Performance of medial pivot, posterior stabilized and rotating platform total knee arthroplasty based on anteroposterior stability and patient-reported outcome measures; a multicentre double-blinded randomized controlled trial of 210 knees.

BACKGROUND: Despite advancements in total knee arthroplasty (TKA), 10-20% of patients remain dissatisfied after surgery. Improved anteroposterior (AP) stability provided by medial pivot (MP) implants may theoretically lead to higher patient satisfaction. METHODS: AP stability and patient-reported outcome measures (PROMs) at one-year postsurgery were compared between patients who underwent TKA with MP- (n = 121), posterior stabilized (PS; n = 53) and rotating platform (RP; n = 57) implants in a double-blind multicentre randomized controlled trial (Dutch Trial Register: NL6856, 21-02-2018). AP stability was assessed at 30°, 60° and 90° of knee flexion using a KT-2000 arthrometer. PROMs were measured preoperative and one-year postsurgery. RESULTS: MP-TKA provided significant better AP stability at early flexion (30°) compared to PS- and RP-TKA (median [IQR]; 1.79 [1.14-2.77] mm vs. 3.31 [2.51-4.08] mm vs. 2.82 [1.80-4.03] mm, p < 0.001). Additionally, MP-TKA provided significant better AP stability at mid-flexion (60°) compared to PS-TKA (1.75 [1.23-2.36] mm vs. 2.14 [1.49-2.83] mm, p = 0.014). PROM improvements were comparable between implant designs. AP laxity of ≥ 4 mm at early flexion was independently of implant design associated with significantly worse Kujala scores. The incidence of ≥ 4 mm AP laxity at any knee angle was however not significantly different between implant designs. CONCLUSION: MP-, PS- and RP-TKA all provide excellent and comparable results. Although MP-TKA provided better AP stability at early flexion compared to PS- and RP-TKA, this was found to be unrelated to improved PROMs in favour of MP-TKA. More studies focusing on early and mid-flexion performance based differences between MP and other TKA designs are required to confirm our findings. Other non-implant related factors may play a more important role in the performance of TKA and are potentially worthwhile examining.

Accelerometer Measured Sedentary and Physical Activity Behaviors of Working Patients after Total Knee Arthroplasty, and their Compensation Between Occupational and Leisure Time.

Purpose Objective measurements of sedentary and physical activity (PA) behavior are scarce among working-age patients who undergo total knee arthroplasty (TKA). Aim was to assess sedentary and PA behaviors using accelerometers and to identify compensation effects between occupational and leisure time of sedentary and PA behavior. Methods One year post-TKA, 51 patients wore an ActiGraph(GT3x) accelerometer for 7 days. Sedentary time, prolonged sedentary bouts (≥ 30 min) and PA (light-intensity and moderate-to-vigorous PA) were examined. Compliance with the guideline of > 150 min moderate-to-vigorous PA per week was calculated. Compensation effects were analyzed using multilevel models, splitting effects into routine and within-day compensation, stratifying by physical and non-physical jobs. The routine compensation effects are the ones of interest, representing habitual compensation during a week. Results Participants spent 60% of time in sedentary bouts and 17% in prolonged sedentary bouts, with 37% of PA spent in light-intensity and 3% in moderate-to-vigorous activity. About 70% of patients met the PA guideline. Routine compensation effects were found for workers in physical jobs, who compensated for their occupational light-intensity PA with less light-intensity PA during leisure time. Workers in non-physical jobs did not compensate for their occupational prolonged sedentary bouts, as these continued during leisure time. Conclusion This study showed that working TKA patients are highly sedentary 1 year after surgery, but most met the PA guideline. Especially those with non-physical jobs do not compensate for their occupational prolonged sedentary bouts. This stresses the need to stimulate PA among TKA patients not complying with the guidelines and those with non-physical jobs.

Fine particulate matter measurements in Swiss restaurants, cafés and bars: what is the effect of spatial separation between smoking and non-smoking areas?

