The Kudo 5 total elbow replacement in the treatment of the rheumatoid elbow

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation.

Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component.

With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91).

Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result.

Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components.

Perspectives on domestic violence: case study from Karachi, Pakistan

There is no adequate profile of domestic violence in Pakistan although this issue is frequently highlighted by the media. This case study used qualitative and quantitative methods to explore the nature and forms of domestic violence, circumstances, impact and coping mechanisms amongst selected women victims in Karachi. Violence was a continuum: all the women reported verbal abuse, often escalating into physical, emotional, sexual and economic abuse. The husband was the most common perpetrator. Women suffered in silence due to sociocultural norms, misinterpretation of religious beliefs, subordinate status, economic dependence and lack of legal redress. Besides short-term local measures, public policy informed by correct interpretation of religion can bring about a change in prevailing societal norms.

Pleural and pericardial effusion: a potential ultrasonographic marker for the prenatal differential diagnosis between congenital diaphragmatic eventration and congenital diaphragmatic hernia

OBJECTIVES

To determine whether or not the presence of pleural and/or pericardial effusion can be used prenatally as an ultrasonographic marker for the differential diagnosis between diaphragmatic eventration and diaphragmatic hernia.

METHODS

We present two case reports of non-isolated diaphragmatic eventration associated with pleural and/or pericardial effusion. Additionally, we reviewed the literature for all cases of congenital diaphragmatic hernia (CDH) and diaphragmatic eventration that met the following criteria: (1) prenatal diagnosis of a diaphragmatic defect and (2) definitive diagnosis by autopsy or surgery. The frequencies of pleural effusion, pericardial effusion and hydrops were compared between the two conditions using Fisher's exact test. A subanalysis was conducted of cases with isolated diaphragmatic defects (i.e. diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies).

RESULTS

A higher proportion of fetuses with diaphragmatic eventration had associated pleural and pericardial effusions compared with fetuses with diaphragmatic hernia (58% (7/12) vs. 3.7% (14/382), respectively, P < 0.001). This observation remained true when only cases of diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies were compared (29% (2/7) with eventration vs. 2.2% (4/178) with CDH, P < 0.02).

CONCLUSIONS

The presence of pleural and/or pericardial effusion in patients with diaphragmatic defects should raise the possibility of a congenital diaphragmatic eventration. This information is clinically important for management and counseling because the prognosis and treatment for CDH and congenital diaphragmatic eventration are different. Published by John Wiley & Sons, Ltd.

Preclinical pharmacokinetics, pharmacodynamics, and activity of a humanized anti-CD40 antibody (SGN-40) in rodents and non-human primates

1. Cell-surface expression of CD40 in B-cell malignancies and multiple solid tumors has raised interest in its potential use as a target for antibody-based cancer therapy. SGN-40, a humanized monoclonal anti-CD40 antibody, mediates antibody-dependent cytotoxicity and inhibits B-cell tumor growth in vitro, properties of interest for the treatment of cancers, and is currently in Phase I clinical trials for B-cell malignancies. In this study, we determined in vivo activity and pharmacokinetics properties of SGN-40. 2. Effect of SGN-40 in xenograft model of CD40-expressing B-cell lymphoma in severe-combined immune deficiency mice and its in vivo pharmacokinetics properties in normal mice, rats and cynomolgus monkeys were studied. 3. Treatment with SGN-40 significantly increased the survival of mice xenografted with human B-cell lymphoma cell line. SGN-40 exhibited nearly 100% bioavailability in mice and it cleared faster when given at a low dose. In monkeys, clearance of SGN-40 was also much faster at low dose, suggesting nonlinear pharmacokinetics in these species. In rats, however, SGN-40 clearance at all tested doses was similar, suggesting that pharmacokinetics were linear in this dose range in rats. Administration of SGN-40 to monkeys also produced marked, dose-dependent, and persistent depletion of peripheral CD20(+) B lymphocytes. 4. Data presented in this report suggest that SGN-40 is active in in vivo, and based upon interspecies scaling, SGN-40 clearance in humans is predicted to be similar to observed SGN-40 clearance in monkeys. These data suggest that SGN-40 has appropriate pharmacokinetic properties that support its clinical use.

