Long-term outcome of total hip arthroplasty in patients with haemophilia.

INTRODUCTION: Besides the target joints (elbow, knee and ankle), the hip is one of the commonly affected joints in haemophilic arthropathy. Hip arthroplasty is the therapy of choice after failure of conservative treatment. There are only limited data on long-term results after primary total hip arthroplasty (THA). AIM: The aim of this retrospective study was to analyse clinical outcome and complication rate after total hip replacement in patients with severe haemophilic arthropathy. METHODS: Forty-three patients with haemophilia (PWH), one patient with von Willebrand disease and one patient with a Factor-VII-deficiency undergoing 49 total hip arthroplasties, were evaluated in a retrospective study. Harris hip score (HHS), range of motion (ROM), pain status (visual analogue scale, VAS) complication rate and patient satisfaction were assessed at a mean follow-up of 11.5 years (range: 3-32). RESULTS: HSS, ROM and VAS improved significantly combined with high patient satisfaction. In total, three (6.1%) periprosthetic infections and five (10.2%) aseptic implant loosenings occurred after THA leading to revision arthroplasty. In two (4.1%) cases, a pseudotumour and one (2.0%) periarticular ossification had to be resected after THA. CONCLUSION: Total hip replacement in PWH leads to a significant increase of function, reduction of pain and a high satisfaction. Due to the relatively high complication rate (infections and aseptic loosening) compared to patients without haemophilia, an individual assessment of the risk-benefit ratio from surgical and haemostaseological point of view is needed.

[Preoperative, neuropathic component in patients with back pain]. / Präoperative, neuropathische Komponente bei Rückenschmerzen.

BACKGROUND: The objectification of pain is essential for evaluation, treatment plan and follow-up; therefore, it is necessary to find reliable clinical parameters. OBJECTIVE: The goal of the study was the preoperative screening of a neuropathic component in patients with vertebral compression fracture (WKF), herniated disc (NPP) or spinal cord compression (SKS). MATERIAL AND METHODS: Depending on the preoperative condition on admittance, patients were classified into three groups: group 1 WKF, group 2 NPP and group 3 SKS. To characterize the pain we used the painDETECT questionnaire, the Oswestry questionnaire and further questionnaires. All patients were surgically treated according to the diagnosis, e.g. radiofrequency kyphoplasty, nucleotomy or spondylodesis. RESULTS: We evaluated the data from 139 patients (45% WKF, 34% NPP and 21% SKS). There were no differences in preoperative pain intensity (median ordinal scale 0-10) with a mean preoperative score of 7 for all groups. The total score of the painDETECT questionnaire showed significantly higher results in group 2 (median 18) and in group 3 (median 14) than in group 1 (median 9). There was even a significant difference between groups 2 and 3 (p = 0.03). The highest pain intensity was detected in group 1 with a median visual analog scale (VAS) of 71 mm. The total scores in the painDETECT questionnaire and the scores in the Oswestry questionnaire correlated in groups 2 and 3. CONCLUSION: The painDETECT questionnaire was shown to be a very suitable instrument for evaluating the neuropathic pain component in patients with dorsalgia. This could be very useful in planning further therapy.

Treatment options for vertebral fractures an overview of different philosophies and techniques for vertebral augmentation.

