Femoral neck fracture is accompanied by local changes in the content of transforming growth factor-beta1, interleukin-1beta and collagenase activity.

The aim of the study was to evaluate the relationship between the time from femoral neck fracture and the content of transforming growth factor-beta1 (TGF-beta1), interleukin-1beta (IL-1beta) and collagenase activity in bone samples of the femoral neck. The material consisted of 42 cancellous bone samples from the femoral neck collected from patients after the femoral neck fracture during hip replacement procedure. The content of TGF-beta1, IL-1beta in bone samples was measured with the use of enzyme-linked immunoassay (ELISA) and collagenase activity was measured with spectrofluorimetry. The mean content of TGF-beta1/total protein was 2.29 pg/microg (range from 0.9 to 4.0). The mean content of IL-1beta was 4.93 fg/microg (range from 1.4 to 12.5). The mean activity of collagenase was 49.08 nU/microg (range from 5.6 to 113.7). The content of TGF-beta1 and IL-1beta decreased after the injury. In case of TGF-beta1 the difference was statistically significant (p<0.05). The activity of collagenase was statistically significantly increasing in relation to time from the fracture (p<0.05). We found no correlation between the content of TGF- beta1, IL-1beta and the activity of collagenase and the age and the sex of the patients. Also, no significant discrepancies were found between the examined cytokines in relation to the bone loss of the femoral neck according to Singh's scale. These results confirm mutual changes of activity between examined cytokines in the area of fractured bone.

Age-related decrease in the activity of collagenase in the femoral head in patients with hip osteoarthritis.

The aim of the study was to evaluate the relation between the activity of collagenase in the subchondral bone of the femoral head and the age of patients with hip osteoarthritis. Thirty-two patients were enrolled into the study. The mean age was 66 (range from 37 to 80 years). Bone samples of the femoral head were harvested during total hip replacement. The activity of collagenase was measured through spectrofluorimetry. We found statistically a significant correlation between collagenase activity in the bone and age. The mean activity of collagenase in younger patients (37-68 years) was 64.17 IU/microg. In older patients (69-80 years), the mean collagenase activity was 52.26 IU/microg. In patients with hip osteoarthritis the activity of collagenase in the subchondral bone of the femoral head tended to decrease with an increase in age.

Trauma patients' desire for autonomy in medical decision making is impaired by smoking and hazardous alcohol consumption--a bi-national study.

This cross-sectional investigation studied the association between substance use and patients' desire for autonomy in medical decision making (MDM) in two trauma settings. A total of 102 patients (age 42.7 +/- 17.4 years, 70.6% male) admitted to an orthopaedic service in Warsaw, Poland, and 1009 injured patients (age 34.6 +/- 12.8 years, 62.3% male) treated in an emergency department in Berlin, Germany, were enrolled. Patients' desire for autonomy in MDM was evaluated with the Decision Making Preference Scale of the Autonomy Preference Index. Substance use (hazardous alcohol consumption and/or tobacco use) and educational level were measured. Linear regression techniques were used to determine the association between substance use and desire for autonomy in MDM. Substance use was found to be independently associated with a reduced desire by the patient for autonomy in medical decision making. No differences in patients' desire for autonomy were observed between the study sites. Empowerment strategies that encourage smokers or patients with hazardous alcohol consumption to participate in MDM may increase the effectiveness of health promotion and injury prevention efforts in this population.

Successful eradication of methicillin-resistant Staphylococcus aureus (MRSA) intestinal carrier status in a healthcare worker--case report.

We describe bacteriophage therapy in the case of a healthcare worker whose gastrointestinal tract was colonized by methicillin-resistant Staphylococcus aureus (MRSA) with subsequent urinary tract infection caused by the same pathogen. Oral treatment with anti-MRSA phages resulted in eradication of the carrier status.

Detection of patients at risk for recurrence of atrial fibrillation after successful electrical cardioversion by signal-averaged P-wave ECG.

The aim of the study was to assess the value of signal-averaged ECG of P-wave in predicting recurrence of atrial fibrillation after direct-current electrical cardioversion of chronic atrial fibrillation. The signal-averaged ECG triggered by P-wave was recorded in 35 patients after successful electroconversion. Duration of the high frequency P-wave and the root mean square voltages for the last 20 ms (RMS20) P-wave of the vector magnitude were calculated. After 6 months follow-up recurrence of atrial fibrillation was observed in 11 patients (group I) and in 24 patients sinus rhythm was maintained (group II). A filtered P-wave was significantly longer in group I with recurrence of atrial fibrillation, than in patients from group II who maintained sinus rhythm (145+/-11.8 vs 130+/-10.8 ms, p<0.001). RMS20 was significantly lower in group I than in patients from group II (1.6+/-0.6 vs 2.2+/-0.9 microV, p<0.02). A filtered P-wave of duration >q37 ms associated with a RMS 20 ms <1.9 microV had a sensitivity of 73% and specificity of 71% for the detection of patients with recurrence of atrial fibrillation after successful direct-current electrical cardioversion of chronic atrial fibrillation. These results suggest that signal-averaged ECG of P-wave may be helpful for identification of patients with recurrence of atrial fibrillation after successful direct-current electrical cardioversion.