Treatment of refractory gastroesophageal reflux disease with radiofrequency energy (Stretta) in patients after Roux-en-Y gastric bypass

BACKGROUND

Morbid obesity is associated with gastroesophageal reflux disease (GERD), which, in most cases, completely resolves after Roux-en-Y gastric bypass (RYGB). Patients with persistent or recurrent symptoms have limited surgical options. This study sought to evaluate the application of the Stretta procedure for patients with refractory GERD.

METHODS

The medical records of all patients who underwent Stretta for refractory GERD after RYGB were reviewed. Demographic, preoperative, and postoperative reflux data were collected. Data are presented as mean +/- standard error of the mean. The t-test was used for comparison purposes.

RESULTS

Of 369 patients, 7 received Stretta 27 +/- 6 months after RYGB. All were women with a mean age of 49 +/- 2 years. All the patients had experienced prebypass GERD symptoms for a duration of 45 +/- 8 months. The mean prebypass body mass index was 45 +/- 2 kg/m(2), and this was reduced to 29 +/- 2 kg/m(2) after laparoscopic RYGB (p < 0.001). Before Stretta, all patients underwent a 48-h Bravo pH study, which demonstrated reflux with a mean fraction time of 7% +/- 2% for pH lower than 4. After Stretta, five patients had complete resolution of their symptoms, with normalization of pH studies (mean fraction time of 3% +/- 0% for pH < 4). The follow-up period after Stretta was 20 +/- 2 months. One patient did not have adequate relief of symptoms after Stretta, and one patient was lost to follow-up evaluation.

CONCLUSION

Stretta is a valid option in the treatment of persistent GERD for patients who have undergone gastric bypass. Further study is required to evaluate the long-term efficacy of this procedure.

Depletion of B Cells by a Humanized Anti-CD20 Antibody PRO70769 in Macaca Fascicularis

PRO70769 is a humanized IgG1 monoclonal antibody against the CD20 molecule that is present on normal and malignant B cells. PRO70769 is being evaluated for treatment of B-cell-mediated diseases and is in a phase 1 trial for rheumatoid arthritis. As part of the preclinical toxicology evaluation, B-cell depletion profiles and safety of PRO70769 were assessed in cynomolgus monkeys. Animals were administered drug (IV) on days 1 and 15 with 10, 50, or 100 mg/kg PRO70769 and killed 2 weeks after the second dose and after a 3-month recovery period. In a parallel study, animals were not necropsied but instead were retreated with a second cycle of PRO70769 administered under an identical regimen. PRO70769 suppressed B cells in the blood to undetectable levels and significantly reduced B cells in lymphoid tissues. Splenic B cells were depleted to a greater extent compared with lymph node B cells. A second cycle of treatment resulted in a greater extent of depletion in lymphoid tissues compared with the depletion observed after one cycle of treatment; however, residual B cells in lymphoid tissues were still detectable, even at the highest dose. The rate of B-cell recovery in peripheral blood appeared similar between one and two cycles of treatment. Upon depletion there was a change in the profile of lymph node B-cell subsets. After recovery, B-cell subsets were reconstituted to normal levels. Depletion of CD20-expressing cells and lymphoid follicular atrophy were the only treatment-related effects.

Frequency of food items among households in a low socioeconomic area of Karachi

OBJECTIVE

To describe the frequency of certain food items among families in a low socioeconomic area of Karachi and their association with socioeconomic variables.

METHOD

A cross sectional survey of houses selected through random sampling using a pre-tested structured questionnaire.

RESULTS

A total of 294 houses were surveyed, 23% households consumed meat almost daily, 55% consumed vegetables almost daily.

CONCLUSION

The survey showed that the consumption of food items in our study population is less as compared to what is recommended.

