Opinions regarding neonatal resuscitation training for the obstetric physician: a survey of neonatal and obstetric training program directors.

PURPOSE: Our goal was to garner opinions regarding neonatal resuscitation training for obstetric physicians. We sought to evaluate obstacles to neonatal resuscitation training for obstetric physicians and possible solutions for implementation challenges. MATERIALS AND METHODS: We distributed a national survey via email to all neonatal-perinatal medicine fellowship directors and obstetrics & gynecology residency program directors in the United States. This survey was designed by a consensus method. RESULTS: Ninety-eight (53%) obstetric and fifty-seven (51%) neonatal program directors responded to our surveys. Eighty-eight percent of neonatologists surveyed believe that obstetricians should be neonatal resuscitation program (NRP) certified. The majority of surveyed obstetricians (>89%) believe that obstetricians should have some neonatal resuscitation training. Eighty-six percent of obstetric residents have completed training in NRP, but only 19% of obstetric attendings are NRP certified. Major barriers to NRP training that were identified include time, lack of national requirement, lack of belief it is helpful, and cost. CONCLUSIONS: Most obstetric attendings are not NRP certified, but the majority of respondents believe that obstetric providers should have some neonatal resuscitation training. Our study demonstrates that most respondents support a modified neonatal resuscitation course for obstetric physicians.

[Adolescent idiopathic scoliosis : Guideline for practical application]. / Adoleszente idiopathische Skoliose : Leitfaden für die praktische Anwendung.

Juvenile or adolescent idiopathic scoliosis is a relatively common spinal deformity, with an incidence of more than 1 %. Early diagnosis can lead to successful therapy. In the case of pathological clinical findings, the anteroposterior X­ray of the whole spine leads the way to the correct grading, according to Cobb angle measurement. Depending on the individual risk of progression, brace treatment will be started with a Cobb angle range of 20-25°. Important predictors of therapeutic success are sufficient primary corrective power and patient compliance. COBB angles of 40-50° usually lead to the recommendation for surgery, which is performed as either anterior or posterior spinal fusion in skeletally mature adolescents, depending on the grade of the deformity according to Lenke's classification. To achieve the best possible results, it is recommended that both conservative and surgical treatments are carried out by scoliosis specialists.

Simulation as a tool for improving acquisition of neonatal resuscitation skills for obstetric residents.

OBJECTIVE: Our goal was to compare the confidence, knowledge, and performance of obstetric residents taught initial neonatal resuscitation steps in a simulation-based versus lecture-based format. METHODS: Our study was a prospective randomized controlled trial of 33 obstetric residents. Baseline confidence, knowledge, and clinical skills assessments were performed. Subjects were randomized to traditional lecture (n = 14) or simulation-based (n = 19) neonatal resuscitation curriculum with a focus on initial steps. Follow-up assessments were performed at 3 and 6 months. Total confidence, knowledge, and clinical performance scores and change from baseline in these scores were calculated and compared between groups. RESULTS: Both the lecture-based and simulated-based groups demonstrated significant improvement in confidence, knowledge, and performance over time. However, compared with the lecture group, the magnitude of the mean change from baseline in performance scores was significantly greater in the simulation group at 3 months (2.9 versus 10.1; p < 0.001), but not at 6 months (7.0 versus 9.3; p = 0.11). CONCLUSIONS: Our study demonstrates the superiority of simulation in teaching obstetric residents initial neonatal resuscitation steps compared with a traditional lecture format. Skills are retained for upwards of 3-6 months. Refresher instruction by 6 months post-instruction may be beneficial.

Periacetabular bone metabolism following hip revision surgery. PET-based evaluation of allograft osteointegration.

