[Prosthetic reconstruction of the upper extremity]. / Prothetische Rekonstruktion der oberen Extremität.

BACKGROUND: Prosthetic replacement after amputation or loss of function of the upper extremity has gained therapeutic value over the last years. The control of upper arm prostheses has been refined by the use of selective nerve transfers, and the indication for prosthetic replacement has been expanded. OBJECTIVES: Overview regarding surgical, therapeutic and prosthetic options in upper extremity amputations or their loss of function. METHODS: Selective literature research including the authors' own experience in everyday clinical practice, as well as a review of medical records. RESULTS: Selective nerve transfers of the amputated nerves of the brachial plexus to the remaining stump muscles can create up to six myosignals for intuitive and simultaneous control of the different prosthetic joints. This way, an efficient and harmonious control of the prosthetic device is possible without the need to change between the different control levels. The prosthetic replacement, with consequent elective amputation, represents a new approach in the functional reconstruction of the upper extremity, especially in patients with a functionless hand after massive soft tissue or nerve damage.

Hand Transplantation Versus Hand Prosthetics: Pros and Cons.

Composite tissue transplantation and new developments in the field of prosthetics have opened new frontiers in the restoration of function among upper limb amputees. It is now possible to restore hand function in affected patients; however, the indications, advantages, and limitations for either hand transplantation or prosthetic fitting must be carefully considered depending on the level and extent of the limb loss. Hand transplantation allows comprehensive hand function to be restored, yet composite tissue transplantation comes with disadvantages, making this method a controversial topic in the hand surgical community. Alternatively, prosthetic limb replacement represents the standard of care for upper limb amputees, but results in the known limitations of function, sensation, and usage. The indication for hand transplantation or prosthetic fitting strongly depends on the level of amputation, as well as on the extent (unilateral/bilateral) of the amputation. In this review, we discuss the advantages and disadvantages of hand transplantation and prosthetic replacement for upper limb amputees in general, as well as in regard to the different levels of amputation.

[Exoprosthetic Replacement of the Upper Extremity]. / Exoprothetischer Ersatz bei Amputationen der oberen Extremität.

During the last years, the prosthetic replacement in upper limb amputees has undergone different developments. The use of new nerve surgical concepts improved the control strategies tremendously, especially for high-level amputees. Technological innovation in the field of pattern recognition enables the control of multifunctional myoelectric hand prostheses in a natural and intuitive manner. However, the different levels of amputation pose different challenges for the therapeutic team which concern not only the prosthetic attachment; also the expected functional outcome of prosthetic limb replacement differs greatly between the individual levels of amputation. Therefore, especially in partial hand amputations the indication for prosthetic fitting has to be evaluated critically, as these patients may benefit more from biologic reconstructive concepts. The value of the upper extremity, in particular of the hand, is undisputable and, as such represents the driving force for the technological and surgical developments within the exoprosthetic replacement. This article discusses the possibilities and limitations of exoprosthetic limb replacement on the different amputation levels and explores new developments.

Correlation of hormone receptor status between circulating tumor cells, primary tumor, and metastasis in breast cancer patients.

PURPOSE: Estrogen receptor (ER) and progesterone receptor (PR) status is prognostic and predictive in breast cancer. Because metastatic breast tumor biopsies are not routinely feasible, circulating tumor cells (CTCs) offer an alternative source of determining ER/PR tumor status. METHODS/PATIENTS: Peripheral blood was collected prospectively from 36 patients with metastatic breast cancer. CTCs were isolated using the microfluidic OncoCEE™ platform. Detection was accomplished with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. ER/PR protein expression was assessed by immunocytochemistry (ICC) on the CK+ cells and compared to the primary and/or metastatic tumor by immunohistochemistry (IHC). RESULTS: Among the 24 CK + CTC cases, a concordance of 68 % (15/22) in ER/PR status between primary breast tumor and CTCs and 83 % (10/12) between metastatic tumor and CTCs was observed. An overall concordance of 79 % (19/24) was achieved when assessing CTC and metastatic tumor (primary tumor substituted if metastatic breast biopsy not available). A test sensitivity of 72 % and specificity of 100 % was identified when comparing CTCs to tumor tissue. Of the 7 discordant cases between CTCs and primary tumor tissue, 2 were concordant with the metastatic biopsy. CONCLUSIONS: CTC ER/PR status using the OncoCEE™ platform is feasible, with high concordance in ER/PR status between tumor tissue (IHC) and CTCs (ICC). The prognostic and predictive significance of CTC ER/PR protein expression needs further evaluation in larger trials.