PURPOSE: For more than 30 years, minimally invasive surgical procedures have been available to stabilize the fractured vertebrae by cement augmentation leading to significant pain relief, a distinct improvement in quality of life and decreased mortality for patients suffering from osteoporotic vertebral compression fractures. This overview article is designed to provide information on the wide range of augmentation methods previously tested and clinically applied in surgery in an attempt to compile the clinically relevant information on safety and efficacy in the published literature. METHOD: Based on an extensive literature review on the topic of "vertebral fractures--surgical augmentation techniques" we summarized the results of published clinical trials and experimental testing which address clinically relevant questions. The selection of the publications in reference books and scientific journals covers the time period from the end of the 1970s until the present. RESULTS: The final selection of more than 50 publications with, in the opinion of the authors, clinically relevant data led to the following results, which can be of significance for clinical application. The prerequisites for the success of all augmentation methods include the earliest possible surgical intervention, optimal technical equipment and an experienced, interdisciplinary team, as well as thorough consideration of the situation of the individual patient. The selection of the material for vertebral augmentation depends on the surgical method. The material of choice remains polymethylmethacrylate (PMMA), and the best record of efficacy and safety is displayed by radiofrequency kyphoplasty with ultrahigh-viscosity cement. Regarding clinical efficacy and safety, there are many convincing documentations showing superiority of vertebroplasty and kyphoplasty in comparison with conservative therapeutic regimens. Initial results of clinical studies with additional implants indicate a trend toward further improvement in clinical success and suggest possible broader clinical possibilities of application. CONCLUSION: Modern, minimally invasive augmentation techniques represent a real alternative to conservative treatment of patients with vertebral fractures. Further technical and clinical development in this area should aim at optimizing procedural safety while continuing to achieve comparably good results to current methods. Minimizing damage to the remaining trabecular structures as well as to adjacent vertebral disks and vertebrae should be paramount of importance. SUMMARY: Options for the treatment of vertebral fractures: Reductions in bone density and pathological changes in bone structure are associated with an elevated risk of fractures, which can lead to decisive functional impairment, pain, and a host of further comorbidities. Vertebral augmentation can be considered as an alternative conservative treatment, in order to achieve immediate and lasting pain relief as well as improvement in functional impairment. To achieve greater safety, instrumentation for transpedicular access and incorporation of radiopacifiers in PMMA for vertebroplasty were developed in mid-eighties. Balloon kyphoplasty was introduced in the end nineties, and results of prospective, randomized clinical studies have confirmed the safety and efficacy; the destruction of the remaining native spongiosa structures during balloon expansion is viewed as a disadvantage of this method. The two step method of cavity creation followed by cement delivery known as kyphoplasty has been further refined and developed by and varied by technology/procedural developments. This includes most the radiofrequency kyphoplasty (DFINE Inc., San Jose, CA, USA), in which ultrahigh-viscosity cement is delivered at a controlled delivery rate, following producing a bone sparing size and side specific cavity which minimizes loss of spongiosa, allowing for mechanical stability upon interdigitation of cement into that remaining trabecular bone. This combination has been shown to preserve vertebral structures and reduces the risk of leakages. Finally, systems have been available in which cement augmentation of implants to enhance mechanical stability of the implants or the overall fracture is constructed by load sharing.

[Allergies and school - what makes me itch? A primary school project in Bielefeld on health promotion for allergic diseases]. / Allergie und Schule - Was juckt mich das?Ein Grundschulprojekt in Bielefeld zur Gesundheitsförderung bei allergischen Krankheiten.

INTRODUCTION: According to KiGGS the 12-month prevalence of asthma, hay fever and atopic dermatitis for 7-10-year-old children amounts to 16.7%. Primary school children are not at home with their disease, in everyday school life many detrimental and stigmatising aspects can be observed. In an interdisciplinary primary school project in Bielefeld between 2008 and 2010 the prevalence, disease knowledge and health attitudes of children in the 3rd school year were recorded; an appropriate approach to these diseases was also to be provided. METHODS: In classes of the 3rd school year a 2-hour teaching unit on allergic diseases was carried out. Before and after (1st + 2nd examination time points [ETP]) the children were questioned about their knowledge and attitudes to allergic diseases and their general opinions about health. The parents were similarly questioned. RESULTS: In 2008, 23 schools with 64 classes and 1 345 children participated in the project, the average age of the children was 8.9 years. Data were obtained for 1 216/1 211 children at the 1st and 2nd ETPs, respectively. 336 (27.6%)/367 (30.3%) stated that they had an allergic disease, of these 16.6%/17.3% had an allergy, 5.1%/5.9% asthma and 4.0%/6.6% atopic dermatitis (the parents reported 15.1%, 5.4% and 7.8%). Clear deficits were found in disease knowledge but could be markedly improved. CONCLUSIONS: In comparison to KiGGS data published in 2007, our prevalence rates for allergies are higher - albeit with a wider definition of allergy; the numbers for asthma and atopic dermatitis are comparable. The knowledge deficits among children indicate the necessity for further information. The project was continued in 2011 and should be implemented in the primary school teaching programme.

