SWISSspine: a nationwide registry for health technology assessment of lumbar disc prostheses

SWISSspine is a so-called pragmatic trial for assessment of safety and efficiency of total disc arthroplasty (TDA). It follows the new health technology assessment (HTA) principle of "coverage with evidence development". It is the first mandatory HTA registry of its kind in the history of Swiss orthopaedic surgery. Its goal is the generation of evidence for a decision by the Swiss federal office of health about reimbursement of the concerned technologies and treatments by the basic health insurance of Switzerland. During the time between March 2005 and 2008, 427 interventions with implantation of 497 lumbar total disc arthroplasties have been documented. Data was collected in a prospective, observational multicenter mode. The preliminary timeframe for the registry was 3 years and has already been extended. Data collection happens pre- and perioperatively, at the 3 months and 1-year follow-up and annually thereafter. Surgery, implant and follow-up case report forms are administered by spinal surgeons. Comorbidity questionnaires, NASS and EQ-5D forms are completed by the patients. Significant and clinically relevant reduction of low back pain VAS (70.3-29.4 points preop to 1-year postop, p < 0.0001) leg pain VAS (55.5-19.1 points preop to 1-year postop, p < 0.001), improvement of quality of life (EQ-5D, 0.32-0.73 points preop to 1-year postop, p < 0.001) and reduction of pain killer consumption was revealed at the 1-year follow-up. There were 14 (3.9%) complications and 7 (2.0%) revisions within the same hospitalization reported for monosegmental TDA; there were 6 (8.6%) complications and 8 (11.4%) revisions for bisegmental surgery. There were 35 patients (9.8%) with complications during followup in monosegmental and 9 (12.9%) in bisegmental surgery and 11 (3.1%) revisions with 1 [corrected] new hospitalization in monosegmental and 1 (1.4%) in bisegmental surgery. Regression analysis suggested a preoperative VAS "threshold value" of about 44 points for increased likelihood of a minimum clinically relevant back pain improvement. In a short-term perspective, lumbar TDA appears as a relatively safe and efficient procedure concerning pain reduction and improvement of quality of life. Nevertheless, no prediction about the long-term goals of TDA can be made yet. The SWISSspine registry proofs to be an excellent tool for collection of observational data in a nationwide framework whereby advantages and deficits of its design must be considered. It can act as a model for similar projects in other health-care domains.

Low Mannan-binding lectin serum levels are associated with complicated Crohn's disease and reactivity to oligomannan (ASCA)

OBJECTIVES: Mannan-binding lectin (MBL) acts as a pattern-recognition molecule directed against oligomannan, which is part of the cell wall of yeasts and various bacteria. We have previously shown an association between MBL deficiency and anti-Saccharomyces cerevisiae mannan antibody (ASCA) positivity. This study aims at evaluating whether MBL deficiency is associated with distinct Crohn's disease (CD) phenotypes. METHODS: Serum concentrations of MBL and ASCA were measured using ELISA (enzyme-linked immunosorbent assay) in 427 patients with CD, 70 with ulcerative colitis, and 76 healthy controls. CD phenotypes were grouped according to the Montreal Classification as follows: non-stricturing, non-penetrating (B1, n=182), stricturing (B2, n=113), penetrating (B3, n=67), and perianal disease (p, n=65). MBL was classified as deficient (<100 ng/ml), low (100-500 ng/ml), and normal (500 ng/ml). RESULTS: Mean MBL was lower in B2 and B3 CD patients (1,503+/-1,358 ng/ml) compared with that in B1 phenotypes (1,909+/-1,392 ng/ml, P=0.013). B2 and B3 patients more frequently had low or deficient MBL and ASCA positivity compared with B1 patients (P=0.004 and P<0.001). Mean MBL was lower in ASCA-positive CD patients (1,562+/-1,319 ng/ml) compared with that in ASCA-negative CD patients (1,871+/-1,320 ng/ml, P=0.038). In multivariate logistic regression modeling, low or deficient MBL was associated significantly with B1 (negative association), complicated disease (B2+B3), and ASCA. MBL levels did not correlate with disease duration. CONCLUSIONS: Low or deficient MBL serum levels are significantly associated with complicated (stricturing and penetrating) CD phenotypes but are negatively associated with the non-stricturing, non-penetrating group. Furthermore, CD patients with low or deficient MBL are significantly more often ASCA positive, possibly reflecting delayed clearance of oligomannan-containing microorganisms by the innate immune system in the absence of MBL.