Facility-based inreach strategies to promote annual mammograms.

Mammography facilities frequently use inreach strategies, such as reminders, to encourage annual returns by asymptomatic women 50 years of age and older. We describe three pilot studies that systematically compared various strategies. In each study, patients seen for a screening mammogram during a specified period were randomly assigned to a novel reminder condition or a comparison condition one year later, and return rates were monitored. In study 1, return rates for subjects receiving a standard mailed reminder (36%) and subjects receiving a mailed reminder plus incentive (32%) were similar. In study 2, return rates for subjects receiving a mailed reminder (44%) and subjects receiving a phoned reminder (48%) also were similar. However, study 3 focused on a mailed reminder on the referring physician's letterhead sent by the mammography facility versus no reminder, and a significant increase in return rates resulted (47% versus 19%). We present the implications of this pattern of findings and discuss the need for a larger trial of the physician-endorsed reminder.

The effects of co-worker-delivered prompts on breast self-examination frequency.

In this study, we evaluated the efficacy of co-worker-delivered reminders to perform breast self-examination (BSE). Before participating in a BSE training workshop, subjects (n = 36) were randomly assigned in pairs (of co-workers who registered together) to one of two experimental conditions: contract or control. Subjects in the contract condition, after discussing specific prompting strategies as part of a "buddy system" in their workshop, contracted to prompt their designated peers at least once a month for six months following the workshop. In addition, subjects in both conditions received mailed prompts monthly. We assessed BSE adherence and prompting behaviors in retrospective interviews. Results indicated that subjects in both conditions significantly increased BSE frequency above pre-workshop levels. However, the magnitude of this increase did not differ between conditions. A process evaluation indicated that the control group pairs were similar to the contract group pairs in their prompting behavior.

Misleading nutrition claims on cracker packages prior to and following implementation of the Nutrition Labeling and Education Act of 1990.

OBJECTIVES: This study compared patterns in selected health claims on snack cracker packaging and fat content prior to and following enforcement of the Nutrition Labeling and Education Act of 1990 (NLEA). METHODS: Through observations at supermarkets in 1991 and 1995, the prevalence on packages of health claims that consumers associate with heart disease prevention was evaluated. The fat content of each product also was recorded. Criteria for potentially misleading claims were developed. RESULTS: Analysis of both cross-sectional data and products that were available in both years showed that fat content, as well as the number of products containing target claims, had significantly decreased by 1995. The prevalence of potentially misleading claims also declined significantly, from 77% in 1991 to 49% in 1995. CONCLUSIONS: Although the data regarding the changes from 1991 to 1995 are encouraging, the prevalence of potentially misleading health claims for this food category continues to be high.

A survey of recreational sun exposure of residents of San Diego, California.

The incidence of skin cancer in San Diego is one of the highest in the nation. Research has documented that excessive unprotected exposure to ultraviolet (UV) radiation over time significantly increases a person's risk for developing various types of skin cancer. Our study investigated the amount of sun exposure and the practice of sun protection among San Diegans and examined factors thought to be associated with these behaviors. In April 1994, a random sample of 864 San Diego residents was surveyed by telephone. Because most survey questions specifically asked about sun exposure and sun protection when tanning versus recreating, the analyses were presented separately for recreators (i.e., those who spent time in the sun during the hours of 8:00 am and 6:00 pm for recreation last summer; n = 786) and tanners (i.e., those who spent at least 10% of their time in the sun to get a tan last summer; n = 464), a subset of recreators. Study results indicated that on average, 27% of the tanners' time in the sun last summer was spent getting a tan, and tanners reported using sunscreen about 50% of the time on both their face and body. In terms of sun protection while recreating, survey respondents reported using sunscreen on their face approximately 40% of the time compared to approximately 30% of the time on their body. Correlates of sun exposure and sun protection for both tanners and recreators included demographic characteristics, susceptibility factors, attitudes, and knowledge. The findings from this study support the need for education on skin cancer prevention. The practical implications of these findings are discussed in terms of appropriate community skin cancer prevention interventions. Medical Subject Headings (MeSH): skin cancer, sunlight, behavior.

