"Os post peronei" and the posterolateral nutcracker impingement syndrome

Impingement syndromes have been described in relation to accessory or anomalous bony additions to the foot skeleton. We describe a hitherto undescribed accessory bone in the hindfoot causing posterolateral impingement in a 28-year-old woman.

Molecular genetics of spectral tuning in New World monkey color vision

Although most New World monkeys have only one X-linked photopigment locus, many species have three polymorphic alleles at the locus. The three alleles in the squirrel monkey and capuchin have spectral peaks near 562, 550, and 535 nm, respectively, and the three alleles in the marmoset and tamarin have spectral peaks near 562, 556, and 543 nm, respectively. To determine the amino acids responsible for the spectral sensitivity differences among these pigment variants, we sequenced all exons of the three alleles in each of these four species. From the deduced amino acid sequences and the spectral peak information and from previous studies of the spectral tuning of X-linked pigments in humans and New World monkeys, we estimated that the Ala --> Ser, Ile --> Phe, Gly --> Ser, Phe --> Tyr, and Ala --> Tyr substitutions at residue positions 180, 229, 233, 277, and 285, respectively, cause spectral shifts of about 5, -2, -1, 8, and 15 nm. On the other hand, the substitutions His --> Tyr, Met --> Val or Leu, and Ala --> Tyr at positions 116, 275, and 276, respectively, have no discernible spectral tuning effect, though residues 275 and 276 are inside the transmembrane domains. Many substitutions between Val and Ile or between Val and Ala have occurred in the transmembrane domains among the New World monkey pigment variants but apparently have no effect on spectral tuning. Our study suggests that, in addition to amino acid changes involving a hydroxyl group, large changes in residue size can also cause a spectral shift in a visual pigment.

Objective and subjective measures of the pharmacodynamic effects of Adderall in the treatment of children with ADHD in a controlled laboratory classroom setting

In a randomized double-blind crossover study of children with attention deficit hyperactivity disorder (ADHD), the time course effects of four doses of Adderall (5, 10, 15, and 20 mg) and an inactive (placebo) control, and an active (Ritalin) control were evaluated. A laboratory classroom setting was established in which subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measurements were taken every 1.5 hours across the day. In addition to significant time and dose effects of Adderall, significant time-of-day effects were documented in the placebo condition for the subjective measure of deportment and objective measures of performance. Regression analyses were used to estimate the magnitude of these baseline effects. Correlations across time were used to evaluate the test-retest reliability of each measure in the face of these time-dependent placebo effects. After placebo/time adjustments, within-subject correlations between pairs of measures were used to evaluate the validity of the math test as a measure of response to stimulant medication.

Analog classroom assessment of Adderall in children with ADHD

OBJECTIVE

This was a randomized, double-blind, crossover study of 30 children with attention-deficit/hyperactivity disorder (ADHD) that evaluated the time course effects of four doses of Adderall (5, 10, 15, and 20 mg), an inactive control (placebo), and a positive control (clinical dose of methylphenidate).

METHOD

For each treatment condition, a capsule was administered in the morning and assessments were performed in an analog classroom setting every 1.5 hours across the day. Subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measures were obtained for each classroom session, and these measures were used to evaluate time-response and dose response effects of Adderall.

RESULTS

For doses of Adderall greater than 5 mg, significant time course effects were observed. Rapid improvements on teacher ratings and math performance were observed by 1.5 hours after administration, and these effects dissipated by the end of the day. The specific pattern of time course effects depended on dose: the time of peak effects and the duration of action increased with dose of Adderall.

CONCLUSIONS

This documentation of efficacy in a controlled study supports the addition of Adderall to the armamentarium of psychotropic medications for the treatment of ADHD. The differences in time-response patterns of Adderall and methylphenidate may help tailor treatment to meet specific clinical needs of different children with ADHD.