Tin-containing fluoride solutions as anti-erosive agents in enamel: an in vitro tin-uptake, tissue-loss, and scanning electron micrograph study

Tin-containing fluoride solutions can reduce erosive tissue loss, but the effects of the reaction between tin and enamel are still not clear. During a 10-d period, enamel specimens were cyclically demineralized (0.05 M citric acid, pH 2.3, 6 x 5 min d(-1)) and remineralized (between the demineralization cycles and overnight). In the negative-control group, no further treatment was performed. Three groups were treated (2 x 2 min d(-1)) with tin-containing fluoride solutions (400, 1,400 or 2,100 ppm Sn2+, all 1,500 ppm F-, pH 4.5). Three additional groups were treated with test solutions twice daily, but without demineralization. Tissue loss was determined profilometrically. Energy-dispersive X-ray spectroscopy was used to measure the tin content on and within three layers (10 mum each) beneath the surface. In addition, scanning electron microscopy was conducted. All test preparations significantly reduced tissue loss. Deposition of tin on surfaces was higher without erosion than with erosion, but no incorporation of tin into enamel was found without demineralization. Under erosive conditions, both highly concentrated solutions led to the incorporation of tin up to a depth of 20 mum; the less-concentrated solution led to small amounts of tin in the outer 10 mum. The efficacy of tin-containing solutions seems to depend mainly on the incorporation of tin into enamel.

Overweight children have a greater proportion of fat mass relative to muscle mass in the upper limbs than in the lower limbs: implications for bone strength at the distal forearm

BACKGROUND: The influence of adiposity on upper-limb bone strength has rarely been studied in children, despite the high incidence of forearm fractures in this population. OBJECTIVE: The objective was to compare the influence of muscle and fat tissues on bone strength between the upper and lower limbs in prepubertal children. DESIGN: Bone mineral content, total bone cross-sectional area, cortical bone area (CoA), cortical thickness (CoTh) at the radius and tibia (4% and 66%, respectively), trabecular density (TrD), bone strength index (4% sites), cortical density (CoD), stress-strain index, and muscle and fat areas (66% sites) were measured by using peripheral quantitative computed tomography in 427 children (206 boys) aged 7-10 y. RESULTS: Overweight children (n = 93) had greater values for bone variables (0.3-1.3 SD; P < 0.0001) than did their normal-weight peers, except for CoD 66% and CoTh 4%. The between-group differences were 21-87% greater at the tibia than at the radius. After adjustment for muscle cross-sectional area, TrD 4%, bone mineral content, CoA, and CoTh 66% at the tibia remained greater in overweight children, whereas at the distal radius total bone cross-sectional area and CoTh were smaller in overweight children (P < 0.05). Overweight children had a greater fat-muscle ratio than did normal-weight children, particularly in the forearm (92 +/- 28% compared with 57 +/- 17%). Fat-muscle ratio correlated negatively with all bone variables, except for TrD and CoD, after adjustment for body weight (r = -0.17 to -0.54; P < 0.0001). CONCLUSIONS: Overweight children had stronger bones than did their normal-weight peers, largely because of greater muscle size. However, the overweight children had a high proportion of fat relative to muscle in the forearm, which is associated with reduced bone strength.

Studies on Electrophilic Substitution Reactions of 3-Phenyl-cycl[3.2.2]azine

Acetylation and formylation of 3-phenyl-cycl[3.2.2]azine derivatives, in the presence of Lewis acids, have been Investigated. It has been found that the orientation of substitution in 2-carbomethoxy- 3-phenyl-cycl[3.2.2]azine for these two reactions, under Identical conditions, is different.