Evaluation of a worksite mammography program.

We implemented a one-year program to promote mammography for employees at one campus of a state university system; a second campus served as a comparison site. Measurement cohorts, who were surveyed immediately before and after the intervention, had been randomly selected at each site; all of the subjects had insurance coverage that included mammographic screening. The intervention consisted of print media, on-site workshops, and incentive drawings. Results indicated that mammography rates increased significantly at both sites, for both those 40-49 years of age and for those > or = 50 years of age. The rate increases for the 40- to 49-year-old age group at the intervention and control sites were 17.6% and 13.6%, respectively, and, for the > or = 50-year-old age group, 11.9% and 6.3%. However, the differential changes in rates between the sites were not significant for either age category. The intervention was perceived positively by the intervention site cohort, and participation in the various components was encouraging. We present suggestions for future research on this topic.

Evaluation of a media-based mammography program.

Reports indicate that only 15%-20% of women 50 years of age and older have had a mammogram. To promote screening mammography, the San Diego County Unit of the American Cancer Society sponsored a community-wide program that featured (1) discounted mammograms through participating clinics, (2) program promotion through television news, and (3) availability of a phone bank for obtaining referrals for mammography. Pre- and postintervention random sample phone surveys indicated that women's intentions to obtain a mammogram increased significantly after the media campaign, particularly in those aware of the program. Women's intentions after the media campaign predicted mammography compliance in the following year. A total of 3,102 women received mammograms directly through the program, with a "suspicious finding" rate of 4%. Participant satisfaction with the program was high.

Solar protection behaviors among outdoor workers.

Due to the lack of information regarding how US workers protect themselves from ultraviolet radiation, this study explored solar protection behaviors among three groups of outdoor workers. This cross-sectional research involved two separate studies. Study 1 consisted of observations of 312 outdoor workers, and Study 2 was a paper and pencil survey (n = 240). For each data set, occupational groups were compared on ultraviolet radiation protection. Observational data indicated that 50.4% of the workers had adequate protection. Across occupational groups, the ranking from highest to lowest levels of protection was consistent for both data sets. Face and lower arms were consistently the least protected sites. The pattern of findings suggests the importance of assessing protection of individual body sites, as well as composite protection.

Project Salsa: development and institutionalization of a nutritional health promotion project in a Latino community.

PURPOSE: Project Salsa was a community-based effort seeking to promote health through nutritional behavior change in a Latino community of San Diego, California. The purpose of this article is to report on program factors related to long-term institutionalization of Project Salsa interventions. DESIGN: Project Salsa was a demonstration rather than an experimental project. To ensure maximum sensitivity to the needs and values of the community, Project Salsa began with an extensive health needs assessment, including development of an advisory council, telephone survey, archival research, and key informant interviews. SETTING: Project Salsa interventions took place in San Ysidro, California, located near the U.S.-Mexico border adjacent to Tijuana from 1987 to 1992. SUBJECTS: The intervention community had 14,500 residents, of which nearly 83% were Latino. INTERVENTIONS: Interventions included coronary heart disease risk factor screenings, meal preparation classes, newspaper columns, point-of-purchase education, school health and cafeteria programs, and breast-feeding promotion. MEASURES: Institutionalization of intervention components. RESULTS: Two of the interventions, the risk factor screenings and school health programs, are still in operation 4 years after the end of project funding. CONCLUSIONS: Four factors common to institutionalized components are presented in the paper.

Long-term smoking status of cardiac patients following symptom-specific cessation advice.

Although physicians routinely advise postcardiac event patients to stop smoking, the effect of a modified advice format targeting specific health concerns has not been investigated. Also, no studies of cessation advice with cardiac patients have used biochemical verification of self-reported abstinence. The present study included 48 veterans with a history of smoking and cardiac problems; of these, 31 were smoking and 17 were abstinent at initial assessment. Alveolar carbon monoxide (COa) levels served to: (1) augment cessation advice by demonstrating smoking risks and cessation benefits specific to cardiac patients and (2) verify self-report. At 12 months followup, following cessation advice, 18% of the abstinent subjects had resumed smoking while none of the smokers had become abstinent. Those who maintained abstinence significantly increased their estimates of the contribution of smoking to their cardiac problems whereas those who continued to smoke showed no change.

