[Complication management following resection and reconstruction of the upper limbs and shoulder girdle]. / Komplikationsmanagement nach Tumorresektion und Defektrekonstruktion an der oberen Extremität und am Schultergürtel.

BACKGROUND: Sarcomas of the upper limbs commonly affect the proximal humerus or scapula. Complications after tumor resection and reconstruction are rare but cannot be neglected, particularly after tumor endoprosthetic reconstructions. MATERIALS AND METHODS: The most common complications after resection of sarcomas of the upper limbs and shoulder girdle are described, and current knowledge regarding complication management is presented. Additionally, a selective literature search was performed, incorporating personal experiences. RESULTS: Wound healing disorders and infections after tumor resection without specific reconstruction (clavicle resection, scapulectomy) usually respond well to conservative or surgical treatment. However, periprosthetic infections after reconstruction using a megaendoprosthesis constitute a severe and frequent complication, with an incidence of 5-10%. Two-stage implant replacement still represents the gold standard, although in selected cases, one-stage revision with retention of the prosthetic stem appears warranted. Secondary amputation as a result of periprosthetic infection is rare compared to the situation with infections of the lower limb. Mechanical complications necessitating surgical revision are mostly limited to joint dislocation after inverse total shoulder replacement (TSR). (Sub)luxation in anatomic TSR can be tolerated provided there is no tendency toward perforation of the skin in a asymptomatic patient. Biological reconstructions are most often indicated for reconstruction of intercalary defects of the humerus, and revision is necessitated most frequently by mechanical complications. Despite multiple surgical revisions, stable reconstructions and limb salvage can usually be achieved in the upper limb.

The epidemiology of non-fatal injuries among 11-, 13- and 15-year old youth in 11 countries: findings from the 1998 WHO-HBSC cross national survey.

The primary objective was to present a cross-country comparison of injury rates, contexts and consequences. The research design was the analysis of data from the 1998 cross-national Health Behaviour in School-aged Children survey and 52955 schoolchildren from 11 countries, aged 11, 13 and 15 years, completed a self-administrated questionnaire. A total of 41.3% of all children were injured and needed medical treatment in the past 12 months. Injury rates among boys were higher than among girls, 13.3% reported activity loss due to injury and 6.9% reported severe injury consequences. Most injuries occurred at home and at a sport facility, mainly during sport activity. Fighting accounted for 4.1% of injuries. This paper presents the first cross-national comparison of injury rates and patterns by external cause and context. Findings present cross-country similarities in injury distribution by setting and activity. These findings emphasize the importance of the development of global prevention programmes designed to address injuries among youth.

Myelin phagocytosis by peritoneal macrophages in organ cultures of mouse peripheral nerve. A new model for studying myelin phagocytosis in vitro.

Organ cultures of degenerating nerve fascicles were exposed to cultured macrophages obtained by peritoneal lavage. Invasion of the nerve fascicle by phagocytes was shown by prelabeling with carbon and with electron microscopy. There was massive active phagocytosis of degenerating myelin sheaths. The invading phagocytic cell population was identified as Fc receptor-positive, Mac-1-positive macrophages by immunocytochemistry. The Schwann cell population persisted without significant myelin phagocytosis. The vitality of the Schwann cell population was shown by subsequent reimplantation of the organ cultures into host animals. The reimplants had retained their ability to remyelinate regenerating axon sprouts. These observations were made in cultures exposed to cytostatic agents. If cytostatic agents were omitted, there was proliferation of endogenous phagocytes in the nerve fascicles without added peritoneal cells. These endogenous phagocytes were identified as proliferating resident monocytes and were positive for the Fc receptor and Mac-1 markers. This model allows studies on how monocytes recognize and digest degenerating myelin apart from surviving Schwann cells.

Bicycle helmet law for children: a case study of activism in injury control.