[Modified percutaneous achillotentomy according to Hoke for minimally invasive treatment of pointed foot]. / Modifizierte perkutane Achillotenotomie nach Hoke zur minimal-invasiven Spitzfußbehandlung.

OBJECTIVE: Various underlying diseases can lead to a pointed foot in children and adults. If the gastrocnemius and soleus muscles are structurally shortened, various surgical procedures are available to correct this malposition. A preferred method for restoring a normal dorsiflexion of the upper ankle joint is percutaneous achillotentomy according to Hoke. Consideration of the physiological-anatomical torsion of the Achilles tendon as it corresponds to the White technique and is recommended by some authors shows in our experience no advantages. In the present work, we show a modified, likewise minimally invasive form of this surgical method with which immediate full weight-bearing of the affected lower extremity is possible from postoperative day 1. INDICATIONS: All clinically relevant structural pointed foot, for primary and/or for revision treatment. CONTRAINDICATIONS: Infection in the area of the operation. SURGICAL TECHNIQUE: No tourniquet, 3 incisions with the 15 mm knife: (1) medial distal at the transition from the Achilles tendon to the calcaneus, (2) medial proximal approximately 7 cm proximal to the 1st stab incision, (3) lateral, midway between the first two incisions; no skin suturing, application of a lower leg cast. POSTOPERATIVE MANAGEMENT: On postoperative day 1, cast hybridization using Scotchcast (3M Deutschland GmbH, Neuss, Germany), followed by pain-adapted full weight-bearing; removal of the cast in the outpatient department after 4 weeks. RESULTS: A total of 104 patients underwent surgery, 1 case of a local pressure point, no infections, no overcorrections, no Achilles tendon ruptures, in one case a postoperative relapse due to a broken cast. The risk of overcorrection to the foot, which was considered the main complication in the literature, did not occur in any of the cases.

High-power solid-state cw dye laser.

In the present paper we describe a high-power tunable solid-state dye laser setup that offers peak output power up to 800 mW around 575 nm with excellent long-time power stability and low noise level. The spectral width of the laser emission is less than 3 GHz and can be tuned over more than 30 nm. A nearly circular mode profile is achieved with an M(2) better than 1.4. The device can be integrated in a compact housing (dimensions are 60 × 40 × 20 cm(3)). The limitation of long-time power stability is mainly given by photo decomposition of organic dye molecules. These processes are analyzed in detail via spatially resolved micro-imaging and spectroscopic studies.

Balloon-assisted sacroplasty as a successful procedure for osteoporotic sacral insufficiency fractures after failure of the conservative treatment.

Osteoporotic vertebral fractures without prior adequate traumatization are frequent diagnosed in orthopedics because of the increasing life expectancy and incidence of osteoporosis. The associated high mortality is caused by reduced mobilization which leads to a higher risk of infection and a bedridden state. On the other hand the diagnosis of sacral insufficiency fractures is often prolonged because of unspecific symptoms while being associated with similar risks. This article presents an overview of the present scientific literature and a retrospective analysis of patients treated via balloon-assisted sacroplasty. In 8 years, ten patients (three men and seven women) were treated. The average age was 78.4 years and the average time until the diagnosis 4.6 weeks. In most patients a significant pain reduction after the failure of conservative treatment thanks to operative treatment as well as increased mobility was observed. Only one experienced a minor surgical complication being cement leakage with nerval impaction which did not compromise her clinical outcome or satisfaction with the procedure. Balloon-assisted sacroplasty can possibly be seen as an effective symptomatic therapy in osteoporotic insufficiency fractures.