Effects of a peer-led AIDS intervention with university students.

Acquired immune deficiency syndrome (AIDS) has become a major health threat to university students. This study evaluated a peer-led AIDS intervention program with university students (1) increase knowledge of human immunodeficiency virus (HIV) transmission and infection; (2) change attitudes to reflect scientific information on AIDS-related facts; and (3) change behavioral intentions to correspond with safer sexual practices. Subjects were students (N = 142) from four undergraduate classes and were predominantly female (65%), white (82%), and sexually active (86%). A non-equivalent control group design was used, with two classes receiving the intervention and two classes receiving no information. For the intervention, peer educators presented AIDS-related information, modeled ways to use condoms safely and ways to discuss condom use with sexual partners, and led discussions on HIV infection and use with sexual partners, and led discussions on HIV infection and AIDS, relationships, sexuality, and condom use. A questionnaire was administered to assess differential changes in AIDS-related knowledge, attitudes, and behavioral intentions between the intervention and control groups. The results showed significant improvements among intervention subjects on the knowledge, attitudes, and behavioral intentions scales compared with the control group.

Theoretical and practical aspects of receptor hormone assay in breast cancer.

The Authors have discussed the importance of ER/PR assay in breast cancer care. 162 patients were studied. The dextran-coated charcoal technique was used as the standard most readily available. The Authors point out the importance of specimen handling as is shown by time-decay studies, and the differences in ER/PR level at the time of the biopsy and mastectomy cut-section, and its eventual influence to better understanding assay results. The establishment of a center of control between different labs would also help in the development of more exact regimens for cancer care.

Promoting low-fat entree choices in a public cafeteria.

Reductions in dietary fat have been recommended in the prevention of coronary heart disease. Because entrees contribute substantially to total meal fat content, we evaluated a cafeteria-based intervention for increasing the purchase rate of low-fat entrees (M = 6.83 g) relative to nonlow-fat entrees (M = 25.59 g). The intervention included a poster listing the benefits of a LF diet and the daily LF entrees (i.e., broiled or baked chicken and fish dishes). During 6 days per phase, food selections (N = 3,264) were monitored by trained observers. The intervention, which cost $80.00, produced significant increases (i.e., from 20% to 35%) in the purchase rate of LF entrees.

Annual return rates to mammography facilities by women age 50 and older.

Data were collected at multiple mammography facilities to determine the use of inreach strategies for asymptomatic women age 50 and older and the annual return rates for screening by this age group. Interviews with 26 facility managers indicated that the majority use a reminder strategy. Using chart audits in a subset (n = 10) of the facilities of 475 randomly-selected patients, the return rate in 1991 (of patients seen in 1990) averaged 41% within 18 months after the 1990 appointment. Those data suggest that mammography providers, as well as the women they serve, could benefit from interventions to encourage annual mammograms.

Assessing breast self-examination compliance in the natural environment.

An indirect behavioral measure for measuring the frequency of breast self-examination (BSE) in the natural environment was developed and evaluated. BSE was performed using a lubricant (i.e., baby oil), and then a sheet of absorbent tissue was applied to the examined area. The tissue, which retained an oil stain, provided a trace measure of the exam. Results indicated that the measure remedied some of the weaknesses in verbal report, although for certain subjects it underestimated compliance.

The effects of social demand on breast self-examination self-report.

The measurement of breast self-examination (BSE) adherence typically relies on verbal self-report. These studies systematically manipulated social demand within a face-to-face interview and examined the effects on self-reported BSE frequency. In Study 1, subjects (n = 37) received either a high-demand or a low-demand preface prior to being asked about BSE practice over the past year. Study 2 (n = 89) was a replication, with the addition of a no-preface (control) condition. Results from Study 1 indicated that although the conditions were comparable on demographic and breast cancer/BSE knowledge variables, the high-demand condition reported a significantly higher number of BSEs than the low-demand condition. An attenuation of this pattern was found in Study 2, with the control condition reporting a frequency between the low demand's and the high demand's reported frequencies. The implications for BSE intervention and prevalence research are discussed.