Changing Europe and The Relevance of Care and The Caring Professions

The aim of the paper is to introduce the challenges of the international care debate of the last ten years in order to grasp basic social needs, to analyse their treatment in the public and private sphere and to look at the orientation of professional answers by the care-professions. The concept of care enhances the societal dealing with - or ignoring of - different forms of dependency on informal and formal personal and social services throughout the life-cycle (child-care, nursing sick or handicapped persons, supporting the elderly) and in special life situations (from help to lone mothers and their children, via help to drug-addicts to help for homeless people). All societies have different approaches to deal with these life-situations, they do so by employ-ing various mixtures of: familial support, mostly provided by women, social politics, organized by the state, public and/or private social services. This welfare-mix shows different combinations of private and public obligations, paid and und unpaid work, professional and laymen's tasks based on a specific understanding of mo-rality and justice embedded in the gender structure and intergenerational relationships. The importance of social work as a profession in this context differs according to the historical developments and cultural traditions. Characteristic for the profile of social work is the rele-vance of a care ethics and the existence of social rights, the tension of mothering and profes-sional methods, the relationship between help, denial and punishment and the ways of institu-tionalisation. The actuality of this debate is closely intertwined with the restructuring of societal bonds in the face of globalisation, the political reorganisation of states, the changes in the living to-gether of different generations and both sexes and the consequences for the organisation and contents of welfare. Looking at Germany and Eastern Europe two new phenomena of social relevance for the dis-cussion of care work and care needs can be taken as an example: the extent of cheap illegal women laborers travelling between east and west, especially Polish women working intermit-tendly in private care for old people and the highly organized traffiking of women from Russia to Germany to work in the sex business. The care debate entails a reframing of welfare issues in the light of social justice between classes, ethnicities and gender groups.

Italia: La chiusura della Casa dell’Emigrante come spunto riflessione sui rientri degli emigrati italiani

