Teledentistry for screening new patient orthodontic referrals. Part 2: GDP perception of the referral system

OBJECTIVE

To evaluate GDP opinion about a teledentistry system to screen new patient orthodontic referrals.

STUDY DESIGN

Cross-sectional questionnaire.

SAMPLE

Two hundred general dental practitioners (GDPs) were approached from Stockport, Rochdale, Oldham, Bury and Bolton in Greater Manchester, and High Peak in Derbyshire.

METHOD

A questionnaire about a teledentistry system for new orthodontic patients was developed, following interviews with eight GDPs participating in a teledentistry trial. The questionnaire was posted to another 200 GDPs who were asked questions on issues such as the efficiency of a teledentistry system; the usefulness of a teledentistry system from the patients' point of view; their view of a teledentistry system; and any concerns they had relating to security, confidentiality and consent.

RESULTS

Seventy one per cent of GDPs thought teledentistry for orthodontic referrals would be a good idea. At least 90% of responders agreed or neither agreed nor disagreed that patients would benefit from such a system. Over half of GDPs agreed or strongly agreed that there would be implications on their surgery time, expense and equipment security.

CONCLUSIONS

GDPs generally supported a teledentistry system for new patient orthodontic referrals. Although perceived patient advantages were agreed, GDPs tended to be less sure about the impact on them in terms of set-up expenses, time in the surgery and appropriate remuneration.

Teledentistry for screening new patient orthodontic referrals. Part 1: A randomised controlled trial

OBJECTIVE

The primary aim was to evaluate the validity of a teledentistry system for screening new patient orthodontic referrals. The secondary aims were to evaluate whether the teledentistry system affected i) referral rates ii) inappropriate referral rates iii) number of failed appointments.

STUDY DESIGN

Randomised controlled trial.

SAMPLE

Fifteen dental practices in Greater Manchester, UK, were randomly allocated to either a teledentistry test group (n = 8) or a control group (n = 7). They referred 327 patients over a 15 month period.

METHOD

Practitioners in the test group referred patients to one of two consultant orthodontists via a 'store and forward' teledentistry system consisting of photographs sent as email attachments. The decision to accept or not accept a referral on this basis was compared with the same decision choice when the same patient was subsequently seen on a new patient clinic. This measured the validity of the system with the clinic's decision used as the gold standard. Patients in the control group were referred using the usual letter system. Referral rates, inappropriate referrals and number of failed appointments were then compared between the teledentistry and control groups.

RESULTS

The sensitivity (true positive value) of the teledentistry system was high at 0.80 with a positive predictive value of 0.92. The specificity (true negative value) was slightly lower at 0.73 with a negative predictive value of 0.50. The inappropriate referral rate for the teledentistry group was 8.2% and for the controls 26.2% (p = 0.037). There was no statistically significant difference in clinic attendance between teledentistry and control groups (p = 0.36).

CONCLUSIONS

Teledentistry is a valid system for positively identifying appropriate new patient orthodontic referrals. However, there is a risk that a patient is not accepted on the teledentistry system who would benefit from a full clinical examination. Teledentistry could be a significant factor in reducing the inappropriate referral rate. Patient participation in a teledentistry system does not appear to mean they are any more likely to attend their hospital appointment.

Quantifying the passive extensibility of the flexor pollicis longus muscle in people with tetraplegia

STUDY DESIGN

Repeat measures design.

OBJECTIVE

The purpose of this study was firstly, to describe a simple clinical tool that can be used to measure the extensibility of the flexor pollicis longus (FPL) muscle; secondly, to test its reliability; and thirdly, to attain some 'normative' data of the extensibility of the FPL muscle in a representative sample of people with tetraplegia.

SETTING

A spinal cord injury unit in Sydney.

SUBJECTS

A total of 37 people (62 hands) with C4-C7 tetraplegia.

