals to limit the negative consequences to the patients. It would be absolutely wrong to leave the medical services of the insurance companies to define the diagnosis-related groups and determine the charges. The revision of the health system is beneficial in that it supports the economical independence of hospital departments. It is a good idea for them to be paid by results; however, there are no established methods of measuring results or efficacy in medicine. Germany is about 10 years behind the USA in this, so that our country is not yet ready for this reform. Hospital departments do have the freedom to make economic decisions, being heavily dependent on the insurances and the government, because most people who work in hospital are paid from these sources. Departments of trauma or orthopaedic surgery are disadvantaged by the reform, because of the number and kind of diagnosis related groups and the method of reimbursement. This leads to a profit-oriented system of medical documentation, with possible upcoding of diagnoses in future. The present health reform most probably will not increase the efficiency of hospitals; it will not be possible to attain cost reductions with the same level of medical care. The reduced reimbursement will force doctors to cut down their expenses and restrict diagnostic and therapeutic procedures. On the other hand the administration sector in hospitals and insurances will expand dramatically in future.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of somatostatin to biochemical parameters in patients with primary hyperparathyroidism.

Somatostatin (SRIF) is effective in the nonoperative management of a variety endocrine tumors. A potential role of SRIF for treatment of patients with primary hyperparathyroidism (pHPT) has been suggested. In a controlled, prospective, triple-blinded, randomized clinical trial, the somatostatin analogue octreotide (SMS 201-995, Sandostatin) was evaluated in 40 patients with well documented pHPT. Amongst other biochemical parameters, serum calcium and-phosphate and levels of parathyroid hormone, calcitonin, and osteocalcin as well as octreotide were assessed before and for 4 hours after a single iv. application of 200 micrograms ocreotide or placebo. SRIF-receptor autoradiography was performed in parathyroid tissue samples. Baseline values revealed a constellation of biochemical parameters typically found in pHPT. Following 200 micrograms octreotide, no significant changes in any of the biochemical parameters investigated for were observed. Multivariate analysis was performed to identify patient subpopulations in which any given combination of laboratory parameters changed in response to either drug or placebo. However, no 'responders' to octreotide were identified. 45% of patients receiving octreotide, reported side effects. Parathyroid tissue samples were negative for SRIF-receptor expression. It is concluded that a single dose iv. application of octreotide does not result in appreciable changes of biochemical parameters relevant in pHPT and carries a high rate of side effects. Furthermore, absence of SRIF-receptors in parathyroid tissue from patients with pHPT, together with lack of octreotide effects, suggests that somatostatin-analogues may not be effective in the non-operative therapy of pHPT.

Resorbable dowels for osteosynthesis of noncongruent bone fragments.

Dowels, in contrast to screws, offer the great advantage in osteosynthesis that no pressure peaks occur by functional loading rectangular to the screw axis; consequently, there is no bone resorption and no loosening of the fixation because of the even contact of dowel and bony surface. However, dowels must be made of resorbable materials because they cannot be removed. We developed double-spreading dowels with a slotted tube whose outside is cylindric and the inside conical at both ends. Two conical screws in the core of the dowel moved toward each other cause symmetric expansion of the outer surface. Dowel material consisted of polylactic acid with an inherent viscosity > 7 dl/g (Resomer 214, Böhringer Ingelheim). A model simulating retromolar sagittal split osteotomy was chosen for experimental research because, in this case, noncongruent bone segments have to be osteosynthesized to regenerate in the sense of distance osteogenesis. Two segments of synthetic material were synthesized like proximal and distal segments after retromolar sagittal split osteotomy fixed by two or three dowels without coherent contact. The synthesized segments underwent a continuous jiggling stress test comparable with the physiologic stress of a jaw for about 4 weeks. Dowel fixation proved to be nearly as stable as position-screw fixation. Resorbable dowel fixation yields experimentally the required stability for the time needed for bony regeneration.

[Is prevention of thromboembolism in ambulatory and conservative therapy of rupture of the fibular ligament of the upper ankle joint necessary?]. / Ist eine Thromboembolieprophylaxe bei ambulanter und konservativer Therapie der fibularen Bandruptur des oberen Sprunggelenks erforderlich?

In a prospective clinical study, 111 outpatients with tears of the lateral ankle ligaments were investigated for the occurrence of deep venous thrombosis (DVT). All patients had been treated by a plaster cast for 1 week and had not received any form of DVT prophylaxis. After removal of the plaster cast (mean 7.1 days), colour flow imaging of the veins of the injured leg was performed. A phlebography was undertaken whenever there was any suspicion of DVT. Risk factors for thrombosis [3, 10] were documented in all patients. Besides injury and immobilisation, a median of 1.2 (0-4) risk factors for DVT was involved. Only 31 patients had no additional risk factors at all. Median age of the patients was 26.1 years (16-53 median range). Only 1 patient over 40 years of age was diagnosed as having DVT, and none under 40. Therefore, medicamentous prophylaxis of DVT is not considered necessary in outpatients younger than 40 years with ankle ligament tears treated by bi-valved casts in cases when there are no additional risk factors (Table 4) for DVT.

Unknown effects of clinically used drugs as bias in clinical trials: antihistaminergic activity of the antihypertensive fixed-dose combination Betathiazid.

In a controlled clinical trial on histamine release in anaesthesia, it was suspected that the antihypertensive fixed-dose combination drug Betathiazid masked clinical signs of histamine release. By structure analysis of its constituents (propranolol, triamterene and hydrochlorothiazide), hydrochlorothiazide was considered to be most likely an H1-antagonist. An aqueous solution of the whole drug tablet (2 x 10(-4) M propranolol, 2.9 x 10(-5) M triamterene, 1.7 x 10(-5) M hydrochlorothiazide) and of the individual substances (1 microM each) was tested in the classical H1-receptor assay using the guinea pig ileum. Betathiazid in total suppressed the contraction to histamine (78% inhibition), but not to carbachol. Propranolol and triamterene had depressive effects (14% and 38% inhibition), but hydrochlorothiazide potentiated the contractions to histamine (75% potentiation). In all cases, the type of antagonism was not competitive. Although different mechanisms may account for the modulatory effects of Betathiazid, they have to be considered in the interpretation of clinical studies, especially for relating mediator concentrations with clinical signs.

Selection of variables using 'independence Bayes' in computer-aided diagnosis of upper gastrointestinal bleeding.

In this paper two problems of computer-aided diagnosis with 'independence Bayes' were investigated: selection of variables and monotonicity in performance as the number of measurements is increased. Using prospective data from patients with upper gastrointestinal bleeding, the stepwise forward selection approach maximizing the apparent diagnostic accuracy was analysed with respect to different kinds of bias in estimation of the true diagnostic accuracy and to the stability of the number and type of variables selected. The results of this study suggest first that the selection of variables should be evaluated against the estimated true diagnostic accuracy obtained using all variables, and secondly that the results of a single selected sequence may be severely biased.