UNLABELLED: We performed 124 measurements of particulate matter (PM(2.5)) in 95 hospitality venues such as restaurants, bars, cafés, and a disco, which had differing smoking regulations. We evaluated the impact of spatial separation between smoking and non-smoking areas on mean PM(2.5) concentration, taking relevant characteristics of the venue, such as the type of ventilation or the presence of additional PM(2.5) sources, into account. We differentiated five smoking environments: (i) completely smoke-free location, (ii) non-smoking room spatially separated from a smoking room, (iii) non-smoking area with a smoking area located in the same room, (iv) smoking area with a non-smoking area located in the same room, and (v) smoking location which could be either a room where smoking was allowed that was spatially separated from non-smoking room or a hospitality venue without smoking restriction. In these five groups, the geometric mean PM(2.5) levels were (i) 20.4, (ii) 43.9, (iii) 71.9, (iv) 110.4, and (v) 110.3 microg/m(3), respectively. This study showed that even if non-smoking and smoking areas were spatially separated into two rooms, geometric mean PM(2.5) levels in non-smoking rooms were considerably higher than in completely smoke-free hospitality venues. PRACTICAL IMPLICATIONS: PM(2.5) levels are considerably increased in the non-smoking area if smoking is allowed anywhere in the same location. Even locating the smoking area in another room resulted in a more than doubling of the PM(2.5) levels in the non-smoking room compared with venues where smoking was not allowed at all. In practice, spatial separation of rooms where smoking is allowed does not prevent exposure to environmental tobacco smoke in nearby non-smoking areas.

Sending specialist reports to GPs using EDI.

This paper describes a project in which specialist reports are sent to general practitioners using EDI. The reports were protocolled to better meet the wishes of the GPs. This also made it possible to achieve a further structurization of the existing EDI-message, using free-text qualifiers. Future developments of specialist-GP communication are discussed, specifically regarding the integration of their electronic medical records. It is concluded that EDI can and will play an important role in this.

31P magnetic resonance spectroscopy of the liver: correlation with standardized serum, clinical, and histological changes in diffuse liver disease.

The goal of this study was to analyze the possibilities of 31P MR spectroscopy to detect abnormal hepatic histological changes in patients with diffuse liver disease. 31P MR spectroscopy was performed, on a 1.5 T whole-body spectrometer using an image guided localization technique (ISIS), on 38 patients with various diffuse liver diseases, who all underwent histological and serum analysis, and 22 healthy volunteers. Phosphomonoester expressed as a fraction of total phosphorus (PME/P) showed a correlation with abnormal serum aspartate transaminase (AST), histological intralobular degeneration/focal necrosis, portal inflammation, and piecemeal necrosis. We found a lower correlation for PME/P with fibrosis. It was not possible to differentiate between fibrosis and cirrhosis. In summary, 31P MR spectroscopy is a technique to detect intralobular degeneration, inflammation and necrosis and to a less extent fibrosis. No diagnostic value was found with respect to steatosis and cholangitis. Furthermore, 31P MR spectroscopy is a poor method for classifying patients into diagnostic categories.

Extraction, preparation, and presentation of patient classification-data for the benefit of management overviews.

In the Free University Hospital, the nursing staff enters data daily into the computerized patient classification system. The computer calculates and gives a retrospective overview of the patient workload per day and per nursing unit. The present system does not comply with the information needs of the middle and higher management. This is due to differences in the manner of working on the various nursing units. For these reasons, the patient classification data was extracted from the central HIS database and copied to a PC environment. Here, the data was further ordered and processed to produce overviews for the nursing management. This was done by developing a user friendly interface with the spreadsheet program QuattroPro.

[The significance of endometrial cells in the cervical smear]. / De betekenis van endometriumcellen in de cervixuitstrijk.