MAIN OUTCOME MEASURES

Angle of the carpometacarpal (CMC) joint of the thumb was measured in all subjects with the application of a series of thumb extensor torques. A device specifically designed for this purpose was used to standardize the torque and objectively quantify the CMC joint angle. In addition, repeat measurements were taken 3-5 days later in one subgroup of 13 subjects (one hand per subject) and 3 months later in another subgroup of 13 subjects (one hand per subject).

ANALYSIS

Intraclass correlation coefficients and percent close agreement scores were derived to quantify the 3-5 days and 3-month reliability between repeat measurements.

RESULTS

The median CMC angle of the thumb with the application of a 0.044 Nm torque was 63 degrees (range, 20-93 degrees). The intraclass correlation coefficients with the application of a 0.044 Nm torque were 0.88 (95% CI, 0.65-0.96) for measurements taken 3-5 days apart, and 0.90 (95% CI, 0.67-0.97) for measurements taken 3 months apart.

CONCLUSION

This study describes a simple and reliable way of measuring the extensibility of the FPL muscle in people with tetraplegia. This assessment tool and the 'normative' data provided in this study can be used to further investigate the contribution of the passive mechanical properties of the FPL muscle to hand function of people with C6 and C7 tetraplegia.

Reliability of a device designed to measure ankle mobility

STUDY DESIGN

Repeated measures design.

OBJECTIVE

To assess the reliability of a device designed to measure ankle mobility in the clinical setting.

SETTING

Spinal Cord Injury Unit, Sydney, Australia.

METHODS

Consecutive sample of 15 patients with paraplegia and tetraplegia with injuries of less than 1 year duration was studied. Ankle mobility was measured on two separate occasions 2 or 3 days apart. Stretch torque was standardised and ankle range of motion measured with an inclinometer attached to the footplate. Intraclass correlation coefficients and percent close agreement scores were used to assess agreement between mean measurements obtained on days 1 and 2.

RESULTS

The intraclass correlation coefficient was 0.95 (95% CI, 0.91-0.98). Measurements obtained on day 1 were within 3 degrees of the measurements obtained on day 2 77% of the time and within 6 degrees 97% of the time.

CONCLUSION

The footplate is a reliable and simple way to measure ankle mobility in people with spinal cord injuries.

Effect of elbow flexion contractures on the ability of people with C5 and C6 tetraplegia to lift

BACKGROUND AND PURPOSE

It is commonly assumed that minor elbow flexion contractures prevent people with C5-C6 tetraplegia and paralysis of the triceps brachii muscles from bearing full body weight through their upper limbs. The aim of the present study was to determine the effect of simulated bilateral elbow flexion contractures on the ability of these individuals to bear weight through their upper limbs and to determine whether full passive elbow extension is truly critical for lifting body weight.

METHOD

A biomechanical study was performed. Body weight lifted was measured under conditions that simulated bilateral elbow flexion contractures. Five people with motor complete C6 tetraplegia and one person with motor complete C5 tetraplegia, all with bilateral paralysis of the triceps brachii muscles, were recruited to the study. Subjects were fitted with bilateral elbow splints that restricted elbow extension but did not restrain elbow flexion nor prevent the elbow from collapsing, and were seated on an instrumented platform that measured vertical forces under the buttocks. Subjects pushed down through their hands and lifted under five different conditions, namely: with no elbow splints; with bilateral elbow splints adjusted to restrict elbow extension by 5-10 degrees; by 15-20 degrees; by 25-30 degrees and with bilateral elbow splints adjusted to allow unrestricted movement of the elbow joint. Maximal weight lifted from under the buttocks, for each condition, was expressed in relation to weight under the buttocks during unsupported sitting (that is, 'seated body weight').

RESULTS

Subjects lifted progressively less weight from under their buttocks as passive elbow restriction was progressively restricted. However, one subject lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and another lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and 15-20 degrees.

CONCLUSIONS

Minor elbow flexion contractures will not alone prevent people with tetraplegia and paralysis of the triceps brachii muscles from lifting. Full passive elbow extension is not critical for the performance of this task.

Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment

The clinical efficacy of cognitive behavior therapy (CBT) for chronic insomnia has been established, yet clinical effectiveness is less clear. This study presents data on 109 patients from general practice during a formal evaluation of clinical effectiveness. Two thirds achieved normative values of < or =30 min for sleep latency and wakefulness during the night after CBT. Furthermore, almost half of the sample reduced sleeplessness by > or =50%. Logistic regression revealed that initial severity did not contraindicate good outcome. Rather, greater sleep disturbance was positively associated with large symptom reduction, although lower endpoint scores were less likely. Similarly, symptoms of anxiety, depression, and thinking errors positively predicted good outcome. Hypnotic using patients responded equally well to CBT, and demographic factors were of no significant predictive value. It is concluded that CBT is clinically and durably effective for persistent insomnia in routine practice.

Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment

The clinical efficacy of cognitive behavior therapy (CBT) for chronic insomnia has been established, yet clinical effectiveness is less clear. This study presents data on 109 patients from general practice during a formal evaluation of clinical effectiveness. Two thirds achieved normative values of < or =30 min for sleep latency and wakefulness during the night after CBT. Furthermore, almost half of the sample reduced sleeplessness by > or =50%. Logistic regression revealed that initial severity did not contraindicate good outcome. Rather, greater sleep disturbance was positively associated with large symptom reduction, although lower endpoint scores were less likely. Similarly, symptoms of anxiety, depression, and thinking errors positively predicted good outcome. Hypnotic using patients responded equally well to CBT, and demographic factors were of no significant predictive value. It is concluded that CBT is clinically and durably effective for persistent insomnia in routine practice.

The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice

Chronic insomnia is a very common clinical condition which may respond well to non-pharmacological treatment. Indeed, the literature supports the efficacy of cognitive behaviour therapy (CBT). However, there has been no substantial study of clinical effectiveness. Since insomniacs typically present in general medical practice this is a crucial gap in the outcome research. This study, therefore, specifically investigated the clinical effectiveness of CBT delivered by Health Visitors (primary care nurses) trained as therapists. One hundred and thirty-nine insomniacs (mean age 51 yr) were randomised to CBT or Self-Monitoring Control (SMC) in a controlled trial. CBT comprised six group sessions (n=4 to 6 patients). After the controlled phase, SMC patients entered deferred treatment (CBT-DEF), allowing both treatment replication and long-term outcome to be investigated for a sizeable, treated sample. Repeated measures ANOVAs demonstrated superiority of CBT over SMC in substantially reducing sleep latency and wakefulness during the night. CBT-DEF replicated similar effects and maintained improvement was observed in both groups one year later. Furthermore, total sleep increased significantly during follow-up and 84% of patients initially using hypnotics remained drug-free. Results suggest that CBT administered by Health Visitors offers a clinically effective treatment for insomnia.

Mechanical comparison of two extensor tendon repairs of ankle tendons

Complete disruption of the extensor tendons is commonly encountered with lacerations to the dorsal aspect of the ankle. The purpose of this study was to compare two tendon repairs (modified Krackow and Kessler-Tajima) to determine which repair was stronger in an anatomical cadaver model. Twenty tendons (10 extensor hallucis longus and 10 tibialis anterior tendons) from 10 fresh-frozen cadaver legs were lacerated and then repaired with either a modified Krackow or Kessler-Tajima repair. Each tendon repair was tested for gap formation and maximum load failure. Results showed that the mean force to produce gap formation in the modified Krackow repair was 64.7 N in the extensor hallucis longus and 82.3 N with the tibialis anterior. Mean gap formation for the Kessler-Tajima in the extensor group was 26.0 N and the tibialis anterior was 41.8 N. This represented a 40% and 50% greater resistance to gap formation for the modified Krackow in these groups. With maximum load failure, the mean for the modified Krackow was 99.5 N for the extensor hallucis longus and 126.8 N for the tibialis anterior, while the Kessler-Tajima was 45.6 N and 72.1 N for these groups. This represented a 45% and 58% greater difference in the maximum load failure for the modified Krackow. Statistical analysis using a Student's t-test (p < .05) showed that there was a significant statistical difference between the two repairs for gap formation and maximum load failure. The authors conclude that the modified Krackow is stronger than the Kessler-Tajima repair.