In 1990, the first regulation requiring the use of helmets for bicyclists younger than 16 years of age was passed in Howard County, Maryland. This unexpected injury control measure resulted from the convergence of multiple factors and efforts: the bicycle-related deaths of two children from the same middle school, creative students and teachers motivated by these deaths, a responsive legislator to introduce the legislation, available surveillance and research statistics supporting the need and efficacy for helmet use, increased national awareness of the importance of helmet use to prevent bicycle-related head injuries, and organized national and local public health groups to support the legislation. This case study of activism in injury control illustrates the importance of supporting research, of well-organized public health coalitions and groups, and of creative community activists motivated by local circumstances.

Childhood injury prevention counseling in primary care settings: a critical review of the literature.

OBJECTIVES: The American Academy of Pediatrics (AAP) believes that health education, through office-based counseling, can contribute to childhood injury prevention. This report presents the results of a critical review of the scientific literature on the effectiveness of primary care-based counseling to prevent childhood unintentional injury. METHODS: A panel selected from the AAP Committee and the AAP Section on Injury and Poison Prevention searched the English-language scientific literature for all articles about childhood unintentional injury prevention counseling. A standardized format was developed to record data on each study. Two members of the panel independently reviewed each article. Articles that were original reports and in which unintentional injury prevention counseling took place in a primary care setting were included. Articles were encoded and analyzed by computer and then grouped by quality of evidence using the US Preventive Services Task Force (USPSTF) method of categorizing results of medical care evaluation. Articles were rated by strength of study design in order to compare studies within each USPSTF group. RESULTS: Twenty articles met the criteria for inclusion. Of these, 18 showed positive effects of injury prevention counseling including five randomized/controlled, 10 non-randomized/controlled, two multiple time series, and one descriptive study. In 15 of the positive studies, physicians performed the counseling. Positive outcomes as measured by increased knowledge, improved behavior, or decreased injury occurrence were reported for both motor vehicle and non-motor vehicle injuries. CONCLUSIONS: The literature review supports the recommendation of the AAP to include injury prevention counseling as part of routine health supervision. This recommendation has implications for health care reimbursement and care content.

Strategies to increase adherence with tuberculosis test reading in a high-risk population.

OBJECTIVE: To determine the most effective strategy to encourage adherence with tuberculosis test reading in a high-risk population. Design. Prospective randomized controlled trial. SETTING/PARTICIPANTS: Consecutive sample of 627 children ages 1 to 12 years due for a tuberculosis (TB) test in an urban children's hospital outpatient department. One child per family was enrolled. INTERVENTION: All families received education regarding the importance of skin testing for TB and the need for follow-up, and written and verbal instructions regarding test reading. Families were randomly assigned to one of five strategies for follow-up TB test reading at 48 to 72 hours: 1) routine verbal and written instructions, 2) reminder phone call, 3) transportation tokens and toy on return, 4) withholding of school forms until time of reading and need to repeat TB test if not timely read, 5) parents taught to read induration with nurse home visit. Those who did not have tests read at 48 to 72 hours by a trained professional were phoned 1 week later. RESULTS: The five groups did not differ with regard to TB risk factor score, maternal education, transportation source, or perceived importance of TB testing. Before the study the follow-up rate of TB test reading by a trained professional was 45%. Reading rates in this study were 58%, 70%, 67%, 70%, and 72% for groups 1 to 5, respectively. In group 4, only 39% had school forms to be completed and their adherence rate was 84% (53/63). Compared to group 1, the only statistically significant improvement was in group 4, especially for those who needed school forms completed, and in group 5. Those not adhering in groups 1 to 4 did not differ from returnees with regard to TB risk factors, maternal education, transportation, or perceived importance of testing. The most common reasons for failing to return included forgetfulness, transportation, and time constraints. Group 5 was stopped early because of difficulty with nurse visits (N = 98). When told of the nurse visit, 9% (9/98) families could not find a time for the visit. Seventeen percent (17/98) were visited but the child was not home, and 7% (7/98) were not visited because of a nurse scheduling problem. CONCLUSIONS: In a high-risk population, adherence with TB test reading is poor. However, education and return of school forms at reading time can significantly improve adherence. Although requiring larger investment in resources, visiting nurses may also aid in test reading.

Phototherapy for neonatal hyperbilirubinemia: six-year follow-up of the National Institute of Child Health and Human Development clinical trial.