Presence of atypical endometrial cells in a cervical smear is quite unusual; but if they are found the woman needs extra attention because of the risk of adenocarcinoma of the uterus. Postmenopausal women sometimes also have endometrial cells without atypia in the cervical smear, as a sign of endometrial pathology. We conducted a retrospective follow-up study of these women. From 1978 to 1989, 52 smears from a total of about 50,000 postmenopausal women were classified as Pap IIIA, due to the presence of normal endometrial cells. Histological follow-up was performed in 25 cases and 3 times an adenocarcinoma of the endometrium was diagnosed (6%). The smears from 142 women (pre- and postmenopausal) contained atypical endometrial cells and therefore were classified as Pap IIIA or higher. Histological follow-up was performed in 104 cases. In 48% (n = 68) an adenocarcinoma was diagnosed. In 75% of these cases (n = 51) the atypical cells were graded as severe or worse (> or = Pap IIIB). Cervical smears are not taken to detect pathology of the endometrium, but whenever atypical cells are found in the smear there is a strong indication for further (gynaecological) examination.

Histopathological findings in placentae from patients with intra-uterine fetal death and anti-phospholipid antibodies.

Anti-phospholipid antibodies are associated with first trimester abortions and late intra-uterine fetal death. The histopathology of 47 placentae from 45 women with intra-uterine fetal death, including 16 patients with anti-phospholipid antibodies, was studied in order to detect potential differences between placentae from women with and without these antibodies. Thirteen patients had systemic lupus erythematosus or lupus-like disease, including 6 women with anti-phospholipid antibodies. In placentae from patients with anti-phospholipid antibodies, a decrease in vasculo-syncytial membranes, fibrosis mainly in infarcted areas, hypovascular villi and thrombosis or infarction was seen significantly more often than in placentae from women without these antibodies. Of 17 placentae from 16 patients with anti-phospholipid antibodies, only 3 did not demonstrate signs of thrombosis or infarction. Thrombosis/infarction was significantly associated with a decrease in vasculo-syncytial membranes, fibrosis, hypovascular villi and an increase in syncytial knots. These findings are most likely to be the result of prolonged hypoxia due to thrombosis or infarction. It is concluded that thrombosis or infarctions are prominent features in placenta from patients with anti-phospholipid antibodies and intra-uterine fetal death. Consequently, antithrombotic treatment during pregnancy forms a rational approach in these patients.

[Cervix smears with mild atypia classified as Pap-class IIIA: results of a changed policy]. / Cervixuitstrijken met geringe atypie ingedeeld in Pap-klasse IIIA: resultaten van een gewijzigd beleid.

To evaluate the changed policy regarding cervical smears with mild atypia in the Netherlands (before 1988 classified as Pap II, thereafter as Pap IIIA), an descriptive study was carried out in the laboratory of gynaecological cytology Cyt-U-Universitair (University of Utrecht). All women who in 1988 had a first smear with mild atypia were included. After a follow-up period of 2 years the final diagnosis was noted. The results of the follow-up of cervical smears with mild atypia were compared with the follow-up results of moderate atypia. A selection was made of 477 women. In 55% of the cases no dysplasia was found during the 2 years of follow-up. In 12% of the cases severe dysplasia, carcinoma in situ or carcinoma was found. Compared with the smears with moderate atypia the dysplasia in the follow-up of mild atypia led to fewer cases of proven dysplasia. In addition the dysplasia in these cases was of a lower grade. The group of women referred to the gynaecologist after the smear with mild atypia was remarkably large (30%). As the results show, the policy of careful follow-up of women with mild atypia in the cervical smear has been a good one. It implies classifying mild atypia as Pap IIIA. As many women (55%) do not display cervical dysplasia within a 2 year follow-up period, the policy of making a repeat smear before referring appears justified.

Leiomyoma of the distal oesophagus mimicking achalasia.