[Methods for organisational health services research]. / Methoden für die organisationsbezogene Versorgungsforschung.

On 1 July 2009, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned below and published in this journal (Gesundheitswesen 2009; 71: 505-510). The focus of this part of the Memorandum III "Methods for health services research" is on the questions and methods of organisational health services research. In a first step, we describe the central questions which are at the core of organisational health services research. In a second step, we describe the methodological standards and requirements with regard to a) sampling, b) measurement and c) research design. We present a phase model for complex intervention trials. This model allows to conduct high quality organisational health services research, to integrate different methods of social research and to show in which phase they are of special importance.

Substitution treatment of injecting opioid users for prevention of HIV infection.

BACKGROUND: Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. OBJECTIVES: To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts SELECTION CRITERIA: Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion. DATA COLLECTION AND ANALYSIS: One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers. MAIN RESULTS: Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. AUTHORS' CONCLUSIONS: Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

A statistical method for estimating the proportion of cases resulting from cross-transmission of multi-resistant pathogens in an intensive care unit.

Multi-resistant bacteria are an increasing challenge for infection control in hospitals and the proportion of patients newly colonized with multi-resistant bacteria during their hospital stay can be used to assess the effectiveness of infection control measures. Current laboratory methods for estimating this require expensive additional tests. We propose an alternative statistical method to estimate the proportion of cases resulting from transmission in a hospital from the distribution of time intervals between subsequent cases. A prerequisite for the application of this method is the existence of records from regular screening of the patients during their hospital stay, usually performed in intensive care units (ICUs). We describe the method and present an example of its application using records of two multi-resistant pathogens collected in an ICU over a three-year period. The estimated proportion of cases resulting from transmission was 0.73 (95% CI: 0.56-0.90) for meticillin-resistant Staphylococcus aureus and 0.45 (95% CI 0.15-0.75) for imipenem-resistant Pseudomonas aeruginosa. The method proposed here can be used for retrospective evaluation of clinical records in order to evaluate the effectiveness of infection control measures in low endemicity settings.

Comparison of radiofrequency kyphoplasty and balloon kyphoplasty in combination with posterior fixation for the treatment of vertebral fractures.

BACKGROUND: In case of complex vertebral fractures, posterior fixation is often required for correction of deformity and instability. Fixation is commonly supported by balloon kyphoplasty (BKP) anterior. A development of BKP is radiofrequency-targeted vertebral augmentation (RF-TVA), which leads to comparable results for augmentation and pain relief. OBJECTIVE: This prospective study evaluates the outcome of posterior fixation combined with RF-TVA or BKP, respectively. METHODS: VAS, ODI, kyphosis angle and vertebral height of 44 patients were evaluated preoperatively, 3 and 12 months postoperatively. RESULTS: Both treatments improved vertebral height and kyphosis angle. At 12 months, vertebral height restoration was still significantly better in the BKP group (p < 0.001) and the improvement of kyphosis angle was comparable between both groups (p = 0.71). VAS and ODI improvements were significantly better in the RF-TVA group (p < 0.001). 8% of BKP patients had cement extravasations, compared to 10.5% in the RF-TVA group (p = 1.0). CONCLUSIONS: Combining posterior fixation with RF-TVA leads to better results of VAS and ODI, whereas the vertebral height restoration was favorable for patients treated with BKP. Cement leakage was comparable between both groups. It was asymptomatic and within reported ranges. Limitations of this study are the patient number and different stabilization instrumentation.

[Palliative approach in outpatient care in Westphalia-Lippe--Follow-up study five years after inception of a structured home-based palliative care system]. / Ambulante Palliativversorgung in Westfalen-Lippe--Eine Follow-up-Erhebung fünf Jahre nach Einführung einer strukturierten Versorgung im häuslichen Umfeld.