UNLABELLED: The treatment of loosened total hip replacement (THR) acetabular components may require the management of severe bone defects. Although being applied for decades, there is only limited scientific data about the osteointegration of cancellous bone allografts (CBA) and other void fillers. Monitoring of periprosthetic bone regeneration could possibly help to optimize this process thereby reducing late failure rates. The aim of this study was to show osteometabolic changes in periprosthetic CBA after THR revision with the use of sodium-[18F]-fluoride (NaF) and positron emission tomography (PET). PATIENTS, METHODS: Twelve patients undergoing THR revision with the use of CBA were prospectively enrolled in the study. Nine patients completed all necessary examinations and were included in the evaluation. The temporal pattern of osteointegration was assessed via NaF-PET at one (PET1) and six weeks (PET2) after surgery. CBA, tantalum implants, supraacetabular regions ipsilateral and contralateral, and parasymphyseal pubic bones were delineated as volumes of interest (VOI) in postop CT scans, which were then merged with the PET data. RESULTS: In comparison to the contralateral supraacetabular reference bone, a significant 1.5-fold increase of osteometabolic activity from PET1 to PET2 was seen in the CBA region. Also, the ipsilateral supraacetabular host bone showed a higher NaF-influx in week 6, compared to the first postoperative week. The supraacetabular site exhibited a significantly 1.8- to 2-fold higher influx and uptake than bone regions in non-operated sites. Tantalum implants had a low NaF influx at both time points investigated. CONCLUSION: Using NaF-PET osteometabolic changes of CBA and implant-bone-interfaces can be monitored. Applying this method we demonstrated early periprosthetic temporal bone regeneration patterns in THR cup revision patients.

[Academic clinical medicine in orthopedic and trauma surgery: which route will the next generation choose?]. / Akademische klinische Medizin in Orthopädie und Unfallchirurgie: Welchen Weg geht der Nachwuchs?

BACKGROUND: An increasing clinical pressure forces academic surgeons in Germany to decide between private life and research activities. How do those people decide and how do they develop their individual career plan? MATERIAL AND METHODS: In an e-mail survey German orthopedic and trauma surgeons were interviewed on their way of reconciliation of private life, clinical duties and research. The survey included the same questions as the previous survey and a follow-up of 66 % was achieved. RESULTS: The number of consultants in the questioned cohort increased from 44 % to 66 %. More than 80 % reported that the workload had increased which was accompanied by a more clinical orientation of research activities. When asked about personal priorities and wishes leisure time was ranked first, surgical skills, research and income followed in that order. The majority were content with the current situation and career path. CONCLUSIONS: This is the first study on occupational conditions in orthopedic and trauma surgeons in a time-line based manner. It became evident that a more clinical orientation of research is needed to match the interests of clinically engaged surgeons in orthopedics and traumatology.

Senior-Løken syndrome: a syndromic form of retinal dystrophy associated with nephronophthisis.

Senior-Løken syndrome (SLS) is an autosomal recessive disease characterized by development of a retinitis pigmentosa (RP)- or Leber congenital amaurosis (LCA)-like retinal dystrophy and a medullary cystic kidney disease, nephronophthisis. Mutations in several genes (called nephrocystins) have been shown to cause SLS. The proteins encoded by these genes are localized in the connecting cilium of photoreceptor cells and in the primary cilium of kidney cells. Nephrocystins are thought to have a role in regulating transport of proteins bound to the outer segment/primary cilium; however, the precise molecular mechanisms are largely undetermined. This review will survey the biochemistry, cell biology and existing animal models for each of the nephrocystins as it relates to photoreceptor biology and pathogenesis of retinal degeneration.

Skin carotenoid status measured by resonance Raman spectroscopy as a biomarker of fruit and vegetable intake in preschool children.

