Microstructural analysis of subchondral bone in knee osteoarthritis.

The results of this study show increased formation of bone in the subchondral areas in advanced stages of osteoarthritis of the knee. These changes seem to be influenced by mechanical factors. INTRODUCTION: Subchondral bone changes seem to contribute to the progression of knee osteoarthritis (OA). This study aimed to analyze subchondral bone microstructure in specimens of late-stage knee OA in respect to articular cartilage damage, meniscus integrity, and knee joint alignment. METHODS: Thirty proximal tibiae of 30 patients (20 female and 10 male) with late-stage OA retrieved during total knee arthroplasty were scanned using a high-resolution micro-computed tomography. The scans were semi-automatically segmented into five volumes of interest. The volumes of interest were then further analyzed using commercially available software. The degree of articular cartilage damage was assessed semi-quantitatively by magnetic resonance imaging before surgery. RESULTS: The mean bone fraction volume (bone volume/total volume (BV/TV)) in all weight-bearing locations was significantly higher compared to the non-weight-bearing reference point below the anterior cruciate ligament (p = 0.000). The mean BV/TV in the medial compartment was significantly higher compared to the lateral compartment (p = 0.007). As for the BV/TV in intact menisci, there was a significantly lower subchondral bone fraction volume compared to subluxated or luxated menisci in the medial (p = 0.020) and lateral compartment (p = 0.005). Varus alignment had a significantly higher subchondral BV/TV in the medial compartment, whereas valgus alignment had a significantly higher subchondral BV/TV in the lateral compartment (p = 0.011). CONCLUSIONS: The results show significant differences of subchondral bone microstructural parameters in respect to cartilage damage, meniscus' structural integrity, and knee joint alignment. Therefore, subchondral bone changes seem to be a secondary process in the late-stage OA of the knee caused by mechanical changes.

End-of-life decision making by Austrian physicians - a cross-sectional study.

BACKGROUND: Austria has recently been embroiled in the complex debate on the legalization of measures to end life prematurely. Empirical data on end-of-life decisions made by Austrian physicians barely exists. This study is the first in Austria aimed at finding out how physicians generally approach and make end-of-life therapy decisions. METHODS: The European end-of-life decisions (EURELD) questionnaire, translated and adapted by Schildmann et al., was used to conduct this cross-sectional postal survey. Questions on palliative care training, legal issues, and use of and satisfaction with palliative care were added. All Austrian specialists in hematology and oncology, a representative sample of doctors specialized in internal medicine, and a sample of general practitioners, were invited to participate in this anonymous postal survey. RESULTS: Five hundred forty-eight questionnaires (response rate: 10.4%) were evaluated. 88.3% of participants had treated a patient who had died in the previous 12 months. 23% of respondents had an additional qualification in palliative medicine. The cause of death in 53.1% of patients was cancer, and 44.8% died at home. In 86.3% of cases, pain relief and / or symptom relief had been intensified. Further treatment had been withheld by 60.0%, and an existing treatment discontinued by 49.1% of respondents. In 5 cases, the respondents had prescribed, provided or administered a drug which had resulted in death. 51.3% of physicians said they would never carry out physician-assisted suicide (PAS), while 30.3% could imagine doing so under certain conditions. 38.5% of respondents supported the current prohibition of PAS, 23.9% opposed it, and 33.2% were undecided. 52.4% of physicians felt the legal situation with respect to measures to end life prematurely was ambiguous. An additional qualification in palliative medicine had no influence on measures taken, or attitudes towards PAS. CONCLUSIONS: The majority of doctors perform symptom control in terminally ill patients. PAS is frequently requested but rarely carried out. Attending physicians felt the legal situation was ambiguous. Physicians should therefore receive training in current legislation relating to end-of-life choices and medical decisions. The data collected in this survey will help political decision-makers provide the necessary legal framework for end-of-life medical care.

First reported implementation of a German-language progress test in an undergraduate dental curriculum: A prospective study.

INTRODUCTION: Progress testing is a special form of longitudinal and feedback-oriented assessment. Even though well established in human medical curricula, this is not the case in dental education. The aim was the prospective development and implementation of the first reported German-language Dental Progress Test (DPT) for the undergraduate dental curriculum at the Medical University of Graz, Austria. MATERIAL AND METHODS: Participation in DPT was compulsory for all dental students in terms 7-12 (years 4-6). Three tests, each consisting of 100 items out of a pool of 375, were administered within 3 consecutive terms in 2016 and 2017. Rasch analyses were used to evaluate the questionnaire and identify misfitting items. RESULTS: In the item responses, 59.7% were "correct," 27.0% were "false" and 13.3% were answered with "don't know," with similar results at all 3 time points. The assumption of parallel ICC was met (T1: χ2  = 51.071, df = 74, P = .981; T2: χ2  = 57.044, df = 67, P = .802; T3: χ2  = 58.443, df = 72, P = .876) and item difficulties for the thematic fields were similarly distributed across the latent dimensions. CONCLUSION: The newly introduced DPT is appropriate for testing dental students and is well balanced for the tested target group.