Anomalous inferior vena cava mimicking aortic dissection on transesophageal echocardiography.

Transesophageal echocardiography (TEE) is considered an excellent method for the diagnosis of aortic dissection, especially that involving the descending aorta. It has also proved useful in the evaluation of conditions mimicking aortic dissection, usually disclosing in these situations other types of severe aortic disease. We are not aware of any report dealing with venous abnormalities which presented diagnostic problems in a patient evaluated with TEE because of a suspected aortic dissection.

Amiodarone in restoration and maintenance of sinus rhythm in patients with chronic atrial fibrillation after unsuccessful direct-current cardioversion.

BACKGROUND: When direct-current (DC) cardioversion is used, sinus rhythm can be restored, at least temporarily, in 80-90% of patients with atrial fibrillation. However, there is a small but significant group of patients with chronic atrial fibrillation in whom DC cardioversion has failed to restore sinus rhythm. The value of antiarrhythmic drug pretreatment before DC cardioversion is still controversial. HYPOTHESIS: The aim of our study was to assess (1) the effectiveness of repeat DC cardioversion in patients with chronic atrial fibrillation after pretreatment with amiodarone, and (2) the efficacy of amiodarone in maintaining sinus rhythm after repeat cardioversion. METHODS: Forty-nine patients with chronic atrial fibrillation after ineffective DC cardioversion were included in the study. Repeat DC cardioversion was performed after loading with oral amiodarone, 10-15 mg/kg body weight/day for a period necessary to achieve the cumulative dose of over 6.0 g. RESULTS: Spontaneous conversion to sinus rhythm during amiodarone pretreatment was achieved in 9 of 49 patients (18%). Direct-current cardioversion was performed in 39 patients and sinus rhythm was achieved in 23 of these patients (59%). Mean heart rate decreased from 95 beats/min before to 68 beats/min after DC cardioversion (p < 0.001). Systolic blood pressure significantly (p < 0.05) decreased from 126 +/- 23 to 108 +/- 25 mmHg. Complications occurring in four patients just after electroconversion were well tolerated and of short duration. After 12 months, 52% of patients maintained sinus rhythm on low dose (200 mg/day) amiodarone therapy. CONCLUSION: Pretreatment with amiodarone and repeat DC cardioversion allows for restoration of sinus rhythm in about 65% of patients with chronic atrial fibrillation after first ineffective DC cardioversion. Direct-current cardioversion can be performed safely with the use of standard precautions in patients who are receiving amiodarone. At 12 months' follow-up, more than 50% of patients maintain sinus rhythm on low-dose amiodarone after successful repeat cardioversion.

Carbon fiber scaffolds in the surgical treatment of cartilage lesions.

We present a new method of treatment of chondral defects of the knee with the usage of carbon fibers. The prospective study describes experience with carbon fibers used as scaffolds in the drilled lesions to enhance ingrowth of regenerative tissue. We treated 35 patients for chondral defects with that method from December 93 to June 97. Average age was 46 years (range, 19-68 years) and average follow-up was 48 months (range, 24-55 months). The results were assessed by HSS knee scale, the Wallgren-Tegner activity score, VAS (visual analogue scale to measure pain) and patients assessment of the surgery. Twenty-five (71%) of 35 patients were rated good or excellent. The most striking result was good pain relief. Early follow-up results are good, but these must be confirmed in long-term observations.

[Diagnosis of congenital anomaly of the inferior vena cava simulating aortic dissecting aneurysm by the method of transesophageal echo- cardiography]. / Wrodzona anomalia zyly glównej dolnej nasladujaca rozwarstwienie aorty w badaniu metoda echokardiografii przezprzelykowej.

A case of 59 year old woman with acute myocardial infarction is presented in whom chest X-ray film revealed double outlined aortic arch suggestive of dissection. Transesophageal echocardiography (TEE) disclosed presence of two vascular canals in the place of thoracic aorta. Atypical dissection of thoracic aorta or a vascular anomaly were suspected because the image of dissection of intima was not characteristic and no connection between the two canals was found. Computed tomography ruled out presence of aortic aneurysm but the image of inferior vena cava was difficult for interpretation. Final diagnosis of congenital anomaly of inferior vena cava, originating from two iliac veins, passing along left side of the spine and emptying to the right atrium at the level of aortic arch, was established by means of cavography. Familiarity with TEE image of this vascular anomaly may allow avoidance of diagnostic error in cases suspected of aortic dissection.

