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PubMed2004

The infected total knee arthroplasty: just when you thought it was over.

Of the various options available for infected total knee arthroplasties (TKAs), a successful primary-exchange revision technique offers decreased morbidity for the patient by eliminating a second major surgery and associated hospitalization, and substantially reduces the cost associated with this dreaded condition. In 22 infected TKAs treated by a 1-stage revision and followed for an average of 10.2 years (range, 1.4-19.6 years), 90.9% were free of recurrent infection. Knee scores averaged 79.5, with 85.7% good or excellent results. The physiologic classification of the host appeared to influence the outcome of revision. All patients in class A or B (20 knees) had successful eradication of their primary infection after 1-stage revision; 2 physiologic class C patients developed early failure secondary to poor wound healing.

Algorithms↗
PubMed2004

Long-term outcomes of valve replacement with modern prostheses in young adults.

OBJECTIVES: To examine the multiple impacts of valve replacement on the lives of young adults. METHODS: Patients (N=500) between age 18 and 50 who had aortic valve replacement (AVR) and/or mitral valve replacement (MVR) with contemporary prostheses were followed annually. Events, functional status, and quality of life were examined with regression models. RESULTS: Median follow-up was 7.1+/-5.3 years (maximum 26.7 years). Five, 10, and 15-year survival was 92.7+/-1.7, 88.3+/-2.4 and 80.1+/-4.7% after AVR, and 93.1+/-2.3, 79.5+/-4.3 and 71.5+/-5.4% after MVR, respectively. Survival decreased with concomitant coronary disease (hazard ratio (HR): 4.5) and preoperative LV grade (HR: 2.0/grade increase) in AVR patients, and with atrial fibrillation (HR: 5.5), coronary disease (HR: 5.7), preoperative left atrial diameter (HR: 3.0/cm increase) and NYHA class (HR: 2.1/class increase) in MVR patients. Despite reoperation, late survival was equivalent between bioprostheses and mechanical valves in both implant positions. The ten-year cumulative incidence of embolic stroke was 6.3+/-2.4% for mechanical AVR patients, 6.4+/-2.9% for bioprosthetic AVR patients, 12.7+/-3.9% for mechanical MVR patients, and 3.1+/-3.1% for bioprosthetic MVR patients. Atrial fibrillation (HR: 2.8) and smoking (HR: 4.0) were risk factors for stroke in MVR patients. In AVR patients, SF-12 physical scores, freedom from recurrent heart failure, and freedom from disability were significantly higher in bioprosthetic than mechanical valve patients. Career or income limitations were more often subjectively linked to a mechanical prosthesis in both implant positions. CONCLUSIONS: Late outcomes of modern prosthetic valves in young adults remain suboptimal. Bioprostheses deserve consideration in the aortic position, as mechanical valves are associated with lower physical capacity, a higher prevalence of disability, and poorer disease perception. Early surgical referral and atrial fibrillation surgery may improve survival after MVR.

Adolescent↗
PubMed2000

Conditionally replicating herpes simplex virus mutant, G207 for the treatment of malignant glioma: results of a phase I trial.

G207 is a conditionally replicating derivative of herpes simplex virus (HSV) type-1 strain F engineered with deletions of both gamma(1)34.5 loci and a lacZ insertion disabling the UL39 gene. We have demonstrated the efficacy of G207 in treating malignant glial tumors in athymic mice, as well as the safety of intracerebral G207 inoculation in mice and in Aotus nancymai. We sought to determine the safety of G207 inoculation into cerebral malignant glial tumors in humans. Criteria for inclusion into this dose-escalation study were the diagnosis of histologically proven malignant glioma, Karnofsky score > or = 70, recurrence despite surgery and radiation therapy, and an enhancing lesion greater than 1 cm in diameter. Serial magnetic resonance images were obtained for volumetric analysis. The trial commenced at a dose of 10(6) plaque forming units (p.f.u.) inoculated at a single enhancing site and was completed when the 21st patient was inoculated with 3x10(9) p.f.u. at five sites. While adverse events were noted in some patients, no toxicity or serious adverse events could unequivocally be ascribed to G207. No patient developed HSV encephalitis. We found radiographic and neuropathologic evidence suggestive of anti-tumor activity and long-term presence of viral DNA in some cases.