BACKGROUND/OBJECTIVE: Dietary assessment in children is difficult, suggesting a need to develop more objective biomarkers of intake. Resonance Raman spectroscopy (RRS) is a non-invasive, validated method of measuring carotenoid status in skin as a biomarker of fruit/vegetable intake. The purpose of this study was to examine the feasibility of using RRS in preschool children, to describe inter-individual variability in skin carotenoid status and to identify factors associated with the biomarker in this population. SUBJECTS/METHODS: We conducted a cross-sectional study of 381 economically disadvantaged preschoolers in urban centers in Connecticut (USA). In all, 85.5% were black non-Hispanic or Hispanic/Latino, and 14.1% were obese and 16.9% were overweight by age- and sex-specific body mass index (BMI) percentiles. Children had their skin carotenoid status assessed by RRS in the palm of the hand. Fruit/vegetable consumption was assessed by a brief parent/guardian-completed food frequency screener and a liking survey. RESULTS: We observed inter-individual variation in RRS values that was nearly normally distributed. In multiple regression analysis, higher carotenoid status, measured by RRS, was positively associated with fruit/vegetable consumption (P=0.02) and fruit/vegetable preference (P<0.01). Lower carotenoid status was observed among younger children, those participating in the US Supplemental Nutrition Assistance Program, and those with greater adiposity (P<0.05 for all). CONCLUSIONS: We observed wide variability in skin carotenoid status in a population of young children, as assessed by RRS. Parent-reported fruit/vegetable intake and several demographic factors were significantly associated with RRS-measured skin carotenoid status. We recommend further development of this biomarker in children, including evaluating response to controlled interventions.

Demographics and awareness of diabetic retinopathy among diabetic patients attending the vitreo-retinal service at a tertiary eye care center in Nepal.

INTRODUCTION: Diabetic retinopathy (DR) is one of the leading causes of blindness in Nepal. OBJECTIVE: To investigate the demographic characteristics and awareness of diabetic retinopathy among new cases of diabetes mellitus (DM) attending the vitreo-retinal service of a tertiary eye care centre in Nepal. MATERIALS AND METHODS: A hospital-based, cross-sectional study including all consecutive new cases of DM was carried out. Detailed demographics of the subjects and their awareness of potential ocular problems from diabetes mellitus were noted. RESULTS: A total of 210 patients with a mean age of 57 +/- 10.4 years were included. Brahmins (34.8 %) and Newars (34.3 %) were the predominant ethnic groups. Housewives (38.6 %) and office workers (18.6 %) were the major groups affected. Two-fifths (37 %) of the cases were unaware of DR and its potential for blindness. Awareness was significantly higher among literate patients (P = 0.006). Fundus evaluation was done for the first time in 48.6 %, although almost four-fifths had a duration of diabetes of five years or more. DR was found in 78 % of the cases, with 16.7 % already at the proliferative stage and about 40 % exhibiting clinically significant diabetic macular edema. CONCLUSION: A lack of awareness of DR coupled with a high proportion of cases already at a sight-threatening stage of retinopathy at their first presentation reflects the need for improved awareness programs to reduce the burden of blindness from DR in Nepal.

Expression pattern differences between osteoarthritic chondrocytes and mesenchymal stem cells during chondrogenic differentiation.

OBJECTIVE: The use of mesenchymal stem cells (MSCs) for cartilage regeneration is hampered by lack of knowledge about the underlying molecular differences between chondrogenically stimulated chondrocytes and MSCs. The aim of this study was to evaluate differences in phenotype and gene expression between primary human chondrocytes and MSCs during chondrogenic differentiation in three-dimensional (3D) pellet culture (PC). MATERIALS AND METHODS: Chondrocytes isolated from cartilage samples obtained during total knee alloarthroplastic procedure (N=8) and MSCs, purified from bone marrow aspirates of healthy donors (N=8), were cultivated in PC under chondrogenic conditions. Immunohistology and quantitative reverse transcribing PCR (RT-PCR) were performed for chondrogenic-specific markers (i.e., Sox9, Collagen II). Global gene expression of the so-cultivated chondrocytes and MSCs was assessed by a novel approach of microarray-based pathway analysis. Refinement of data was done by hypothesis-driven gene expression omnibus (GEO) dataset comparison. Validation was performed with separate samples in transforming growth factor (TGF)ß+ or TGFß- conditions by use of quantitative real-time RT-PCR. RESULTS/CONCLUSIONS: Chondrogenic commitment of both cell types was observed. Interestingly, chondrocytes demonstrated an upregulated fatty acid/cholesterol metabolism which may give hints for future optimization of culture conditions. The novel microarray-based pathway analysis applied in this study seems suitable for the evaluation of whole-genome based array datasets in case when hypotheses can be backed with already existing GEO datasets. Future experiments should further explore the different metabolic behaviour of chondrocytes and MSC.