Emergency vaccination of pigs against foot-and-mouth disease: protection against disease and reduction in contact transmission

The protective ability of two novel oil-based FMD vaccines in pigs was examined. Both vaccine formulations were shown to protect pigs against airborne challenge with homologous FMDV within four days of vaccination, but not at two and three days post-vaccination. Protection was associated with the induction of variable and low titre serum antibody responses. A transmission study showed that protective immunisation resulted in reduced virus excretion. Vaccination at seven days, but not at four days, prior to challenge prevented contact transmission of FMD. The two formulations tested in this study have the favourable characteristics of low viscosity, low reactivity and high potency emergency FMD vaccines for use in strategic vaccination campaigns to assist the control of outbreaks of FMD.

Contextual influences and goal perspectives among female youth sport participants

This study investigated two research questions: (1) do goal involvement and state anxiety vary between athletic games and athletic practices? and (2) do goal orientations change over the course of a competitive season as a function of the perceived team motivational climate? Middle school athletes (n = 127) were assessed on goal orientations, goal involvement, state anxiety, and motivational climate. Results indicated that athletes were more task involved and less anxious in practice than in game situations, and task goal orientation changed over the season relative to perceptions of mastery and performance climates. These results may indicate that sport offers an environment different from the academic setting and that mainstream psychology theories need to be adapted for the sport context.

Quality care for cardiology patients

To evaluate outcome measures in a cardiology unit, patient satisfaction was measured. Patients consistently related problems in two areas: pain management and the waiting period before their procedure. After a major system change, patient satisfaction increased 16% and 29% respectively.

Nitric oxide compartments in the mushroom bodies of the locust brain

All insect brains contain mushroom-shaped neural bodies which are implicated in associative learning. Here we show that the mushroom bodies of the locust brain have a remarkable and hitherto undescribed neural organisation consisting of six tubular structures in which bundles of axons are enclosed by cylindrical walls of nitric oxide synthase (NOS) expressing processes. A dynamic temporo-spatial simulation shows that the tubular organization allows NO to attain and maintain locally elevated concentrations within highly structured domains in the CNS. A diffusible gaseous signalling molecule such as NO can therefore selectively affect computational processes occurring in discrete parallel channels of information flow in the brain. The implications of this are discussed in relation to the role of NO in a compartmental model of the mushroom bodies and more generally in the context of the targetting of diffusible messenger molecules in the brain.

Association of the dopamine receptor D4 (DRD4) gene with a refined phenotype of attention deficit hyperactivity disorder (ADHD): a family-based approach

Previously in this journal, we reported an association of the dopamine D4 receptor gene (DRD4) and attention deficit hyperactivity disorder (ADHD). In a population-association (case-control) study of 39 children with a refined phenotype of ADHD and 39 ethnically matched controls, we observed an increased percentage of the 7 repeat allele (29% vs 12%) and the 7+ genotype (49% vs 21%) in the ADHD group compared to the control group. In a replication and an extension of our initial study, we recruited another sample of ADHD subjects and found percentages of the 7 repeat allele (28%) and the 7+ genotype (48%) consistent with our previous findings. We used a family-based approach to evaluate a predicted association of DRD4 and ADHD based on a test of allele transmission focused on the 7 repeat allele. We identified 52 families based on the diagnosis of the refined phenotype of ADHD in the proband and the availability of DNA from both biological parents as well as the proband. Haplotype relative risk (HRR) analysis was performed to test our a priori hypothesis and produced significant results (chi-square = 4.65, P < 0.035). This provides additional evidence that the DRD4 gene is associated with a refined phenotype of ADHD.

Physician use of an ambulatory medical record system: matching form and function

An ambulatory medical record system was implemented as a pilot project to determine the clinical and operational impacts of using interactive, computer-based systems in the outpatient setting. Of the 58 physicians who attempted to use the AMR system, 28 continue as active users. Physicians who discontinued use of the system reported a variety of reasons for their dissatisfaction. As a result of the pilot, the AMR implementation team and physicians understand better how to fit the AMR system to a physician's specific requirements, as well as enhance the operation of the physician's practice. Armed with the experience gained during the early phases of the implementation, the Cleveland Clinic Foundation now intends a cautious expansion and continued evaluation of the AMR system, with the objective of meeting organizational needs with appropriate technical functions.