Adult↗
PubMed1993

Meningiomas with vertebrobasilar artery encasement: review of 17 cases.

Seventeen patients with petroelival and foramen magnum meningiomas encasing the vertebral or basilar arteries and their branches were surgically excised over a 3-year period. All six cases with vertebral artery encasement were totally excised. One vertebral artery was occluded, one was repaired, and one was replaced with a vein graft. None of the patients had a permanent major neurologic deficit. In one patient with vertebral and basilar artery encasement, a hypoplastic vertebral artery was occluded and the tumor was totally excised. She had a transient worsening of hemiparesis, presumably due to the dissection of tumor from the brainstem. Among the ten patients with encasement of the basilar artery and branches, injury to the basilar artery occurred in two patients, both were repaired. Injuries to one superior cerebellar artery, one anterior inferior cerebellar artery, and one perforating vessel could not be repaired. Three patients sustained major neurologic deficits, but only in two did this result in permanent functional deterioration. Three of the ten patients had a gross total resection, five had subtotal resection (90% or more of tumor volume), and two had resection of 70% of the tumor volume. Eight patients had improvement in their Karnofsky scores. None showed recurrence or regrowth on follow-up ranging from 2 to 6 years. Greater difficulty with dissection was experienced in previously operated patients, and in patients who did not have an arachnoid plane between the brainstem and the tumor. Magnetic resonance imaging was the most useful preoperative test. It is concluded that meningiomas with vertebrobasilar artery encasement can be removed successfully with modern skull base surgery techniques. The surgeon needs to exercise caution and judgment in deciding how far the removal of these lesions should be pursued.

Journal Article↗
PubMed2005

Recurrent structural RNA motifs, Isostericity Matrices and sequence alignments.

The occurrences of two recurrent motifs in ribosomal RNA sequences, the Kink-turn and the C-loop, are examined in crystal structures and systematically compared with sequence alignments of rRNAs from the three kingdoms of life in order to identify the range of the structural and sequence variations. Isostericity Matrices are used to analyze structurally the sequence variations of the characteristic non-Watson-Crick base pairs for each motif. We show that Isostericity Matrices for non-Watson-Crick base pairs provide important tools for deriving the sequence signatures of recurrent motifs, for scoring and refining sequence alignments, and for determining whether motifs are conserved throughout evolution. The systematic use of Isostericity Matrices identifies the positions of the insertion or deletion of one or more nucleotides relative to the structurally characterized examples of motifs and, most importantly, specifies whether these changes result in new motifs. Thus, comparative analysis coupled with Isostericity Matrices allows one to produce and refine structural sequence alignments. The analysis, based on both sequence and structure, permits therefore the evaluation of the conservation of motifs across phylogeny and the derivation of rules of equivalence between structural motifs. The conservations observed in Isostericity Matrices form a predictive basis for identifying motifs in sequences.

Base Pairing↗
PubMed1985

A prognostic score for Graves' disease.

We have reanalysed the clinical and laboratory data on 196 individuals with Graves' disease. The consensus of two clustering techniques and a new method of allocating patients to a cluster resulted in two groups of patients, those with a severe and others with a mild disease. The severe disorder is characterized by a high frequency of HLA-B8 and -Al, a low complement level, high titres of circulating immune complex and anti-thyroglobulin antibody, a high lymphocyte transformation index and serum T3 level, a low level of active E-rosettes, large goitres and a high value for the Crooks test. The mild disorder shows a higher frequency of HLA-B12 and an abnormally low absolute lymphocyte number. A weight was calculated for each character according to the relative frequency in the two clusters. A total score could then be calculated for each patient based on their clinical and laboratory findings. There were two distinct distributions of scores corresponding to the two subgroups. This suggests different aetiological factors which may be more easily studied in these more homogeneous groups. Prognostic predictions can be made using the score. The risk of recurrence and the frequency and severity of ophthalmopathy increases dramatically as the score increases. The use of the score in making therapeutic decisions needs to be tested.

Adolescent↗
PubMed1992

Effect of external beam radiotherapy on prostatic carcinoma DNA content as measured by static image cytometry.