INTRODUCTION: Since 2009, based on an agreement to implement palliative care for terminally ill patients at home in Westfalia-Lippe, family doctors and palliative doctors cooperate, supported by coordinators. METHOD: Since 2009, this cooperation is evaluated, concerning supply structure, number of patients and their places of death. RESULTS: In Westfalia-Lippe, yearly approx. 91.000 patients die, approx. 19 % of them, 17.699 patients, were included in palliative care structures, compared to some 6 % in 2009/2010. Whereas in the first years about 70 % of the palliative patients died at home, 2014 this number increased to 75 %. Only 9 % of our patients 2014 died in a hospital (normal ward) - compared to about 13 % in 2009/2010. This applies both for urban and rural areas. CONCLUSIONS: The idea of home based, family doctor supported palliative care led to a significant strengthening of the general out-patient palliative care. The number of patients, integrated in our structures of palliative care in 2014 tripled compare to those of 2009/2010. Well trained and experienced coordinators are the essential guarantee of multidisciplinary and multiprofessional team-work. The results of the regional palliative care structures are different also after the agreement came in effect. Data for quality assurance should be periodically collected and evaluated in the future to develop the palliative care structures for outpatients.

Diagnosis of Neuropathic Components in Patients with Back Pain Before and After Surgery.

Background: The perception of back pain subjective is hard for physicians to measure. For this reason, questionnaires are an important instrument to evaluate the pain 1. The main point of this study was to verify differentiation of pain symptoms in patients with different pain mechanisms. The most important parameter was the PainDetect questionnaire, which can differentiate between nociceptive and neuropathic pain. Additional parameters were measured before and after surgery to characterise pain symptoms in detail. Material and Methods: We selected patients with diagnosed vertebral compression fracture, herniated disc or with spinal cord compression. To characterise the preoperative condition on admittance, we collected the data from the physical examination, as well as clinical data, including X-ray, CT and MRI. To characterise the pain, we used the painDetect questionnaire, the Oswestry Index questionnaire (ODI) and the visual analogue scale (VAS). Depending on the diagnosis, patients were treated by surgery (radiofrequency kyphoplasty, nucleotomy, spondylodesis). At 2 to 3 days and 6 months after surgery, we repeated the questionnaire and compared the results with those before the operation. Data on patient satisfaction and adverse events were also collected. Results: This study included 62 patients with vertebral compression fracture (group 1: VBF, 89 % female, mean age 71 years) and 77 patients with herniated disc or spinal cord compression (group 2: non-VBF, 55 % female, mean age 53 years). There was no difference between both groups in preoperative pain intensity (acute, maximum, average): median ordinal scale 0 to 10; group 1: 6, 8, 7; group 2: 6, 9, 7. The total score in the painDetect questionnaire differed significantly between the two groups (median group 1 = 9, group 2 = 17; effect size r = 0.5; p = 0.000). The existence of neuropathic pain was presumed (> 90 %) in 3 % of the patients in group 1 and in 13 % of patients it was not excluded. In contrast, in group 2 it was presumed (> 90 %) in 43 % of patients and in 30 % of patients it could not be excluded. Patients with vertebral compression fracture had greater pain intensity (VAS 71) than patients from group 2 (VAS 53). There was no difference in the total score of the Oswestry questionnaire between the two groups (56 % vs. 58 %). Pain intensity was significantly reduced in both groups after the operations. Six months postoperatively, pain intensity (median ordinal scale 0 to 10; acute, maximum, average) was 2, 5, 3 in group 1 and 2, 4, 2 in group 2. Moreover, the final scores of the painDetect questionnaires were significantly lower in both groups after the operations (4 in both groups). The median score of the ODI was reduced in both groups, with an effect size of 0.6. 98 % of the patients in group 1 and 94 % in group 2 were satisfied with the outcome of the operation. Conclusion: The preoperative pain characteristics of patients with vertebral compression fracture is different from those of patients with herniated disc or with spinal cord compression. 43 % of patients in group 2 exhibited a neuropathic pain component and in 30 % this could not be excluded. In contrast, in group 1 only 3 % of the patients exhibited a neuropathic pain component. Postoperatively, pain symptoms were significant reduced in both groups, so that the risk of chronic pain was considerably less.