Pre-school assessment project comparing assessment in the clinic or home

From clinical experience it has been found that it is often difficult to assess young children in a clinical environment. Therefore, the aim of this project was to assess the communication of children in either the home or the clinic environment and to determine whether a more realistic impression of the child's language was obtained from home initial assessment. The results of this study suggest that for children who are 39 months old or less on the date of referral to speech and language therapy, a more representative sample of communication skills does emerge from initial assessment in the home environment. The conclusions drawn also indicate that the attendance rates for home assessments were significantly better than those for clinic appointments and this in turn meant that there was a subsequent cost saving to the department.

Speech and language characteristics of children with strokes due to sickle cell disease

The receptive and expressive language skills of 10 children with strokes due to sickle cell disease were significantly poorer than those of their matched controls. The children with strokes had greatest difficulty in following oral directions and formulating sentences.

Inv(10)(p11.2q21.2), a variant chromosome

We present 33 families in which a pericentric inversion of chromosome 10 is segregating. In addition, we summarise the data on 32 families in which an apparently identical inv(10) has been reported in the literature. Ascertainment was through prenatal diagnosis or with a normal phenotype in 21/33 families. In the other 12 families, probands were ascertained through a wide variety of referral reasons but in all but one case (a stillbirth), studies of the family showed that the reason for referral was unrelated to the chromosome abnormality. There has been, to our knowledge, no recorded instance of a recombinant chromosome 10 arising from this inversion and no excess of infertility or spontaneous abortion among carriers of either sex. We propose that inv(10)(p11.2q21.2) can be regarded as a variant analogous to the pericentric inversion of chromosome 2(p11q13). We conclude that prenatal chromosome analysis is not justified for inv(10) carriers. In addition, family investigation of carrier status is not warranted in view of the unnecessary concern this may cause parents and other family members.

Influence of time and storage conditions on plasma HIV viral load measurements

Quantification of human immunodeficiency virus (HIV) RNA in plasma from HIV-infected patients is now widely used as a clinical indicator of disease prognosis and of response to antiretroviral therapy. However, controversy exists as to whether values obtained under different testing conditions could vary significantly, thus jeopardizing the appropriate interpretation of data. Herein, we demonstrate that results obtained after testing plasma versus whole blood, or immediate versus deferred processing, do not appear to influence viral load measurements significantly. Thirty blood samples from HIV-infected patients were analysed. The second generation branched-DNA assay was used for quantification of plasma viral load. HIV RNA remained stable for at least 24 h at room temperature, either in plasma or in whole blood, in 72.4% of the samples (< 0.2 log difference in viral load values) although lower levels of HIV RNA tend to be seen in samples after being stored as whole blood at room temperature. Only 3.4% of samples showed a decline > 0.5 log when they were left as whole blood at room temperature for 24 h in comparison with testing after immediate plasma separation. Although immediate separation and refrigeration of plasma samples may reduce the chance of significant falls in viral load measurements, this level of processing can be limited in regions where clinical blood samples cannot be processed rapidly. Our data provide confidence in the results obtained when testing specimens, either plasma or whole blood, 24 h after venepuncture and storage at room temperature, mimicking the conditions in the transport of blood samples to reference centres.

Specialist registrar training: ideas for a five year programme

Proposals for specialist registrar training in accident and emergency medicine in Mid-Trent Region are outlined. These may provide a framework for other schemes as well as stimulating further ideas.