Static image cytometry was used to study the effect of radiotherapy on the DNA content of prostatic carcinoma. Feulgen-stained specimens from 50 patients before and after radiotherapy were examined. The DNA index increased significantly after treatment (p less than 0.03), and it occurred equally in those with low (less than 1.5) and high (greater than or equal to 1.5) indices. The level of the initial DNA index was significantly related to the rate of symptomatic progression (p less than 0.05). The initial change in and final DNA indices were not related to survival however. There was a significant increase in Gleason score (p = 0.001) and histological grade (p = 0.01) after irradiation and, when taken individually, the degree of change was related to survival in both, p = 0.05 and 0.004, respectively. As Gleason score, Mayo grade and clinical stage were not independent variables; none of them was related to survival when corrected for the other factors. Thus, DNA content or ploidy, as well as Mayo grade and Gleason score, increases in recurrent tumor after radiotherapy. This may be of importance when considering what treatment to use and how intensively the patients should be followed up.

Actuarial Analysis↗
PubMed2006

Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia.

BACKGROUND: Reconstruction of the medial patellofemoral ligament has been proven to restore stability in patients with lateral patellar instability. No study to date has examined the results in a patient population with the predisposing factor of femoral trochlear dysplasia. HYPOTHESIS: Reconstruction of the medial patellofemoral ligament restores stability and provides pain relief in patients who have lateral patellar instability in association with trochlear dysplasia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-four patients with chronic patellar instability and trochlear dysplasia were treated with medial patellofemoral ligament reconstruction using an adductor tendon autograft, bone-quadriceps tendon autograft, or bone-patellar tendon allograft. All patients were evaluated preoperatively and postoperatively with Kujala, Lysholm, and Tegner scores at a minimum of 24 months. RESULTS: Thirty-four patients were followed for a mean of 66.5 months (range, 24-130 months) after surgery. Kujala scores improved from 53.3 to 90.7, Lysholm scores improved from 52.4 to 92.1, and Tegner activity scores improved from 3.1 to 5.1. All improvements were highly statistically significant (P < .001). No statistical difference was found between the postoperative Lysholm, Kujala, and Tegner scores and the degree of dysplasia, graft type, or degree of symptoms. There were 85.3% and 91.1% good and excellent results based on Kujala and Lysholm scores, respectively. No recurrent dislocations have occurred. CONCLUSION: Medial patellofemoral ligament reconstruction provides excellent long-term pain relief and functional return in patients with patellar instability and femoral trochlear dysplasia. In addition, reconstruction prevents recurrent dislocation, despite the diminished bony constraint of a dysplastic trochlea.

Adult↗
PubMedDate not supplied

Objective and subjective evaluation of endoscopic nasal surgery outcomes.

BACKGROUND: Chronic rhinosinusitis (CRS) symptoms include nasal obstruction, rhinorrhea, and facial pain associated with rhinosinusitis disability. When resistance to medical treatment is associated with endonasal anomalies, endoscopic nasal surgery (ENS) can be proposed. However, objective and subjective assessment criteria regarding the evaluation of ENS outcomes remain unclear. The aims of this study were to evaluate the correlation between the inflammation in the nasal mucosa, objective recordings of nasal airway resistance (NAR), subjective evaluation of symptom intensity, and the impact of ENS on patient-perceived rhinosinusitis disability. METHODS: Sixty-one consecutive patients (35 men and 26 women; mean age, 37.5 years) suffering from CRS were monitored at 4 months and 2 years after ENS. All middle turbinate mucosa were analyzed for the density of nonspecific inflammatory cells. All patients scored their own subjective rhinosinusitis symptoms and complaints of rhinosinusitis disability. An active anterior rhinomanometry was performed. RESULTS: A good correlation was observed between subjective and objective NAR (p < 0.001). We found a significant correlation between the density of inflammatory cells in the nasal mucosa, subjective nasal obstruction, and the rhinosinusitis disability score (p < 0.001). Recurrent CRS was seen only in subjects with moderate to severe inflammation of the middle turbinate mucosa sampled at the first surgical intervention. Subjective rhinosinusitis symptoms, objective NAR, and rhinosinusitis disability improved significantly after ENS. CONCLUSION: The degree of inflammation seems to be a good prognostic indicator regarding CRS recurrence. Long-term outcome after ENS for CRS showed significant improvement in subjective rhinosinusitis-specific symptoms, objective NAR, and rhinosinusitis disability.