[A method of averaged ECG signal does not identify patients with ventricular tachycardia in disorders of intraventricular conduction]. / Technika usredniania sygnalu EKG nie pozwala na wyodrebnienie chorych z czestoskurczem komorowym przy zaburzeniach przewodnictwa sródkomorowego.

Conduction defect are known to delay and fragment the ecg signal and may be expected to cause changes on the signal-averaged ecg that mimic ventricular late potentials. The aim of our study was to asses whether signal-averaged ECG (SAE) identify patients (pts) with sustained ventricular tachycardia (VT) after myocardial infarction (MI) who display right or left bundle branch block (RBBB or LBBB). We studied 23 pts with RBBB and 25 pts with LBBB. SEA was recorded with bidirectional filters at 25-250 HZ and 40-250 Hz using Simson method. The total filtered QRS duration (QRSd), root mean square voltage in the terminal 40ms of the QRS (RMS40) and low amplitude signal duration less than 40uV (LAS40)) were measured. Signal-averaged parameters with a filter at 25-250 Hz were: [table: see text] Signal-averaged parameters with a filter at 40-259 Hz were: [table: see text] In conclusion SAE parameters do not allow separation of pts with sustained VT from pts with RBBB or LBBB after MI. These data indicate that conduction defects have effects on signal-averaged ecg parameters and may result in masking of ventricular late potentials.

[Contemporary views on treatment of cruciate ligament injuries]. / Wspólczesne poglady na leczenie uszkodzen wiezadla krzyzowego.

It is commonly assumed that the anterior crucial ligament is injured most often from all ligaments of the knee. Complexity of the structure and function of the whole capsular-ligamentous system of the knee makes the operative treatment extremely difficult. In the light of the contemporary views the problems concerning the treatment of the failure of the anterior crucial ligament belong to the main orthopedic problems requiring solution.

Principles for the management of deep infections following total hip replacement.

Current methods are presented for the management of deep infection of total hip replacements. The goal of treatment is to maintain the improvement of function gained by hip replacement. In cases without loosening, precise surgical debridement without removal of implants is indicated. Management in septic loosening depends on the general medical condition of the patient, the local bone stock, and the spread of infection. Satisfactory bone stock allows for reimplantation of a new prosthesis, prefably using antibiotic-loaded cement, after scrupulous removal of all potentially infected tissues and particles. The reimplantationcan be done as a one- or two-stage operation. In the two0stage procedure, antibiotic-loaded cement spacer can be used, but both two- and one-stage reimplantation have similar results as regards infection control. Definitive removal of the prosthesis is indicated in patients whose general medical condition is poor, who have no usable bone stock, or who present with a persistent Gram-negative bacterial infection. This procedure is not fully effective, however (infection brought under control in 83% of patients), although it does not cause significant negative effect for the functional status of this group of patients.

Principles for the diagnosis of infections following total hip arthroplasty.

Based on authorial material consisting of 19 patients operated in the period 1993-2000 for infections following total hip replacements, and on information from the literature, the authors discuss the suitability of various diagnostic methods. It is particularly important to diagnose infections with a slow course, without the classic clinical signs. The diagnostic criteria accepted by the Disease Control Center in Atlanta are presented, along with the radiological symptoms of latent infections and scintigraphic methods of varying sensitivity and specificity to regards to hip endoprosthesis infections. The article presents the typical changes in the value of erythrocyte precipitation and CRP concentration during the first year following a non-complicated hip arthroplasty, which has a significant impact on the interpretation of results when there is a suspicion of early infection. The decisive test for the diagnosis of a slow infection in a joint with loosened endoprosthesis with obvious clinical signs of infection is peri-operative examination of frozen scraps of the joint capsule for the presence of infiltrations of neutrophil leukocytes.

Results of therapy of infection complicating total hip replacement.

An aim of the management of infection complicating total hip arthroplasty is to control infection and maintain satisfactory hip function. In the period 1993-2000 effectives of therapy of deep injection after total hip replacement in 91 patients was assessed. Infection without loosening of endoprosthesis was diagnosed in 33 hips, septic loosening in 58. In 33 cases without loosening surgical debridement without removal of prosthesis was done with good control of infection in 25 hips. Permanent removal of prosthesis done in 42 cases resulted in recurrence of infection in 6 hips. One stage reimplantation done in 12 patients succeded in 9 hips. Two-stage reimplantation in 3 hips resulted in recurrence of infection in 2 cases. Antibiotic-embedded cement spacer (gentamycin with vancomycin) was used in I case with unsatisfactory result. Recurrent infection was observed in 13 cases of 48 hips treated without implant removal or by reimplantation of new prosthesis.