[Clinical Trial to Test the iFuse Implant System® in Patients with Sacroiliac Joint Syndrome: One Year Results]. / Klinische Studie zur Prüfung des iFuse Implant Systems® bei Patienten mit Iliosakralgelenksyndrom: 1-Jahres-Ergebnisse.

Background: This study reports one year post-operative monitoring of the efficacy and safety of iFuse Implant System® in patients with sacroiliac joint syndrome. Material and Methods: After 6 months of inadequate conservative treatment, patients with properly proven ISG syndrome were selected for surgery. The iFuse implants had a triangular profile and coating of porous titanium plasma spray and were used in the minimally invasive procedures. The procedure was performed under general anaesthesia and fluoroscopic control. In each case, three implants were placed. Results: 24 patients (22 f; 92 %; 54.9 ± 14 years) participated in the study. The operations were performed in 11 patients (46 %) on the left and in 13 patients (54 %) on the right. The mean operative time was 42.4 minutes (95 % CI: 35.6-49.3). The reduction in pain intensity on the VAS scale was 58 ± 11 mm (68 ± 7 %). The Oswestry score showed a median decrease of 44 percentage points (57 %). After 12 months, 15 patients (63 %) reported that they were taking no more painkillers. Conclusion: The minimally invasive treatment of patients with sacroiliac joint syndrome using the iFuse Implant System leads to significant analgesic effects over the period of one year; it also contributes significantly to improving the functioning of the patient.

Radiofrequency Ablation: Temperature Distribution in Adjacent Tissues.

PURPOSE: This clinical study investigates the use of a radiofrequency ablation system specifically developed for the ablation of spinal metastases. The investigation examines possible temperature-associated risks for the adjacent tissues. MATERIAL AND METHODS: A tumour model was simulated for 8 lumbar and 8 thoracic vertebrae of a human cadaveric spine. The tumour mass was ablated with the SpineSTAR electrode (SpineSTAR, DFINE Inc., CA), which has been specifically developed for the ablation of spinal metastases. During the ablation procedure, the temperatures of the vertebra, the epidural space, and the neural foramen were measured with thermocouples. These temperatures were documented as means with standard deviations. Possible differences between lumbar and thoracic vertebrae were analysed with the Mann-Whitney U test. RESULTS: The maximal temperature of the lumbar vertebrae was 46.4 ± 3.3 °C near to the ablation zone, the temperature of the neural foramen was 37.0 ± 0 °C, and the temperature of the epidural space was 37.3 ± 0.7 °C. In the thoracic vertebrae, the temperature was 44.4 ± 1.7 °C near to the ablation zone, 7.9 ± 1.7 °C in the neural foramen, and 37.25 ± 0.7 °C in the epidural space. There was no significant difference in temperature distribution between treated lumbar and thoracic vertebrae. CONCLUSION: Ablation of spinal metastases in a cadaveric model using the SpineSTAR electrode was shown to be a safe method with respect to possible temperature-related risks for the adjacent tissues.

The QuickLine IL-6 lateral flow immunoassay improves the rapid intraoperative diagnosis of suspected periprosthetic joint infections.