Adolescent↗
PubMed2004

Primary exchange revision arthroplasty for infected total knee replacement: a long-term study.

Infected knee replacement is a serious complication that requires significant hospital-based resources for successful management. A successful primary exchange revision technique offers decreased morbidity for the patient by eliminating a second major operation and associated hospitalization, which in turn substantially reduces the cost associated with this dreaded condition. Twenty-two consecutive infected primary total knee arthroplasties in 22 patients were treated with primary exchange revision arthroplasties using antibiotic-impregnated cement. The surgical technique consisted of excision of draining sinuses, complete synovectomy, removal of granulation tissue, and debulking of the extensor mechanism. Postoperative treatment consisted of 4 to 6 weeks of parenterally administered antibiotics and 6 to 12 months of orally administered antibiotics. Both gram-positive and gram-negative organisms were treated. At an average follow-up of 10.2 years (range, 1.4 to 19.6 years), 90.9% were free of recurrent infection. Knee scores averaged 79.5, with 85.7% good or excellent results. The physiological classification of the host appeared to influence the outcome of revision. All patients in class A or B (20 knees) had successful eradication of their primary infection after 1-stage revision, whereas the only failure in the group was a physiological class C patient, who eventually expired from ongoing end-organ liver failure. These results compare most favorably with those of delayed-exchange revision arthroplasty while providing a more cost-effective management program.

Aged↗
PubMed2005

[Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral grafts].

PURPOSE OF THE STUDY: A chondral/osteochondral defect involving the articular surface of a joint is still a therapeutic problem. Many surgical techniques have been studied in an attempt to restore the damaged articular cartilage. Autogenous osteochondral graft has gained in clinical popularity because of its technical feasibility and cost effectiveness, however, only a few series have been reported in the literature. MATERIAL: A retrospective study included 14 patients with 14 knees with focal full thickness articular cartilage defects hospitalised in our department between January 1997 and June 2000. The diagnoses included six knees with osteonecrosis, five knees with osteochondritis dissecans and three knees with traumatic cartilage defect. METHODS: All these patients underwent an osteochondral autografts of the knee with 2 years follow-up. The evaluations were based on functional assessments, which included pain, giving way, locking, recurrent effusion, knee scores, functional scores and Lysholm scores. The postoperative values of functional assessments among the three categories of diagnosis were compared statistically using Kruskal-Wallis test. Radiographs of the knees were examined for joint congruence, joint space narrowing and degenerative changes. RESULTS: The study showed good or excellent clinical results in over than 85%. The duration of pain of the knees relief ranged from six to 16 weeks after surgery. DISCUSSION: There was no correlation of the clinical results with the underlying diagnosis, including osteonecrosis, osteochondritis dissecans and traumatic cartilage defect. Improvement in symptoms appeared time-dependent, ranging from 6 to 16 weeks, suggesting that postoperative protection of the graft is warranted. There was no radiographic progression of degenerative changes of the knee on the medium-term follow-up. CONCLUSION: There was no correlation of the clinical results with the underlying diagnoses. It appears that an osteochondral graft has the potential to prevent or delay the development of degenerative changes of the knee in the medium-term follow-up. Autogenous osteochondral graft is considered as a good method in the treatment of knees with moderately sized articular cartilage defects.

Adult↗
PubMed2000

Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease.

PURPOSE: To determine the prognostic value of pleural fluid pH, pleural fluid glucose, extent of pleural carcinomatosis (EPC) score, and Karnofsky Performance Scale (KPS) score in patients with recurrent symptomatic malignant pleural effusions. DESIGN: Prospective 53-month study. SETTING: Referral center for interventional pulmonology. PATIENTS: Eighty-five consecutive patients (42 men and 43 women) with recurrent symptomatic malignant pleural effusions who were referred to the interventional pulmonary service for thoracoscopic pleurodesis. MEASUREMENTS: Pleural fluid pH, pleural fluid glucose, EPC score, and KPS score. RESULTS: The KPS score was the only statistically significant predictor variable. Patients with a KPS score >/= 70 had a median survival of 395 days, as opposed to a median survival of only 34 days for patients with a KPS score </= 30. No prognostic advantage was evident when patients were categorized by pleural fluid pH, pleural fluid glucose, or EPC score. CONCLUSION: When assessing the prognosis of a patient with a recurrent symptomatic malignant pleural effusion, only the KPS score at the time of thoracoscopy is predictive of survival. Pleural fluid pH, pleural fluid glucose, and EPC scores are not as reliable as initially reported. For patients with a KPS score >/= 70, it may be very reasonable to proceed with thoracoscopic talc pleurodesis for management of their malignant pleural effusions.