Developing combination immunotherapies for type 1 diabetes: recommendations from the ITN-JDRF Type 1 Diabetes Combination Therapy Assessment Group.

Like many other complex human disorders of unknown aetiology, autoimmune-mediated type 1 diabetes may ultimately be controlled via a therapeutic approach that combines multiple agents, each with differing modes of action. The numerous advantages of such a strategy include the ability to minimize toxicities and realize synergies to enhance and prolong efficacy. The recognition that combinations might offer far-reaching benefits, at a time when few single agents have yet proved themselves in well-powered trials, represents a significant challenge to our ability to conceive and implement rational treatment designs. As a first step in this process, the Immune Tolerance Network, in collaboration with the Juvenile Diabetes Research Foundation, convened a Type 1 Diabetes Combination Therapy Assessment Group, the recommendations of which are discussed in this Perspective paper.

[Survey of the simultaneous management of clinical and research burdens in German University orthopaedic and trauma departments]. / Ergebnisse einer Befragung zur Vereinbarkeit von klinischer und akademischer Entwicklung an orthopädischen und unfallchirurgischen Universitätskliniken in Deutschland.

AIM: Academic careers often place the burden of research on top of clinical work. This conflict denotes a demanding task especially in surgical disciplines, such as orthopaedics and traumatology. Driven by changes in the social system, concerning, e.g., leisure and parentship, the future organisation of the academic workplace needs to address these individual issues. With the aim to evaluate individual motivation towards combining research, clinical work and private life and to receive suggestions for improvement we conducted a survey addressing residents employed in the orthopaedic and traumatological departments of German university hospitals. METHOD: With the support of the "Junges Forum der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU)", a survey, containing 21 questions about occupational and private issues, was sent out to the orthopaedic and traumatologic departments of 25 university hospitals in Germany. The focus of the questions was set on motivation, priorities and personal resources. It was possible to answer the questions by e-mail; later an anonymous online version of the survey was set in action as well. RESULTS: Completely answered forms were received from n = 105 physicians, of which 88 % were judged as active researchers. Over 50 % of the participants were satisfied with their clinical career and with their research results. 96 % of the survey participants felt sure that most of the research could only be managed during spare time. A majority of the participants supported the idea of receiving leave of absence from clinical duties for research in order to serialise the scientific and clinical careers. Interestingly, when focusing on priority settings, salary aspects were ranked as low as research interests, falling behind the wish for a more intensive surgical training and more leisure time. CONCLUSIONS: Individual solutions seem to be necessary to achieve a scheduled efficiency of clinical and research careers. This includes structural developments (like a professionally headed lab) and the establishment of dynamic clinical structures. It seems possible that the clinical organisation of physicians in teams might offer solutions to cope with the demands of surgical training and clinical care on the one hand and research on the other hand.

[Perspectives of clinical stem cell therapy in the treatment of musculoskeletal diseases in Germany]. / Perspektiven klinischer mesenchymaler Stammzelltherapie bei muskuloskeletalen Erkrankungen in Deutschland.

AIM: The treatment of large bone defects remains a challenge for the orthopaedic surgeon. Regenerative therapies with the use of mesenchymal stem cells (MSC) may provide an alternative to autogenous bone transplantation, callus distraction or the use of allografts. MATERIAL AND METHODS: On the occasion of an expert workshop of the German Society for Orthopaedic and Trauma Surgery, a literature search regarding studies with the use of MSC was performed to evaluate its potential for future clinical studies. Furthermore, the legislative requirements were examined. RESULTS: Various in vitro and animal studies showed the benefit of MSC in bone regeneration. However, there are sparse data from clinical studies. Due to recent legislative changes there are several regulatory demands to meet if clinical studies are performed with MSC. CONCLUSIONS: For further evaluation of the role of MSC in the treatment of bone defects there is a need for clinical trials. The current paper provides some assistance for the successful application for clinical trials with MSC. Planning and performance of these studies may require early consultation with the regulatory authorities and cooperation of research centres in order to obtain authorisation for the evaluation of MSC. Preclinical data have to be obtained according to good laboratory practice with equivalent protocols that will be used in the clinical trials. In the latter the implementation of the guidelines for good clinical practice are mandatory.