BACKGROUND: When deciding upon the best treatment strategy in revision arthroplasty, it is absolutely crucial to use the best possible preoperative detection whether a periprosthetic joint infection (PJI) is present or not. New molecular markers investigated in serum samples and synovial fluid can help to improve the preoperative diagnosis. In 2001, a novel IL-6 lateral flow immunoassay testing device was introduced which has never been tested in synovial fluid so far. OBJECTIVE: For our study we investigated whether the test can be used safely, feasibly and time effectively with synovial fluid gathered from potentially infected THAs or TKAs and whether the already published cutoff for IL-6 in synovial fluid predicting a PJI can be reproduced using the QuickLine IL-6 immunoassay. METHODS: After ethic approval and within the scope of a prospective controlled trial we investigated 26 patients (m = 9, 34.6%; f= 17, 65.4%) with n = 13 (50%) potentially infected total hip arthroplasties (THAs) and n = 13 (50%) suspected PJIs of total knee arthroplasties (TKAs). Sterile aspirated synovial fluid was examined for total leukocyte count and cell differentiation by a blood count analyzer in body fluid mode as well as for IL-6 (Immulite, Siemens Medical Solutions Diagnostics GmbH, Eschborn, Germany). Another part of the joint aspirate was tested using the QuickLine IL-6 Test by Milenia Biotec (Milenia Biotec, Gießen, Germany). RESULTS: The mean concentration of IL-6 as determined from our reference laboratory testing (Siemens Immulight) for aseptic cases was 1,219 pg/mL (SD 1,369 pg/mL, min 134 pg/mL-max 4,214 pg/mL). The mean IL-6 concentration measured via the IL-6 QuickLine for aseptic cases was 410 pg/mL (SD 371 pg/mL, min 100 pg/mL-max 1562 pg/mL). The test showed no false negative or false positive results in the cases tested. In six patients, PJI was considered proven. The QuickLine Test indicated IL 6 concentrations > 10,000 pg/mL in these cases without further quantification above this maximum detection threshold. Results from the QuickLine Test and the laboratory tests were matched and a non-linear best fit curve (log-log-curve) was applied. The subsequent Spearman correlation showed a correlation coefficient of r = 0.92 (95% CI 0.81-0.97) which corresponds to a two-tailed p-value of < 0.0001, respectively. As a primary finding we were able to show that the Milenia QuickLine IL-6 Test can be used safely, feasibly and time effectively with synovial fluid gathered intraoperatively from potentially infected THAs or TKAs. The test as provided worked well in 84.6% of the samples tested and failed only due to very viscous synovial fluid. As a secondary result we found that the previously published cut-off for IL-6 in synovial fluid predicting a PJI with a sensitivity of 46.88% and a specificity of 97.62% can be reproduced using the QuickLine IL-6 immunoassay. CONCLUSION: Taking the limitations of the low sample size as a given this relatively simple point of care (POC) assay showed promising results in our pilot trial and may help diagnosing PJI. It may help physicians and surgeons to choose the best and least invasive treatment strategy for patients presenting with painful arthroplasty.

[Diagnosis and Treatment of Spondylodiscitis/Spondylitis in Clinical Practice]. / Diagnose und Behandlung der Spondylitis/Spondylodiszitis in der Klinikroutine.

BACKGROUND: The clinical presentation of spondylsodiscitis/spondylitis are manifold. This commonly leads to a period of several months from initial symptoms to final diagnosis. A standardised treatment is difficult. The purpose of this study is to investigate the treatment carried out for patients with spondylodiscitis or spondylitis to develop an individualised standard care for better treatment. PATIENTS AND METHODS: Data of 90 patients were retrospective analysed. In particular documented data of the initial examination and the following treatments concerning identification of causes and systematically control of pathogens were examined. RESULTS: In 91 % of patients a diagnostically conclusive MRI was conducted. The degree of spondylidiscitis/spondylitis was mainly ASA criteria I or II (86 %). In 96 % of patients different diagnostic methods for identification of pathogens were conducted and documented. RESULTS confirmed the most common pathogens mentioned in the literature. 75 % of patients were treated by surgery. In 93 % of patients an antibiotic treatment was documented. 50 patients (81 %) were successfully healed. CONCLUSION: It is important to identify and treat spondylodiscitis/spondylitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualised to each and every patient.

[A Comparison of Dorsal Decompression and Dorsal Decompression Combined with the Dynamic Stabilisation Device LimiFlex™]. / Vergleich dorsaler Dekompression nicht stabilisiert und dynamisch stabilisiert mit LimiFlex™.