Family responsibilities and domestic activities of US women physicians

BACKGROUND

Women physicians may have a multiplicity of domestic roles (eg, cook, housekeeper, child care provider) that are of inherent interest and that may affect their professional lives, but are largely unstudied.

DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES

We report data from respondents (N = 4501) to the Women Physicians' Health Study, a cross-sectional, questionnaire-based study of a stratified random sample of US women MDs.

RESULTS

Women physicians with children aged 0 to 17 years spent a median of 24.4 hours per week on child care. Women physicians typically spent half an hour per day cooking, and another half-hour per day on other housework. Little time was spent on gardening: a median of 0.05 hours (3 minutes) per week. Those performing more domestic tasks are likely to work fewer hours outside the home and to be on call less often. Women physicians who are married or widowed, have more children, have lower personal incomes, and have more highly educated and higher-earning spouses perform more domestic activities. We found no significant adverse relationship between time spent on any domestic activity and career satisfaction or mental or physical health.

CONCLUSIONS

Women physicians spend little time on domestic activities that can be done for them by others, including cooking, housework, and especially gardening. Women physicians spend somewhat less time on child care and substantially less time on housework than do other US women. Despite abundant editorializing about role conflicts of women physicians, our measures of career satisfaction and mental health were not adversely affected by time spent on domestic obligations.

Insomniacs' attributions. psychometric properties of the Dysfunctional Beliefs and Attitudes about Sleep Scale and the Sleep Disturbance Questionnaire

OBJECTIVE

Mental overactivity has been widely implicated in the development and maintenance of insomnia, making the accurate and valid measurement of cognitive variables of some importance. The purpose of this study was to investigate the psychometric properties of two existing attributional scales.

METHODS

Data are presented from 178 clinic attending insomniacs who completed the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) and the Sleep Disturbance Questionnaire (SDQ). Standard procedures for the psychometric evaluation of scales were adopted.

RESULTS

The internal consistency of the DBAS (30 items) was reasonable (Cronbach's alpha = 0.72); however, a revised ten-item short form (DBAS-10) demonstrated a more robust principal component structure than the original scale (three relatively "pure" factors explained 55% of the variance). The derived subscales achieved satisfactory internal consistency, and the DBAS-10 demonstrated treatment-related measurement sensitivity. The DBAS-10, nevertheless, correlated highly (r = 0.826) with the DBAS. A four-factor solution for the SDQ is also presented (61% explained variance) with alpha = 0.67. Internal consistency of these subscales ranged from 0.59 to 0.82. The association between the SDQ and DBAS-10 was modest (r = 0.28), suggesting that the scales have some independence.

CONCLUSIONS

The scales offer potential for clinical and research work on insomnia and possible applications are discussed.

Simultaneous strumal ovarii and lymphoma with emphasis on the diagnostic usefulness of immunohistochemical stains

Strumal ovarii has been rarely associated with other tumors, such as carcinoid tumor, carcinoma, and primary ovarian malignant lymphoma. We report the coexistence of a strumal ovarii and ovarian involvement by malignant lymphoma in a 70-year-old woman. The tumors were detected 10 years following exposure to ionizing radiation during the Chernobyl nuclear tragedy.

Effect of dietary copper intakes on biochemical markers of bone metabolism in healthy adult males

OBJECTIVE

To investigate the effects of changing from a medium (1.6 mg Cu/d) to a low (0.7 mg Cu/d) or a high (6.0 mg/d) Cu intake on biochemical indices of bone turnover in healthy adult males.

DESIGN

A longitudinal intervention trial.

SETTING

The study was conducted at the Institute of Food Research, Norwich, UK.