Preoperative Glasgow Prognostic Score as additional independent prognostic parameter for patients with esophageal cancer after curative esophagectomy.

BACKGROUND: Inflammation accelerates tumor growth followed by reduced survival in patients with cancer. The aim of this study was to evaluate the prognostic relevance of preoperatively increased levels of C-reactive protein (CRP) and the corresponding Glasgow Prognostic Score (GPS) on patients with esophageal carcinoma undergoing curative esophagectomy. METHODS: The data of 174 operated esophageal cancer patients were evaluated retrospectively. Patient's demographic and clinico-pathological data, tumor specific data, preoperative plasma levels of CRP and albumin, the corresponding GPS, overall survival (OS) and progression free survival (PFS) were assessed. RESULTS: 103 (59.2%) had adenocarcinoma and 71 (40.8%) had squamous cell carcinoma. 71 patients (43%) had elevated CRP concentrations. 118 patients (71%) had GPS 0, 41 (25%) GPS 1 and 8 (4%) GPS 2. Mean GPS was 0.3 (0-2). 5-year OS was higher in patients with normal CRP than in those with increased CRP (68% vs. 39%; p = 0.007). 5-year OS in patients with GPS 0 and GPS 1 and 2 were 65% and 31% (p = 0.001). 5-year OS for the whole cohort was 56% (1 year: 83%, 3 years: 64%). Recurrence rate was 16.1% closely associated with GPS (p = 0.002). Median follow-up was 23 months (0-118 months). In multivariate analysis GPS, lymph node involvement, T stage and tumor histology were the independent prognostic parameters (p = 0.004, <0.001, 0.035, 0.010). CONCLUSIONS: Preoperatively increased GPS is significantly associated with reduced postoperative survival and tumor recurrence. The GPS as an independent prognosticator should be interpreted together with the TNM stage when the further postoperative treatment has to be scheduled.

COPART Risk Score, Endothelial Dysfunction, and Arterial Hypertension are Independent Risk Factors for Mortality in Claudicants.

OBJECTIVE: The COPART risk score consists of six variables to assess the prognosis of PAOD patients. The flow mediated dilation (FMD) quantifies endothelial function. The aim of this study was to evaluate the mortality prediction of these two variables in a long-term observation of claudicants. METHODS: 184 consecutive claudicants were included in a prospective observational study over a median observation period of 7.9 (IQR 7.2-8.7) years. The endothelial function was assessed on the day of study inclusion using brachial FMD. RESULTS: Three groups were assigned according to the COPART risk score: low risk (LR), n = 72 (39%); medium risk (MR), n = 59 (32%); and high risk (HR), n = 53 (29%). Overall survival rates differed among COPART risk score groups (p < .001, 5 year survival: LR group 83% [95% CI 74-92%]; MR group 73% [95% CI 62-84%]; HR group 57% [95% CI 43-70%]). Survivors had a significantly better median FMD than non-survivors (4.1% [IQR 1.2-6.4] vs. 1.3% [IQR 0.0-4.2]; p < .001). Also the FMD differed significantly among the three COPART risk groups (LR 4.0% [IQR 1.2-6.3], MR 2.3% [IQR 0.0-6.3], HR 1.7% [IQR 0.0-3.6]; p = .033). Finally, independent predictors for disease specific survival were COPART risk score (p = .033; MR group [HR 1.6], 95% CI 0.7-3.6; HR group [HR 2.7], 95% CI 1.2-5.8), FMD (p = .004; FMD ≤2.5 vs. >2.5, HR 2.6, 95% CI 1.4-4.9), and arterial hypertension (p = .039; HR 3.5, 95% CI 1.1-11.3). CONCLUSIONS: COPART risk score, FMD, and arterial hypertension are independent long-term mortality predictors in this group of claudicants. The best mortality assessment is provided by including all three predictors.

Oropharyngeal suctioning in neonates immediately after delivery: influence on cerebral and peripheral tissue oxygenation.

BACKGROUND: Routine oropharyngeal suctioning in term vigorous neonates immediately after birth is a questionable practice. Current recommendations favor suctioning only in the presence of considerable obstruction due to secretions, blood or other matter. We aimed to analyze the influence of oropharyngeal suctioning on cerebral and peripheral muscle oxygenation in term neonates during transition immediately after birth. METHODS: We included term neonates after elective cesarean section for this prospective observational study. Oropharyngeal suctioning was performed based on the clinicians' judgment of threatening airway obstruction. From a total of 138 enrolled neonates, 36 were suctioned and then compared to 36 controls matched for gestational age. Heart rate (HR) and pre/postductal arterial oxygen saturation (SpO2pre/SpO2post) were measured by pulse oximetry. Cerebral (rSO2brain) and pre/postductal peripheral muscle tissue oxygenation (rSO2pre/rSO2post) were measured by near infrared spectroscopy during the first 15min of life. RESULTS: All neonates in both groups experienced normal postnatal transition with normal Apgar scores (Apgar 9/10/10) and with no events of apnea or bradycardia induced by suctioning. SpO2pre values were slightly lower at 2 and 4min after birth. Suctioning had no main and interaction effect on HR, SpO2post, rSO2brain, rSO2pre and rSO2post in the first 15min after birth. CONCLUSION: In the present study we were able to show that, in term neonates, when correctly indicated, immediate postnatal oropharyngeal suctioning does not compromise cerebral and peripheral muscle tissue oxygenation. However, any suction maneuver must be performed with caution and strict indication during neonatal transition.