[Bone tissue engineering in clinical application : assessment of the current situation]. / Knochen-Tissue-Engineering in der klinischen Anwendung : Eine Standortbestimmung.

Treatment of severe bone defects remains a challenge in orthopaedic surgery and traumatology. Surgical techniques should provide primary stability to reach osseous integration and secondary remodeling of bone grafts and substitute materials. None of the currently available substitute materials provides osteoconduction and osteogenesis comparable to those of human allografts and autografts. To enhance osteoinductive and osteogenetic properties of these implants mesenchymal stem cells are used successfully in bone tissue engineering approaches. The aim of this report is to summarize the currently available data on bone tissue engineering and preliminary experience with a tissue engineered graft in acetabular revision surgery after loosening of a hip replacement.

Aspirin resistance in South African Caucasian patients with thrombotic cerebrovascular events.

OBJECTIVE: Stroke is the second commonest cause of death in both high and low- and middle-income countries [Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet 2006; 367:1747-57]. In South Africa, a population undergoing demographic and epidemiological transition, stroke is the third commonest cause of death [Norman R, Bradshaw D, Schneider M, Pieterse D, Groenewald P. Revised burden of disease estimates for the comparative risk factor assessment, South Africa, 2000. Cape Town: Medical Research Council. 2006]. Although aspirin remains an essential part of stroke prevention, platelet response to therapeutic doses is not uniform. Some patients exhibit aspirin resistance and develop secondary thrombotic events. We decided to determine the prevalence of aspirin resistance and/or platelet hypersensitivity, as determined by platelet aggregometry, in sixty Caucasian patients who have suffered one or more Strokes and/or Transient Ischaemic Attacks (TIAs) as compared with sixty control subjects. METHODS: Aspirin resistance was determined by platelet aggregation (>20%) to one or more of the four agonists, namely arachidonic acid (1.5 mM), adrenaline (0.05 microg/ml), collagen (0.2 microg/ml) or ADP (0.1x10(-5) M). RESULTS: Two patients demonstrated "complete aspirin resistance" (non-responder to aspirin) with resistance to arachidonic acid (high concentration) noted. Three patients demonstrated "partial aspirin resistance" (semi-responder to aspirin). One contol subject showed "complete aspirin resistance". There is a 1.67% chance of a control subject being resistant to aspirin in a general South African Caucasian population. A history of prior stroke or transient ischaemic attack was associated with a statistically significant increase in risk of aspirin resistance with an odds ratio of 5.36. CONCLUSION: These results essentially concur with those of the studied literature in showing an 8% prevalence (statistically significant) of aspirin resistance (complete and partial) in South African Caucasian patients with previous atherothrombotic cerebrovascular events i.e. CVAs and/or TIAs. The current study shows an increased prevalence of aspirin resistance in people who have had prior strokes/TIAs and raises the question whether people who have had these events are somehow predisposed to vascular events or indeed recurrent vascular events. "Aspirin resistant" patients or "poor responders" to aspirin must be considered at heightened risk of atherothrombotic events and laboratory monitoring of antiplatelet therapy may become clinically useful.