Adult↗
PubMed2005

Racial differences in serum prostate-specific antigen (PSA) doubling time, histopathological variables and long-term PSA recurrence between African-American and white American men undergoing radical prostatectomy for clinically localized prostate cancer.

OBJECTIVE: To determine if there are significant differences in biochemical characteristics, biopsy variables, histopathological data, and rates of prostate-specific antigen (PSA) recurrence between African-American (AA) and white American (WA) men undergoing radical prostatectomy (RP), as AA men are twice as likely to die from prostate cancer than their white counterparts. PATIENTS AND METHODS: We established a cohort of 1058 patients (402 AA, 646 WA) who had RP and were followed for PSA recurrence. Age, race, serum PSA, biopsy Gleason score, clinical stage, pathological stage, and PSA recurrence data were available for the cohort. The chi-square test of proportions and t-tests were used to assess basic associations with race, and log-rank tests and Cox regression models for time to PSA recurrence. Forward stepwise variable selection was used to assess the effect on the risk of PSA recurrence for race, adjusted by the other variables added one at a time. RESULTS: The AA men had higher baseline PSA levels, more high-grade prostatic intraepithelial neoplasia (HGPIN) in the biopsy, and more HGPIN in the pathology specimen than WA men. The AA men also had a shorter mean (sd) PSA doubling time before RP, at 4.2 (4.7) vs 5.2 (5.9) years. However, race was not an independent predictor of PSA recurrence (P = 0.225). Important predictors for PSA recurrence in a multivariable model were biopsy HGPIN (P < 0.014), unilateral vs bilateral cancer (P < 0.006), pathology Gleason score and positive margin status (both P < 0.001). CONCLUSIONS: This study indicates that while there are racial differences in baseline serum PSA and incidence of HGPIN, race is not an independent risk factor for PSA recurrence. Rather, other variables such as pathology Gleason score, bilateral cancers, HGPIN and margin positivity are independently associated with PSA recurrence. The PSA doubling time after recurrence may also be important, leading to the increased mortality of AA men with prostate cancer.

Black or African American↗
PubMed1999

Recurrent Clostridium difficile disease: epidemiology and clinical characteristics.

OBJECTIVE: To describe the epidemiology, diagnosis, risk factors, patient impact, and treatment strategies for recurrent Clostridium difficile-associated disease (CDAD). DESIGN: Data were collected as part of a blinded, placebo-controlled clinical trial testing a new combination treatment for recurrent CDAD. Retrospective data regarding prior CDAD episodes were collected from interviews and medical-chart review. Prospective data on the current CDAD episode, risk factors, and recurrence rates were collected during a 2-month follow-up. SETTINGS: National referral study. PARTICIPANTS: Patients with recurrent CDAD. INTERVENTIONS: Treatment with a 10-day course of low-dose (500 mg/d) or high-dose (2 g/d) vancomycin or metronidazole (1 g/d). RESULTS: Recurrent CDAD was found to have a lengthy course involving multiple episodes of diarrhea, abdominal cramping, nausea, and fever. CDAD may recur over several years despite frequent treatment with antibiotics. Recurrence rates were similar regardless of the choice or dose of antibiotic. Recurrent CDAD is not a trivial disease: patients may have multiple episodes (as many as 14), may require hospitalization, and the mean lifetime cost of direct medical care was $10,970 per patient. Fortunately, the disease does not become progressively more severe as the number of episodes increase. Two risk factors predictive for recurrent CDAD were found: increasing age and a decreased quality-of-life score at enrollment. CONCLUSIONS: Recurrent CDAD is a persistent disease that may result in prolonged hospital stays, additional medical costs, and rare serious complications.

Adolescent↗
PubMed2006

Low predictive accuracy of the Kattan postoperative nomogram for renal cell carcinoma recurrence in a population of French patients.