Effect of amoxicillin use on oral microbiota in young children

Dental plaque samples from 40 children were screened for the presence of bacteria resistant to amoxicillin. Fifteen children had used amoxicillin and 25 had not used any antibiotic in the 3 months prior to sample collection. All (100%) of the children harbored amoxicillin-resistant oral bacteria. The median percentage of the total cultivable oral microbiota resistant to amoxicillin was 2.4% (range, 0.1 to 14.3%) in children without amoxicillin use and 10.9% (range, 0.8 to 97.3%) in children with amoxicillin use, with the latter value being significantly higher (P < 0.01). A total of 224 amoxicillin-resistant bacteria were isolated and comprised three main genera: Haemophilus spp., Streptococcus spp., and Veillonella spp. The biodiversity of the amoxicillin-resistant microbiota was similar among the isolates from children with and without previous antibiotic use. The amoxicillin MIC at which 90% of the isolates were inhibited for isolates from children who had used amoxicillin in the previous 3 months was higher (64 mg liter(-1)) than that obtained for the isolates from subjects who had not used antibiotics (16 mg liter(-1)). The majority of the amoxicillin-resistant isolates (65%) were also resistant to at least one of the three antibiotics tested (penicillin, erythromycin, and tetracycline), with resistance to penicillin (51% of isolates) being the most frequently encountered. However, significantly more (P < 0.05) of the amoxicillin-resistant isolates from subjects with previous amoxicillin use were also resistant to erythromycin. This study has demonstrated that a diverse collection of amoxicillin-resistant bacteria is present in the oral cavity and that the number, proportions, MICs, and resistance to erythromycin can significantly increase with amoxicillin use.

The effect of knee flexion on the popliteal artery and its surgical significance

Total knee replacement and high tibial osteotomy are common orthopaedic operations with low complication rates. Such surgery is in close proximity to the popliteal artery (PA), the behaviour of which during flexion of the knee is poorly understood. We used Duplex ultrasonography to determine the distance of the PA from the posterior tibial surface at 0 degrees and 90 degrees of flexion in 100 knees. When the knee was flexed the PA was closer to the posterior tibial surface at 1 to 1.5 cm below the joint line in 24% and at 1.5 to 2 cm below the joint line in 15%. There was a high branching anterior tibal artery in 6% of knees. We provide an anatomical account to help to explain our findings by using cadaver dissections, arteriography and static MRI studies.

Renal cell carcinoma (chromophobe type) in the first trimester of pregnancy

We report a case of renal cell carcinoma (chromophobe type) in a female in the first trimester of her first pregnancy. The tumour was removed completely. Postoperatively single live pregnancy was confirmed and subsequently resulted in spontaneous vaginal delivery at term of a healthy infant.

Funisitis and chorionic vasculitis: the histological counterpart of the fetal inflammatory response syndrome

OBJECTIVE

To determine whether there is a relationship between the presence of histological signs of inflammation in the extraplacental membranes and umbilical cord and the concentrations of fetal plasma interleukin-6 (IL-6).

METHODS

The study examined a cohort of patients who were admitted with preterm labor or preterm premature rupture of the membranes (PROM) and who underwent cordocentesis. Inclusion criteria included fetal plasma available for IL-6 determination, histological examination of the umbilical cord and placenta, and delivery within 48 h of the procedure. This last criterion was used to preserve a meaningful temporal relationship between fetal plasma IL-6 and the results of histological examination of the placenta. Fetal plasma IL-6 was determined by a high sensitivity ELISA. Forty-five patients were available for study: 18 patients had preterm labor with intact membranes and 27 had preterm PROM.