Predictors of H1N1 influenza in the emergency department: proposition for a modified H1N1 case definition.

Reliable and rapid diagnosis of influenza A H1N1 is essential to initiate appropriate antiviral therapy and preventive measures. We analysed the differences in clinical presentation and laboratory parameters between emergency department patients with PCR-confirmed H1N1 influenza infection (n = 199) and those with PCR-negative influenza-like illness (ILI; n = 252). Cough, wheezing, leucopenia, eosinopenia and a lower C-reactive protein remained significant predictors of H1N1 influenza. Proposed combinations of clinical symptoms with simple laboratory parameters (e.g. reported or measured fever and either cough or leucocytes <8.5 × 10(9) /L) were clearly superior to currently used official ILI case definitions that use clinical criteria alone.

Comparison of clinical presentation and laboratory values at admission between PCR-confirmed influenza A H1N1 infection and influenza-like disease, South-East Austria.

PURPOSE: Reliable and rapid diagnosis of influenza A H1N1 is essential to initiate the appropriate antiviral therapy and preventive measures. As PCR assays are time-consuming and rapid antigen tests have a limited sensitivity, official influenza case definitions are used in many clinical settings. These, however, are based exclusively on clinical criteria and have only a moderate potential to differentiate between influenza and other febrile diseases. Only limited data on the differences in clinical and laboratory parameters between influenza and non-influenza febrile diseases are available to date. METHODS: This was a retrospective case-negative control series that was conducted in Styria, southeast Austria. We analyzed the differences in clinical presentation and laboratory admission parameters between patients with PCR-confirmed H1N1 influenza infection (n = 199) and those with influenza-like disease and negative influenza PCR results (ILD group; n = 252). RESULTS: In the multivariable analysis lower C-reactive protein (CRP) level, lower white blood cell (WBC) count, fever, wheezing, cough, and the absence of nausea or sudden onset remained significant predictors of H1N1 influenza in adult patients (n = 263). Lower CRP level, lower WBC count, and cough remained significant predictors in pediatric patients (<16 years; n = 188). CONCLUSION: Lower CRP level, lower WBC count, and cough were significant predictors of H1N1 in both the adult and pediatric patient group. These data may help to develop an improved case definition for suspected H1N1 infection which combines clinical findings and easily available laboratory parameters.

Argyria following the use of silver-coated megaprostheses: no association between the development of local argyria and elevated silver levels.

The aims of this study were to evaluate the incidence of local argyria in patients with silver-coated megaprostheses and to identify a possible association between argyria and elevated levels of silver both locally and in the blood. Between 2004 and 2011, 32 megaprostheses with silver coatings were implanted in 20 female and 12 male patients following revision arthroplasty for infection or resection of a malignant tumour, and the levels of silver locally in drains and seromas and in the blood were determined. The mean age of the patients was 46 years (10 to 81); one patient died in the immediate post-operative period and was excluded. Seven patients (23%) developed local argyria after a median of 25.7 months (interquartile range 2 to 44.5). Patients with and without local argyria had comparable levels of silver in the blood and aspiration fluids. The length of the implant did not influence the development of local argyria. Patients with clinical evidence of local argyria had no neurological symptoms and no evidence of renal or hepatic failure. Thus, we conclude that the short-term surveillance of blood silver levels in these patients is not required.

Reticulocyte hemoglobin content allows early and reliable detection of functional iron deficiency in blood donors.

BACKGROUND: Frequent blood donations may lead to a depletion of body iron stores resulting in manifest anemia. Reticulocyte hemoglobin content (CHr) - a marker for impaired hemoglobinisation (IH) caused by functional iron deficiency (FID) - was investigated regarding its value as a routine screening parameter in frequent whole blood donors. METHODS: In a prospective study, 917 frequent blood donors and 688 first time or reactivated donors were tested for iron status and red blood cell count, including CHr. The ferritin index as a marker to indicate absent iron stores (AIS) was calculated. RESULTS: Depending on the number of donations during the preceding 12 months, AIS were detected in up to 21.4% of male and 27.8% of female donors, respectively. IH was present in up to 6.4% male and 16.7% female donors with 2 and 4 preceding donations, respectively. The defined CHr cut-off value was 28.0 pg to detect IH in frequent whole blood donors with AIS, leading to a test specificity of 98.2% (positive predictive value, PPV: 57.7%) in male and of 97.8% (PPV: 82.9%) in female donors. CONCLUSION: Determination of CHr is feasible to detect FID resulting in IH in frequent blood donors. It may help to prevent the development of anemia in frequent blood donors and also can help to decide whether donor deferral or even iron substitution need to be recommended.