SUBJECTS

Eleven healthy adult males aged 20-59 y were recruited from Norwich Research Park.

INTERVENTION

Subjects were given medium (1.6 mg/d), low (0.7 mg/d) and high (6.0 mg/d) intakes of Cu, in that order, over consecutive 8 week periods with a minimum of 4 week washout periods. On the last d of each dietary period fasting first void urine and blood were collected.

RESULTS

Serum caeruloplasmin or Cu (indices of Cu status), serum osteocalcin (biomarker of bone formation), urinary creatinine (Cr) were unaffected by dietary Cu intake. Urinary Pyr/Cr and Dpyr/Cr (biomarkers of bone resorption) were significantly increased (P < 0.05) (by 30% and 25%, respectively), when subjects were switched from the medium to the low Cu diet and were significantly decreased (P < 0.05) (by 30%) and 22% respectively), when subjects were switched from the low to the high Cu diet.

CONCLUSION

The findings of the present study could have implications for bone health in individuals with marginal Cu intakes. Thus, further studies are warranted to better define the relationship of marginal Cu intakes to bone health.

Concentrations and anti-Haemophilus influenzae activities of beta-casein phosphoforms in human milk

BACKGROUND

The distribution and concentrations of six phosphorylated forms of human beta-casein, a major source of nutrition among breast-fed infants, have not been examined in milk samples without prior fractionation. In this study, the levels of beta-casein phosphoforms in untreated human milk samples were analyzed and their antiadhesion activities determined against Haemophilus influenzae, a pathogen implicated in middle ear infection in infants.

METHODS

Human milk samples were analyzed using urea-polyacrylamide gel electrophoresis of whole-milk samples and scanning densitometry to determine the concentrations of beta-casein and its phosphoforms. A nontypable H. influenzae strain was radiolabeled to monitor its attachment to human pharyngeal cells in microtiter plates. Purified phosphoforms of beta-casein were preincubated for 15 minutes with radiolabeled bacteria to determine their antiadhesion activities.

RESULTS

The average beta-casein concentration in 151 human milk samples was 5.37+/-2.26 mg/ml. On average, the phosphoforms in untreated milk are present in the following order ranked by concentration: tetra- > di- > non- > mono- > tri- > pentaphosphorylated beta-casein. The tri-, tetra-, and pentaphosphorylated forms of human beta-casein exhibited more than 60% inhibition of H. influenzae in the antiadhesion assay when used at a concentration of 0.6 to 0.9 mg/ml.

CONCLUSION

The beta-casein level in untreated human milk is significantly higher than previously reported. The phosphoform distribution of beta-casein in individual donors varies widely. Anti-H. influenzae activity was detected in vitro among human beta-casein molecules with three or more phosphate groups.

Phase I trial of anti-CD3-stimulated CD4+ T cells, infusional interleukin-2, and cyclophosphamide in patients with advanced cancer

PURPOSE

We performed a phase I trial to determine whether in vivo expansion of activated CD4+ T cells was possible in cancer patients. 111Indium labeling was used to observe trafficking patterns of the infused stimulated CD4+ T cells. The influence of cyclophosphamide (CTX) dosing on immunologic outcome was also examined.

PATIENTS AND METHODS

Patients with advanced solid tumors or non-Hodgkin's lymphoma received CTX at 300 or 1,000 mg/m2 intravenously (i.v.). Leukapheresis was performed to harvest peripheral-blood mononuclear cells (PBMCs) either just before the CTX dose, or when the patient was either entering or recovering from the leukocyte nadir induced by CTX. An enriched population of CD4+ T cells was obtained by negative selection. The CD4+ T cells were activated ex vivo with anti-CD3, cultured with interleukin-2 (IL-2) for 4 days, and adoptively transferred. After adoptive transfer, patients received IL-2 (9.0 x 10(6) IU/m2/d) by continuous infusion for 7 days.