RESULTS

The incidence of funisitis was 44.4% (20/45): 27.8% (5/18) in patients with preterm labor and intact membranes and 55.6% (15/27) in patients with preterm PROM. The median values of fetal plasma IL-6 in patients with funisitis, chorioamnionitis without funisitis, and non-inflamed membranes were 51.4, 18.4 and 5.2 pg/ml, respectively. After log transformation of the fetal plasma IL-6 concentration, the means differed significantly from each other (ANOVA, p < 0.02). There was no difference in log fetal plasma IL-6 concentration between patients with funisitis and those with chorioamnionitis without funisitis. The difference in mean concentration of log fetal plasma IL-6 between patients with funisitis or chorionic vasculitis and those without inflammation was highly significant (post-hoc test, p = 0.01 and p < 0.01, respectively). Fetuses with fetal plasma IL-6 > 11 pg/ml had a significantly higher rate of histological signs of inflammation in the extra-placental membranes and umbilical cord than those with fetal plasma IL-6 < 11 pg/ml (funisitis: 55.6% (15/27) vs. 27.8% (5/18), p < 0.05; chorionic vasculitis: 55.6% (15/27) vs. 12.5% (2/16), p < 0.01; chorioamnionitis only: 25.9% (7/27) vs. 16.7% (3/18), p < 0.05; no inflammation: 18.5% (5/27) vs. 55.6% (10/18), p < 0.05, respectively). Fetuses with funisitis had significantly higher rates of clinical and histological chorioamnionitis, and neonatal infectious morbidity (proven + suspected sepsis) than fetuses without funisitis (40% (8/20) vs. 8% (2/25), 90% (18/20) vs. 36% (9/25), and 40% (8/20) vs. 4% (1/25), respectively; p < 0.01 for each). Fetuses with chorionic vasculitis had significantly higher rates of clinical and histological chorioamnionitis as well as neonatal infectious morbidity (proven + suspected sepsis) than fetuses without chorionic vasculitis (100% (17/17) vs. 42.3% (11/26), p < 0.01; 82.4% (14/17) vs. 50.0% (13/26), p = 0.05; and 41.2% (7/17) vs. 7.7% (2/26), p = 0.01).

CONCLUSION

Fetal plasma IL-6 concentration is significantly associated with the presence of inflammatory lesions in the extraplacental membranes and umbilical cord. Fetuses with fetal plasma IL-6 > 11 pg/ml had a significantly higher rate of funisitis and/or chorionic vasculitis than fetuses with fetal plasma IL-6 < 11 pg/ml. These findings suggest that funisitis/chorionic vasculitis is the histological manifestation of the fetal inflammatory response syndrome.

Prenatal diagnosis of a de novo ring chromosome 11

Ring chromosomes are uncommon findings in prenatal diagnosis. Growth retardation is the most significant manifestation, in particular among patients with rings of larger chromosomes. A 30-year-old gravida 1, para 0 white woman was referred for genetic counseling because of maternal anxiety. Cytogenetic analysis of amniotic fluid cells at 16 weeks gestation revealed an abnormal mosaic female chromosome complement; 46,XX,r(11)(p15q25)[14]/45,XX,-11[7]. The ring 11 showed no detectable loss of chromosomal material at 450 band level. Both parents had a normal karyotype. Fluorescence in situ hybridization demonstrated intact subtelomeric regions in the ring chromosome. A targeted ultrasound evaluation at the time of consultation suggested no significant abnormalities. The parents were counseled and subsequently decided to terminate the pregnancy. The autopsy revealed an immature female fetus with abnormal craniofacial features including brachycephaly, low-set ears and hypertelorism, bicornuate uterus, and calcifications in the renal tubules. The abnormal phenotypes could be a consequence of the ring instability, submicroscopic deletion, and/or alteration of genetic material at the site of fusion.

Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma

OBJECTIVE

The objective was to determine whether 2 days of oral dexamethasone (DEX) is more effective than 5 days of oral prednisone/prednisolone (PRED) in improving symptoms and preventing relapse in children with acute asthma.

STUDY DESIGN

This was a prospective randomized trial of children (2 to 18 years old) who presented to the emergency department with acute asthma. PRED 2 mg/kg, maximum 60 mg (odd days) or DEX 0.6 mg/kg, maximum 16 mg (even days) was used. At discharge children in the PRED group were prescribed 4 daily doses (1 mg/kg/d, maximum 60 mg); children in the DEX group received a prepackaged dose (0.6 mg/kg, maximum 16 mg) to take the next day. The primary outcome was relapse within 10 days.

RESULTS

When DEX was compared with PRED, relapse rates (7.4% of 272 vs 6.9% of 261), hospitalization rates from the emergency department (11% vs 12%) or after relapse (20% vs 17%), and symptom persistence at 10 days (22% vs 21%) were similar. In the PRED group more children were excluded for vomiting in the emergency department (3% vs 0.3%; P =.008), more parents were noncompliant (4% vs. 0.4%; P =.004), and more children missed > or =2 days of school (19.5% vs. 13.2%; P =.05).

CONCLUSION

In children with acute asthma, 2 doses of dexamethasone provide similar efficacy with improved compliance and fewer side effects than 5 doses of prednisone.