The National Institute of Child Health and Human Development Randomized, Controlled Trial of Phototherapy for Neonatal Hyperbilirubinemia was conducted to determine whether phototherapy used to control serum bilirubin is safe and is as effective in preventing brain injury as exchange transfusion. The study, conducted at six neonatal care centers, randomly assigned 1339 newborn infants to phototherapy or control groups by the following subgroups: (1) birth weight less than 2000 g; (2) birth weight 2000 to 2499 g and bilirubin level greater than 171 mumol/L (10 mg/dL); or (3) birth weight greater than or equal to 2500 g and bilirubin level greater than 222 mumol/L (13 mg/dL). Phototherapy was administered for 96 hours, and exchange transfusion was used to control hyperbilirubinemia at the same predetermined levels in both groups. Neurological and developmental examinations were conducted at 1 and 6 years of age, with follow-up rates of 83% and 62%, respectively. The two groups did not differ in mortality or diagnosed medical conditions. The phototherapy and control groups had similar rates of cerebral palsy (5.8% vs 5.9%), other motor abnormalities including clumsiness and hypotonia (11.1% vs 11.4%), and sensorineural hearing loss (1.8% vs 1.9%). The Wechsler Intelligence Scale for Children-Revised scores overall were not significantly different for the two groups (Verbal, 96.8 vs 94.8; Performance, 95.8 vs 95.1 for phototherapy and control groups, respectively). Phototherapy effectively controlled neonatal hyperbilirubinemia without evidence of adverse outcome at 6 years of age and was at least as effective as management with exchange transfusion alone.

Intelligence at six years in relation to neonatal bilirubin levels: follow-up of the National Institute of Child Health and Human Development Clinical Trial of Phototherapy.

Results of the National Institute of Child Health and Human Development Randomized Controlled Trial of Phototherapy were examined for the relationship of neonatal bilirubin level to neurological and developmental outcome at 6-year follow-up. This analysis focused on 224 control children with birth weight of less than 2000 g. Bilirubin levels were maintained below previously specified levels by the use of exchange transfusion only (24%). Rates of cerebral palsy were not significantly higher for children with elevated maximum bilirubin level than for those whose level remained low. No association was evident between maximum bilirubin level and IQ (Full Scale, Verbal, or Performance) by simple correlation analysis (r = -.087, P = .2 for Full Scale) or by multiple linear regression adjusting for factors that covary with IQ (beta = -.15, P = .58). IQ was not associated with mean bilirubin level, time and duration of exposure to bilirubin, or measures of bilirubin-albumin binding. Thus, over the range of bilirubin levels permitted in this clinical trial, there was no evidence of bilirubin toxicity to the central nervous system. Measures used to control the level of bilirubin in low birth weight neonates appear to prevent effectively the risk of bilirubin-induced neurotoxicity.

Standard definitions for childhood injury research: excerpts of a conference report.

As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those--core--variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.

Child and adolescent injury research in 1998: a summary of abstracts submitted to the Ambulatory Pediatrics Association and the American Public Health Association.

OBJECTIVE: To describe current research in child and adolescent injury prevention by pediatric and public health investigators for comparison with national recommendations and agendas. DATA SOURCES: Abstracts submitted to the 1998 annual meetings of the Pediatric Academic Societies/Ambulatory Pediatrics Association and the American Public Health Association on injury or violence in children or adolescents. STUDY SELECTION: All abstracts of projects that addressed primarily injury or violence prevention involving children or adolescents. DATA EXTRACTION: For 123 abstracts, 2 coauthors extracted and classified age of the population, type of injury, study design, sizes of the sample and denominator, and type of outcome. RESULTS: Adolescents were the most frequent (49%) age group included. The investigations were concerned most with injuries caused by violence (33%), followed by motor vehicle trauma (14%) and burns (7%). Descriptive surveillance (38%), surveys (32%), and case series (13%) comprised the overwhelming majority of methods used. The studies primarily sought to identify risk factors for injury (32%), describe the victims (20%), or measure knowledge and/or practice (26%). Nine studies (7%) sought to measure the effect of interventions in some way, and only 2 focused primarily on methodology development. CONCLUSIONS: Injury prevention research projects presented at the 1998 Pediatric Academic Societies and American Public Health Association meetings were proportionate to the frequencies of injury by age and by external cause in the United States. However, in comparison with recommendations for agendas of national injury prevention research, more research is needed to improve injury prevention methods and to evaluate interventions.