In the literature on migration, as well as in social policies regarding this phenomenon, the situation of returning emigrants receives scant attention. This essay establishes an intricate connection between attitudes and policies that prevail in a country regarding emigration and those concerning immigration. The case of Italy provides a prime example for this as it once was a classical country of emigration, only to turn, in recent decades, into a country that appears highly attractive (and relatively accessible) to immigrants. The essay traces the pervasive ambiguity that characterizes this country’s attitudes towards emigration from the beginning of mass emigration shortly after the unification of Italy in 1868 to the emigration policies of the fascist regime of Mussolini and the post-World War II waves of emigration right through to the corresponding ambiguity concerning the status of immigrants in contemporary society, including the indifferent treatment of returning Italian emigrants who constitute a considerable numerical phenomenon. These reflections take their origin from the impending closure of a reception centre in Lazio, the Casa dell’Emigrante near Sant’Elia Fiumerapido, Province of Frosinone, ostensibly for financial reasons. This centre had been the only one of its kind in the whole of Italy dealing officially with the needs of repatriated Italians. It had assisted returning emigrants both with practical matters, such as negotiating the labyrinth of Italian bureaucracy , and with psychological implications of a return, which are often considerable given the time lag of experiences with current social realities and the frequently unrealistic expectations associated with the return. Questions of identity become highly acute in those circumstances. The threatened closure of the centre illustrates the unwillingness of the state to face up to the factual prevalence of migratory experiences in the country as a whole and as a core element of national history, experiences of migration in both directions. The statistics speak for themselves: of the 4.660.427 persons who left Italy between 1880 and 1950, 2.322.451 have returned, almost exactly 50%. To those have to be added 3.628.430 returnees of the 5.109.860 emigrants who left Italy between the end of World War II and 1976 for Europe alone. Attitudes towards people leaving changed ostensibly over time. In the first two decades after Unification parliament on the one hand wanted to show some concern over the fate of its citizens, not wanting to abandon those newly created citizens entirely to their own destiny, while on the other portraying their decisions to emigrate as expressions of individual liberty and responsibility and not necessitated by want and poverty. Emigrants had to prove, paradoxically that they had the requisite means to emigrate when in fact poverty was largely driving them to emigrate. To admit that publicly would have amounted to admission of economic and political failure made evident through emigration. In contrast to that Mussolini’s emigration policies not only enforced large population movements within the territory of Italy to balance unemployment between regions and particularly between North and South, but also declared it citizen’s duty to be ready to move also to the colonies, thereby ‘turning emigration as a sign of social crisis into a sign of national strength and the success of the country’s political agenda’ (Gaspari 2001, p. 34). The duplicity continued even after World War II when secret deals were done with the USA to allow a continuous flow of Italian immigrants and EU membership obviously further facilitated the departure of unemployed, impoverished Italians. With the growing prosperity of Italy the reversal of the direction of migration became more obvious. On the basis of empirical research conducted by one of the author on returning emigrants four types of motives for returning can be distinguished: 1. Return as a result of failure – particularly the emigrants who left during the 1950-1970 period usually had no linguistic preparation, and in any case the gap between the spoken and the written language is enormous with the latter often being insurmountable. This gives rise to nostalgic sentiments which motivates a return into an environment where language is familiar 2. Return as a means of preserving an identity – the life of emigrants often takes place within ghetto-like conditions where familiarity is being reproduced but under restricted conditions and hence not entirely authentic. The necessity for saving money permits only a partial entry into the host society and at the same time any accumulating savings add to the desire to return home where life can be lived fully again – or so it seems. 3. Return of investment – the impossibility to become fully part of another society often motivates migrants to accumulate not so much material wealth but new experiences and competences which they then aim to reinvest in their home country. 4. Return to retire – for many emigrants returning home becomes acute once they leave a productive occupation and feelings of estrangement build up, in conjunction with the efforts of having invested in building a house back home. All those motives are associated with a variety of difficulties on the actual return home because, above all, time in relation to the country of origin has been suspended for the emigrant and the encounter with the reality of that country reveals constant discrepancies and requires constant readjustment. This is where the need for assistance to returning emigrants arises. The fact that such an important centre of assistance has been closed is further confirmation of the still prevailing politics of ambiguity which nominally demand integration from nationals and non-nationals alike but deny the means of achieving this. Citizenship is not a natural result of nationality but requires the means for active participation in society. Furthermore, the experiences of returning immigrants provide important cues for the double ambivalence in which immigrants to Italy live between the demands made on them to integrate, the simultaneous threats of repatriation and the alienation from the immigrants’ home country which grows inexorably during the absence. The state can only regain its credibility by putting an end to this ambiguity and provide to returning emigrants, and immigrants alike, the means of reconstructing strong communal identities.

Swiss Army Survey in Switzerland to determine the prevalence of Francisella tularensis, members of the Ehrlichia phagocytophila genogroup, Borrelia burgdorferi sensu lato, and tick-borne encephalitis virus in ticks

A total of 6071 Ixodes ricinus ticks were collected on Swiss Army training grounds in five regions of Switzerland. The aim of the survey was to assess the prevalence of ticks infected with the human pathogens Francisella tularensis, members of the Ehrlichia phagocytophila genogroup, Borrelia burgdorferi sensu lato, and the European tick-borne encephalitis virus. TaqMan PCR (PE Biosystems, USA) and TaqMan RT-PCR (PE Biosystems) analyses were performed on DNA and RNA extracted from pools of ten ticks grouped by gender. Here, for the first time, it is shown that ticks may harbor Francisella tularensis in Switzerland, at a rate of 0.12%. Furthermore, 26.54% of the ticks investigated harbored Borrelia burgdorferi sensu lato, 1.18% harbored members of the Ehrlichia phagocytophila genogroup, and 0.32% harbored the European tick-borne encephalitis virus. A new instrumentation was applied in this study to carry out and analyze more than 2300 PCR reactions in only 5 days. Furthermore, the results reveal that people working in outdoor areas, including army personnel on certain training grounds contaminated with ticks containing tick-borne pathogens, are at risk for different tick-borne diseases.