Surgical tactics in the revision of the hip prosthesis pin.

Parallel to the rise in the number of primary hip arthroplasties the number of complications is also increasing, especially aseptic loosening of cemented implants and uncemented implants with a smooth surface. The loosening of the implant is very often accompanied by the destruction of bone stock, which requires reconstruction.
On the base of 217 cases operated in the years 1997-2000 the authors present the methods of treating deficits in the proximal femur using special instruments, bone transplants, reconstructive systems, and revision prostheses. The so-called biological attitude to the problem is preferred. Operative tactics are presented in respect to bone deficits classified according to Mallory.

Surgical tactics in revision operations of the hip acetabulum.

Surgical tactics in acetabulum revisions is based on 2 elements. The first of these is the assessment of the patient's general health (age, clinical status, and concomitant diseases). Adequate planning makes it possible to avoid further complications, such as problems with bone transplant incorporation and subsequent mobility of the acetabulum. The second element is the assessment of bone stock deficits, especially in the acetabular ring. Although it is possible to determine the extent of bone deficits intraoperatively, in preoperative planning we use conventional X-rays, CT scans, and - in cases of advanced protrusion - angiography. The subsequent surgical technique is planned on the basis of the bone deficits as classified by Paprosky.
In the reconstruction of deficit we use different methods and implant cement or cementless acetabula, depending on the patient's age and the bone quality. In certain cases supporting metal rings, mesh, or other implants are used. To fill the deficit we implant frozen, radiated allogenic bone transplants, morselized or as solid blocks.
The revision operation is planned to reconstruct the joint axis on the same level as on the opposite side to restore the off-set. 338 patients with acetabular loosening were operated in the years 1997-2000.
The material indicates the need for the so-called biological attitude to the problem.

Growth factors and gene therapy: the prospects for treating limited cartilage defects.

The limited regenerative capacities of articular are well known. Among the many methods used to repair the joint surface, among the most innovative involve stimulating chondrocytes to grow and differentiate by local application of exogenous protein growth factors, and attempting to transfer the genes responsible for cell division and maturation. This article presents the current state of knowledge on the possibilities for the treatment of limited cartilage defects used these methods.

Methods for the isolation and culture of human articular chondrocytes.

The tissue engineering of cartilage implants may open new paths for the surgical treatment of joint surface defects. Autologous chondrocyte transplantation (ACT) has been gaining in clinical significance over the last several years. This study presents the methods used for isolation, monolayer culturing, multipication and assesment in transmission light microscopy of human chondrocytes. The tissue was gained from resected fragments of joint during total knee replacement.

Outcome of revision hip arthroplasty.

Background. Clinical material collected from 1989 to 1999 from three orthopedic centers is discussed: the Orthopedic Clinic at the Center for Postgraduate Medical Education in Otwock, the Orthopedic Clinic at the Lublin Academy of Medicine, and the Orthopedic Clinic at the Warsaw Academy of Medicine.
Material and methods. During this period 511 patients with an average age of 66 were treated. The authors explain the reasons for aseptic loosening of hip prostheses, the types of implants replaced, and the methods of surgical treatment.
Analysis of results. The importance of correct surgical technique and modern cementing methods during primary arthroplasty for the duration of good prosthesis functioning is discussed. A good outcome from revision arthroplasty can be expected only when the decision to treat is made early. The authors confirm the usability of impacted camcellous allografts for revision hip arthroplasty. Complications during and after surgery are also discussed. Difficulties in the clinical and radiological evaluation of treatment outcomes caused by differing criteria used in each orthopedic treatment are also discussed in this article.
Conclusions. In the conclusion the authors propose rules for surgical treatment to reduce the number of revision procedures.

Temperature-driven coherence resonance and stochastic resonance in a thermochemical system.

We perform the stochastic analysis of a thermochemical system using a master equation which describes a chemical reaction and includes discrete and continuous temperature jumps. We study the time evolution of the system selecting the temperature of the thermostat as an easily tunable control parameter. Depending on the thermostat temperature, the system can be in an excitable, oscillatory, or stationary regime. Stochastic time series for the system temperature are generated and the distributions of interspike intervals are analyzed in the three dynamical regimes separated by a homoclinic bifurcation and a Hopf bifurcation. Different constructive roles of internal fluctuations are exhibited. A noise-induced transition is observed in the vicinity of the Hopf bifurcation. Coherence resonance and stochastic resonance are found in the oscillatory regime. In a range of thermostat temperatures, a nontrivial behavior of the highly nonlinear system is revealed by the existence of both a minimum and a maximum in the scaled standard deviation of interspike intervals as a function of particle number. This high sensitivity to system size illustrates that controlling dynamics in nanoreactors may remain a difficult task.