BACKGROUND: The aim of the current study was to establish the predictive accuracy of the Kattan postoperative nomogram for nonmetastatic renal cell carcinoma (RCC) by comparing predictions with actual disease recurrence in patients who underwent surgery in a single center in France. METHODS: Between 1985 and 2000, 844 patients were treated for RCC. The following data were collated: age, symptoms, histology, tumor size, grade, TNM 1997 stage, recurrence, and progression. For each patient a prognostic score (predicted probability) for recurrence-free survival (RFS) at 5 years was calculated using the Kattan nomogram. The discriminating ability of the model was assessed by Harrell's concordance index (c-index). Bootstrapping was used to assess confidence intervals. Furthermore, survival was then estimated by the Kaplan-Meier method and Cox proportional hazards regression analysis. RESULTS: In all, 565 patients (median age, 62 years) were included. At the time of the last follow-up, 81 patients had died and 101 had experienced RCC recurrence. The c-index for RFS (Kattan nomogram) was only 0.607 (95% confidence interval [CI]: 0.576-0.635). The 5-year RFS rate and cancer-specific survival rate were 81.5% and 84.7%, respectively. Of the 4 variables included in the nomogram, only TNM stage was associated with recurrence in a multivariate analysis (Cox analysis) (P = .022). CONCLUSIONS: There was a discrepancy between predicted RFS as estimated by the Kattan nomogram and the likelihood of being recurrence-free at 5 years according to the Cox analysis in the current population of patients. However, until new dynamic models become available clinicians may still improve their predictive ability by using the current nomogram.

Carcinoma, Renal Cell↗
PubMed1982

Does psychiatric illness affect the recurrence rate of genital herpes?

The progress of 58 patients with first attacks of genital herpes was monitored for up to 30 weeks. The effects of sex (gender), age, social class, and non-psychotic psychiatric illness (as measured by the "general health questionnaire," GHQ) on the recurrence rate of herpes was studied. The recurrence rates, measured by the actuarial percentage recurrence-free curves, showed that the 29 patients with GHQ scores above 11 had a significantly higher recurrence rate than those who scored less than 11 (P = 0.002). There were no important differences between recurrence rates according according to sex, age, or social class. These findings suggest that non-psychotic states, such as anxiety or obsessionality resulting in GHQ scores above 12, may possibly cause an excess production of adrenergic substances which encourages reactivation of latent genital herpes. Thus, to lessen the recurrence rate in such patients, a psychological or chemical approach to treatment could be used to modify the autonomic sympathetic response.

Adolescent↗
PubMed2000

Early treatment of endometriosis with GnRH-agonists: impact on time to recurrence.

In a study, 52 patients with histologically confirmed endometriosis underwent a "three-step" therapy. The follow-up period was up to 60 months (median 33.5 months). If r-AFS-score was posttherapeutically 0, recurrence occurred latest after 36 months (median 18 months), if stage III was found posttherapeutically, recurrence occurred already latest after 18 months (median 8 months), (log-rank test P=0.0072). In our study we could confirm a clear relationship of recurrence of symptomatic endometriosis to the post-therapeutically achieved r-AFS-score.

Endometriosis↗
PubMed1993

Biological, physical, mental and social dimensions of breast cancer: information based on routine case notes.

551 patients were diagnosed with breast cancer in Tampere University Hospital district, Finland between 1977 and 1980. The number of follow-up visits during the first 5 years was 8248. The biological, physical, mental and social dimensions of breast cancer were measured by death, recurrence of disease, Karnofsky score, physical or mental symptoms, and sick leave. The prevalence rates of an event and the incidence rates of the appearance or disappearance of an event were used to determine the indicators for these different dimensions of breast cancer. The study was based on hospital case notes. Data on death, recurrence, sick leave and Karnofsky score were well recorded, but physical or mental symptoms were recorded infrequently. There was a 4-fold difference between the highest and lowest prevalence for the different dimensions, but the trends were similar by follow-up time. The variation was also large for the incidence rates but the trends differed with length of follow-up time. The biological, physical, mental and social consequences of breast cancer differ in magnitude and have different trends over time, indicating that breast cancer is a different disease depending on the dimension and on the indicator under consideration.

Absenteeism↗