An unusual case of a patient with symptoms suggestive of oesophageal achalasia is described. Most oesophageal tumour growths causing secondary achalasia are associated with malignant tumours. This patient had a large oesophageal leiomyoma closely mimicking achalasia. Treatment consisted of oesophagectomy by laparotomy and right-sided thoracotomy. A gastric tube was constructed with a cervical oesophago-gastrostomy. The patient responded well to the treatment and left the hospital after 13 days. Five other cases of benign oesophageal tumours inducing achalasia-like symptoms could be traced. Three of these were leiomyomas.

Malignant mixed müllerian tumour of the fallopian tube.

We report two cases of primary heterologous malignant mixed Müllerian tumour of the Fallopian tube. One of these was bilateral, a finding which, as far as we know, has not been reported before.

Early involvement of hepatic parenchymal cells in erythrohepatic protoporphyria? An ultrastructural study of patients with and without overt liver disease and the effect of chenodeoxycholic acid treatment.

Liver biopsy specimens obtained from two groups of erythrohepatic protoporphyria patients were studied histopathologically and ultrastructurally. Group 1 comprised seven erythrohepatic protoporphyria patients with a normal liver histology; from two patients liver biopsy specimens were available before and after 1 yr of chenodeoxycholic acid treatment. Group 2 consisted of four patients with a history of liver disease and liver histopathology; three patients were observed before and after 1 yr of chenodeoxycholic acid treatment. Liver specimens of nine kidney transplant donors served as controls. Unlike the morphology at the light microscopic level, the ultrastructure of hepatic parenchymal cells was affected in both groups of erythrohepatic protoporphyria patients. In both groups the nuclei, endoplasmic reticulum, lateral plasma membranes and bile canaliculi were altered. Collagen fibers were frequently present. In addition, in group 2 bile thrombi and intracytoplasmic protoporphyrin crystals were observed. After chenodeoxycholic acid administration, the latter feature had diminished. It is concluded that (a) in erythrohepatic protoporphyria ultrastructural changes are present in the hepatic parenchymal cells even in early stages of the disease. Changes in bile canalicular ultrastructure suggest a defective hepatic excretory function, probably caused by the toxic effect of protoporphyrin. (b) Chenodeoxycholic acid administration causes no distinct improvement of the ultrastructure of organelles in the hepatic parenchymal cell or the bile canalicular system but may decrease crystalline protoporphyrin deposition in the liver.

How critical is frame selection in quantitative coronary angiographic studies?

To analyse quantitatively a coronary arterial segment from a cineangiogram, an end-diastolic or neighbouring frame is usually selected. However, different cardiologists may select other (although usually neighbouring) frames, even when the same selection criteria are followed. It is also possible that the frames are selected from different cardiac cycles. In this study the effects of such phase shifts on the reproducibility of the quantitative measurements were studied. In a total of 38 consecutive patient films obtained at a filmspeed of 25 frames s-1, the frame phi demonstrating the severity of a lesion optimally as judged by a senior cardiologist, the three preceding frames, the three following frames and one frame exactly one cycle prior to or following frame phi were selected; frame phi was always chosen in the end-diastolic phase of the cardiac cycle. In each film one coronary arterial segment with a focal lesion was analysed quantitatively in these total of 8 frames with the Cardiovascular Angiography Analysis System (CAAS). No significant differences were found in the mean difference and the standard deviations of the differences (variabilities) in the obstruction diameter, interpolated reference diameter, percent diameter stenosis, extent of the obstruction and area of atherosclerotic plaque obtained in the various frames with respect to frame phi. Therefore, it may be concluded that the selection of a cineframe for quantitative analysis in the end-diastolic phase of the cardiac cycle is not very critical.(ABSTRACT TRUNCATED AT 250 WORDS)

Immature teratomas in children.

In a retrospective study comprising 216 germ-cell tumours occurring in children from birth to the age of 18 years, 27 immature teratomas were found at a variety of sites. Seventeen of these were curatively treated by means of one operation. Only two patients died as a direct result of tumour growth. Recurrences and metastases often proved to be treatable. In ovarian tumours grading was of considerable prognostic importance. The term malignant teratoma, which is sometimes used to describe these tumours, is confusing and should be avoided.