Consent to treatment by minors attending accident and emergency departments: guidelines

The absolute right to refuse medical treatment, even if the reasons are irrational, is confined to competent adults. Children under 16 years can give legal consent to treatment in the absence of consent from those with parental responsibility. Children under 18 years do not, however, have an absolute right to consent, or refuse to consent, to treatment. The views of children assume increasing importance with age and maturity. Accident and emergency medical and nursing staff may face difficult decisions when children, or those with parental responsibility, refuse to consent to medical treatment. This paper presents guidelines designed to guide the decision making process in immediately or potentially life threatening conditions and in non-life-threatening conditions.

A candidate Ross River virus vaccine: preclinical evaluation

A killed Ross River virus vaccine is being developed in an effort to prevent the, ca 5000 cases of epidemic polyarthritis which occur in Australia each year. The symptoms of epidemic polyarthritis commonly last 30-40 weeks and 25% of patients have symptoms for a year or more. There is no cure. Although there was some strain to strain variation, particularly after a single injection, outbred and inbred strains of mice all produced significant levels of anti-Ross River virus antibody after intramuscular (i.m.) injection with 24 h BEI inactivated, sucrose gradient purified, Ross River virus vaccine. Mice immunized i.m. with two 20 micrograms doses of vaccine or live virus produced similar levels of neutralizing antibody but the reaction of IgG 2a and IgG 2b antibody from these two groups of mice to Ross River virus proteins in western blots differed. Antibody from BALB/c mice immunized with this vaccine neutralized all strains of Ross River virus tested, in vitro, albeit to different degrees.

Secondary cytoreductive surgery at second-look laparotomy in advanced ovarian cancer: a Gynecologic Oncology Group Study

Reports which analyzed the effects of secondary cytoreductive surgery at second-look laparotomy have often included small numbers of patients who have been treated with a variety of first-line chemotherapy regimens and those who may have progressed on first-line therapy. The purpose of this study was to analyze survival following secondary cytoreductive surgery at second-look laparotomy in patients with advanced ovarian cancer. Review of the surgical data of 153 patients allowed classification of tumor size found at second-look laparotomy and tumor size remaining after cytoreduction. Multivariate analysis evaluated multiple risk factors for survival. Of 153 patients, 124 had macroscopic tumor at second-look laparotomy and 29 had microscopic disease only. Fifteen of 69 (22%) patients were found to have tumor > 1 cm in diameter and were cytoreduced to microscopic residual and 18/69 (26%) were left with 1 cm tumor. Twenty-one of 55 (38%) patients with < or = 1 cm tumor were debulked to microscopic residual. The shortest survival relative to patients found to have microscopic disease at second-look laparotomy was observed among patients whose maximum tumor size remained > 1 cm following second-look laparotomy (relative risk = 3.1, P = 0.0004). No difference in survival was seen between patients found to have microscopic disease and those cytoreduced to microscopic disease (P = 0.24). The risk of death was lower among patients debulked to a lower category (< or = 1 cm debulked to microscopic, relative risk = 0.48, P = 0.02; > 1 cm reduced to < or = 1 cm, relative risk = 0.49, P = 0.02; > 1 cm reduced to microscopic, relative risk = 0.44, P = 0.01). Whether this apparent beneficial effect of cytoreductive surgery at second-look laparotomy reflects the biology of the tumor which allows surgical cytoreduction or the effects of cytoreduction can only be addressed in a randomized prospective trial.

Neosartorya fischeri: an invasive fungal pathogen in an allogeneic bone marrow transplant patient

Invasive fungal infections are a complication of allogeneic BMT. We report the first case of a Neosartorya fischeri fungal infection in a patient following allogeneic BMT. Neosartorya fischeri is related to Aspergillus fumigatus, but it is a distinct fungal species. Despite granulocytic engraftment and aggressive anti-fungal therapy with amphotericin B, the patient died of overwhelming fungal infection on day 60 post-BMT. Neosartorya fischeri is a pathogen that grows slowly in culture which can delay or confuse identification. This case further supports the need for more effective prophylaxis and treatment of non-Candida fungal infections in the allogeneic BMT population.