BACKGROUND: Lumbar spinal canal stenosis is commonly treated by dorsal decompression. However, resection of posterior elements increases the biomechanical instability and may lead to further complications. In order to prevent this, fusion of the involved segments is often performed. But further complications may be associated with this, for example, highly reduced flexibility. In order to overcome fusion-related problems, dynamic stabilisation devices, like the new LimiFlex™ Paraspinous Tension Band (PSB), have been developed. This prospective study compares dorsal decompression without stabilisation and dorsal decompression with stabilisation using the PSB in patients with lumbar canal stenosis. METHODS: Sixty-three patients with stenosis involving one or two lumbar vertebral levels were treated with dorsal decompression. Forty received the PSB following decompression surgery. Back, hip and leg pain as well as patient's degree of disability were assessed preoperatively and at 3, 6 and 12 months postoperatively for all patients. Evaluations were conducted using the visual analogue scale (VAS) and the Oswestry disability index (ODI). Adverse events during the study period were evaluated. RESULTS: Patients who received the PSB experienced a better pain relief and improvement in disability compared to patients who received treatment through decompression only. A significant difference of VAS and ODI development was found between both groups when treating two vertebral levels. Furthermore, the total number of adverse events was lower in the PSB group compared to the decompression group. CONCLUSION: Dynamic stabilisation using the PSB delivers better results in terms of VAS and ODI values when compared to only dorsal decompression. In addition, it is also associated with a lower number of complications. The PSB is most favourable when 2 levels are treated.

Is a clinical application of hybrid liver support systems limited by an initial disorder in cellular amino acid and alpha-keto acid metabolism, rather than by later gradual loss of primary hepatocyte function?

The in-vitro amino acid (AA) and alpha-keto acid (KA) metabolism of bioreactors initially seeded with 2.5 x 10(9) pig hepatocytes was investigated with a perfusion technique. Considerable changes in the culture medium concentrations of AA and KA were measured during the first days in culture. This is indicative of dynamic cellular metabolism in the initial phase. While the concentration of pyruvate decreased starting on the first day, alpha-ketoglutarate, alpha-ketoisocaproate, alpha-ketoisovalerate, and alpha-keto-beta-methyl-n-valerate were synthesized. The long term use of hepatocyte cultures in bioreactors and thus a desirable clinical hybrid liver support therapy appears to be possible since the hepatocytes switched, after 15 days in culture, to steady-state conditions with a stable amino acid turnover featuring general AA uptake accompanied by KA release. The release of branched chain KA, in particular that of alpha-ketoisocaproate, reflects an effective transamination activity in the bioreactor system. Primary pig hepatocytes cultivated in hybrid liver support systems for therapy of acute liver failure or as devices for bridging to liver transplantation can sustain amino acid metabolism for at least 30 days in vitro. However, an initial disorder following the cell isolation that is demonstrated may limit immediate utilization of the systems prior to the reorganisation of the cells to tissue-like structures in bioreactors.

Substitution treatment of injecting opioid users for prevention of HIV infection.

BACKGROUND: Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour. OBJECTIVES: To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours. SEARCH STRATEGY: Multiple electronic databases were searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched. SELECTION CRITERIA: Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. DATA COLLECTION AND ANALYSIS: Each potentially relevant study was independently assessed by two reviewers. For studies that met the inclusion criteria, key information was extracted by one reviewer and confirmed by consultation between all four reviewers. MAIN RESULTS: Twenty-eight studies, involving 7900 participants, were included. The majority were not randomised controlled studies. Issues of confounding and bias are discussed. The studies varied in several aspects limiting the extent of quantitative analysis. REVIEWERS' CONCLUSIONS: Oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review. However, these findings add to the stronger evidence of effectiveness of substitution treatment on drug use, and treatment retention outcomes shown by other systematic reviews. On this basis, the provision of substitution treatment for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users should be supported.