Minimising computer script errors

With increasing awareness of informatics and the advantages it can bring, more and more general practitioners are computerising their practices. Many of them are using computer packages for script writing. Invariably with the expanding repertoire, come errors in writing computer scripts and the following article sets some of the main areas in which errors occur and how to correct them. As Medical Director is the most commonly used software for writing medical scripts, it has been used as the example in showing how to write correct scripts.

Congenital left ventricular aneurysm: clinical, imaging, pathologic, and surgical findings in seven new cases

BACKGROUND

Congenital left ventricular aneurysm is a poorly understood and potentially lethal entity. Methods and Results In a clinicopathologic study of 7 new cases, the major presenting features in 6 patients were congestive heart failure in 4, ventricular arrhythmias in a 32-week fetus, and multiple congenital anomalies in a fetus with trisomy 13. Accurate diagnosis was achieved in all 3 living patients by echocardiography, angiocardiography, and magnetic resonance imaging. The aneurysm was predominantly apical in 3 and involved most of the left ventricular free wall in 4. Of the 3 living patients, medical management alone sufficed in 2. The third, a newborn boy, underwent a new and successful aneurysm-exclusion left ventriculoplasty. The mitral valve was abnormal in all 4 autopsied cases, the papillary muscles being short, thin, or absent. The aneurysm was thinner and its area was larger than that of the nonaneurysmal left ventricle in all necropsied patients.

CONCLUSIONS

Congenital left ventricular aneurysm appears to be a developmental anomaly, an idiopathic dysplasia of left ventricular endocardium and myocardium. No evidence of a viral etiology was found. Some neonates can be managed medically, but others require urgent surgical intervention. A new surgical operation is presented, a functional left ventricular aneurysmectomy that minimizes intraoperative and postoperative blood loss and that preserves the coronary arteries.

Prenatal diagnosis of smith-magenis syndrome (del 17p11.2)

Smith-Magenis syndrome is associated with a microdeletion of the short arm of chromosome 17 with phenotypic abnormalities including dysmorphic facies, self-injurious behavior, mental and neurologic disturbances, and congenital cardiac defects. The majority of patients present in mid-childhood or adulthood. We describe a fetus in which the diagnosis of Smith-Magenis syndrome was made at 16 weeks of gestation following amniocentesis for increased risk for Down syndrome detected by second-trimester maternal serum screening. Ultrasound evaluation revealed multiple fetal anomalies. The pregnancy was terminated at 20 weeks of gestation. Post-mortem findings included dysmorphic facial features, tetralogy of Fallot, a thymic duct remnant, pancreatic islet cell hyperplasia, and abnormal lung fissuring. This represents the second case of prenatally diagnosed Smith-Magenis syndrome. Molecular genetic techniques in the diagnosis of the Smith-Magenis syndrome and other small deletions are becoming an important tool in the genetic evaluation of ultrasound abnormalities.

Fetal obstructive uropathy in trisomy syndromes

Fetal obstructive uropathy has seldom been described in trisomy syndromes, and its relationship to these syndromes remains unclear. Five trisomic male fetuses, four with trisomy 18 and one with trisomy 21, were identified out of 110 fetuses evaluated for fetal obstructive uropathy. We performed detailed examination on the urinary tracts of four of these fetuses, three with trisomy 18 and one with trisomy 21, following termination in the second trimester. All four had a markedly distended urinary bladder (megacystis), abdominal wall distension, and a small, poorly developed urethra thoughout its full length. All four also had poor development of the prostate with virtual absence of glandular development, as compared to age-matched controls. Posterior urethral valves were not identified in any case. Three of the fetuses (two with trisomy 18 and one with trisomy 21) had unilateral or bilateral hydroureters, and resulting renal tubulocystic or glomerulocystic change. Review of this database reveals an unexpectedly high frequency of trisomies, particularly trisomy 18, suggesting that the relationship may not be coincidental. Abnormal prostate development may be causally related to fetal obstructive uropathies and may be an under-recognized trait in trisomy syndromes. Karyotypic analysis of all fetuses with obstructive uropathy is important since in utero surgical intervention may be contraindicated in cases of fetal aneuploidy.