Sports and recreation injuries in US children and adolescents.

OBJECTIVES: To estimate and describe morbidity from sports and recreation injuries in children and adolescents. DESIGN: Survey conducted by the National Center for Health Statistics--the Child Health Supplement to the 1988 National Health Interview Survey. SETTING: The general community. PARTICIPANTS: Representative sample of the noninstitutionalized civilian US population. Five percent of the eligible households did not participate. The subject of this report is 11,840 children and adolescents aged 5 to 17 years. MAIN OUTCOME MEASURES: Medically attended nonfatal injuries resulting from sports and recreation, and serious sports injuries, defined as injuries resulting in hospitalization, surgical treatment, missed school, or half a day or more in bed. Sports and recreation injuries were defined as those occurring in a place of recreation or sports, or receiving any of the following International Classification of Diseases, Ninth Revision (ICD-9) E-codes: struck in sports, fall in sports, bicycle-related injury, riding an animal, water sports, overexertion, fall from playground equipment or other vehicles, primarily skates and skateboards. RESULTS: The estimated annual number of all injuries from sports and recreation in US children and adolescents is 4,379,000 (95% confidence interval = 3,147,000 to 5,611,000); from serious sport injuries, 1,363,000 (95% confidence interval = 632,000 to 2,095,000). Sports account for 36% of injuries from all causes. Cause and nature of injury are strongly related to age. Sports do not account for a disproportionate number of serious or repeated injuries compared with other causes of injuries. CONCLUSION: Sports activities account for a large number and substantial proportion of all injuries to children and youth.

Changes of myelin proteins during Wallerian degeneration in situ and in millipore diffusion chambers preventing active phagocytosis.

Changes of myelin proteins in mouse sciatic nerves were studied comparing nerves degenerating in situ with nerves enclosed in millipore diffusion chambers which eliminate invasion of non-resident cells. Nerves kept in chambers showed nearly complete preservation of myelin sheaths with a very slow degradation of myelin proteins. Nerves degenerating in situ showed rapid myelin phagocytosis by macrophages with almost complete disappearance of myelin proteins after 28 days. These data elucidate the role of macrophages for removal of myelin proteins.

Rhabdomyosarcoma of the corpus of the uterus: a case report.

A case of uterine rhabdomyosarcoma is presented. Preoperative chemotherapy resulted in an excellent response.

Factors associated with bicycle helmet use among young adolescents in a multinational sample.

OBJECTIVE: To determine factors associated with variation in bicycle helmet use by youth of different industrialized countries. DESIGN: A multinational cross sectional nationally representative survey of health behaviors including symptoms, risk taking, school setting, and family context. SETTING: School based survey of 26 countries. SUBJECTS: School students, ages 11, 13, and 15 years totaling 112,843. OUTCOME MEASURES: Reported frequency of bicycle helmet use among bicycle riders. RESULTS: Reported helmet use varied greatly by country from 39.2% to 1.9%, with 12 countries reporting less than 10% of the bicycle riders as frequent helmet users and 14 countries more than 10%. Reported helmet use was highest at 11 years and decreased as children's age increased. Use was positively associated with other healthy behaviors, with parental involvement, and with per capita gross domestic product of the country. It is negatively associated with risk taking behaviors. Countries reported to have interventions promoting helmet use, exemplified by helmet giveaway programmes, had greater frequency of reported helmet use than those without programmes. CONCLUSIONS: Bicycle helmet use among young adolescents varies greatly between countries; however, helmet use does not reach 50% in any country. Age is the most significant individual factor associated with helmet for helmet using countries. The observation that some helmet promotion programmes are reported for countries with relatively higher student helmet use and no programmes reported for the lowest helmet use countries, suggests the possibility of a relation and the need for objective evaluation of programme effectiveness.