Nutritional Interventions against Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in the developed world. This disease of the elderly robs them of central vision in one or both eyes leading to a devastating loss of the ability to drive, read, and recognize faces. In recent years, a number of novel treatments for the neovascular form of AMD (also known as "wet" or exudative AMD) have been introduced, and for the first time, the relentless downhill course of vision loss experienced by the majority of patients with this particularly malignant variant of AMD has been transformed to the stabilization and even improvement of vision in at least two-thirds of patients. Likewise, the slower, more insidious form of AMD known as dry AMD which leads to geographic atrophy of the macula has become the focus of pharmaceutical firms' efforts for intervention. Unfortunately, all of these novel treatments have limitations, and they tend to be very expensive. Thus, prevention of AMD is of paramount importance to reduce the healthcare burden of this blinding disorder. Accumulating evidence suggests that encouragement of increased consumption of fruits and vegetables rich in the xanthophyll carotenoids lutein and zeaxanthin is a simple, cost effective public health intervention that might help to decrease the incidence of AMD. In this review article, the scientific underpinnings for these nutritional recommendations will be surveyed.

[Combined hip-dysplasia and femuroacetabular impingement. Diagnosis and simultaneous surgical treatment]. / Koinzidenz von Hüftdysplasie und femuroazetabulärem Impingement. Klinisches Bild und simultane operative Korrektur.

Developmental dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions. We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.

The utility of thrombo-elastography in the monitoring of aspirin therapy.

To assess the utility of the thrombo-elastogram in monitoring of aspirin therapy 25 healthy volunteers were selected and given low-dose aspirin therapy. Thrombo-elastography and platelet aggregometry were conducted at baseline and 1 week later. After 1 week of aspirin therapy, thrombo-elastogram data failed to demonstrate a significant change in the clotting profile. Platelet aggregometry identified significant changes in the clotting profile in response to stimulation with arachidonic acid, adrenaline and ADP. We conclude that thrombo-elastography may not have utility in monitoring of response to aspirin.

[Necrosis of the femoral head in late pregnancy. Necessity of early diagnosis]. / Die peripartale Femurkopfnekrose. Notwendigkeit zur Frühdiagnostik.

Limping and groin pain can issue diagnostic problems during late pregnancy. Differential diagnosis of two idiopathic syndromes, transient osteoporosis and osteonecrosis of the femoral head, is made possible by MRI in the early stages. This case is reported to demonstrate the need to distinguish between those syndromes early so as to prevent further joint damage.

Erythrocyte sedimentation rate as a marker of inflammation and ongoing coagulation in stroke and transient ischaemic attack.

OBJECTIVE: Systemic infection and inflammation have been implicated in the aetiology of thrombotic cerebral events, particularly in younger patients. We decided to determine whether those patients with raised D-dimer levels, indicating continuing thrombosis and fibrinolysis, had evidence of concurrent infection or inflammation as manifested by a raised erythrocyte sedimentation rate (ESR) measured after an ischaemic stroke/transient ischaemic attack (TIA). METHODS: One hundred and forty-eight patients who had suffered either single or recurrent cerebrovascular episodes were analysed. The patients were referred to the thrombosis and haemostasis unit at Johannesburg Hospital for evaluation of their thrombotic profiles, including D-dimer levels. Concurrent infection was assessed by measurement of white cell count (WCC) and ESR. The variable time interval between the date of the most recent cerebrovascular event and the date of venesection was determined. A history was taken, a physical and neurological examination was performed, and a cardiology assessment and neuroimaging studies were done. RESULTS: Raised D-dimer levels correlated significantly with ESR levels (p = 0.0094) in all patients. This was particularly evident when comparing the 70 younger patients (aged less than 45 years) with the 78 older patients (> 45 years) with raised D-dimers (p = 0.0070). When analysing other markers of inflammation/infection in association with raised D-dimer levels and ESR, mean fibrinogen levels were significantly raised at 6.56 g/l (p = 0.0122). An elevated WCC, as a categorical variable, was significantly associated with an elevated ESR (p = 0.0092). CONCLUSION: There is a significant correlation between elevated D-dimer levels (indicating abnormalities of coagulation and fibrinolysis) and markers of inflammatory and/or infective processes. This is particularly evident in black patients below the age of 45 years. These patients are believed to be at decreased risk for generalised atheromatous disease compared with older white patients. The ramifications of these findings are potentially important with regard to thrombotic cerebrovascular disease aetiology, investigation, management and prevention.