RESULTS

The absolute number of CD4+, CD4+/DR+, and CD4+/CD45RO+ T cells increased in a statistically significant fashion in all cohorts after the first course of therapy. The degree of CD4 expansion was much greater than CD8 expansion, which resulted in a CD4:CD8 ratio that increased in 26 of 31 patients. The greatest in vivo CD4 expansion occurred when cells were harvested as patients entered the CTX-induced nadir. One complete response (CR), two partial responses (PRs), and eight minor responses were observed. Trafficking of 111Indium-labeled CD4 cells to subcutaneous melanoma deposits was also documented.

CONCLUSION

CD4+ T cells can be expanded in vivo in cancer patients, which results in increased CD4:CD8 ratios. The timing of pheresis in relation to CTX administration influences the degree of CD4 expansion. Tumor responses with this regimen were observed in a variety of tumors, including melanoma and non-Hodgkin's lymphoma; a high percentage of patients had at least some tumor regression from the regimen that produced the greatest CD4+ T-cell expansion.

CleftNet (Scotland): a network for the treatment of cleft palate speech using EPG

Electropalatography (EPG) has proven its effectiveness in changing abnormal articulatory placement in cleft palate speech but clinicians often do not have ready access to such equipment. In order to improve access to EPG therapy, a network has been established which electronically links cleft palate centres throughout Scotland with EPG specialists based at Queen Margaret College (QMC), Edinburgh. The network was set up through a collaborative project entitled 'CleftNet Scotland', funded by the Scottish Office Department of Health. In this paper, the rationale and overarching aims of CleftNet Scotland are described and the efficacy of this form of EPG therapy illustrated by descriptions of two cases.

Sequential development of structural and functional alterations in T cells from tumor-bearing mice

The TCR alpha beta or -gamma delta chains bind the peptide ligand, whereas the associated CD3 delta epsilon gamma and TCR zeta subunits couple the TCR to intracellular signal transduction components. Recently, several groups have described marked alterations in signal transduction elements in T cells from cancer patients or in mice bearing tumor for a few weeks (>26 days). The sequence in which these alterations develop is unknown. The aim of this study was to explore the kinetics of the development of alterations in signal transduction molecules (TCR zeta chain, NF kappaB family proteins, and tyrosine kinase p56(lck)) in mice bearing MC38 colon adenocarcinoma. The results demonstrate that alterations in NF kappaB family proteins, specifically the failure of p65 translocation to the nucleus, occur earlier and more frequently than the decrease in zeta-chain. These defects are paralleled by an impaired ability to produce Th1 cytokines (IL-2 and IFN-gamma). These initial changes are followed by the eventual loss of TCR zeta chain and p56(lck) and a marked decrease in cytotoxic function. An increased rate of lysosomal degradation is one of the mechanisms responsible for the loss of zeta-chain.

Sequential development of structural and functional alterations in T cells from tumor-bearing mice

The TCR alpha beta or -gamma delta chains bind the peptide ligand, whereas the associated CD3 delta epsilon gamma and TCR zeta subunits couple the TCR to intracellular signal transduction components. Recently, several groups have described marked alterations in signal transduction elements in T cells from cancer patients or in mice bearing tumor for a few weeks (&gt;26 days). The sequence in which these alterations develop is unknown. The aim of this study was to explore the kinetics of the development of alterations in signal transduction molecules (TCR zeta chain, NF kappaB family proteins, and tyrosine kinase p56(lck)) in mice bearing MC38 colon adenocarcinoma. The results demonstrate that alterations in NF kappaB family proteins, specifically the failure of p65 translocation to the nucleus, occur earlier and more frequently than the decrease in zeta-chain. These defects are paralleled by an impaired ability to produce Th1 cytokines (IL-2 and IFN-gamma). These initial changes are followed by the eventual loss of TCR zeta chain and p56(lck) and a marked decrease in cytotoxic function. An increased rate of lysosomal degradation is one of the mechanisms responsible for the loss of zeta-chain.

Comparative metabolism of Mesoplasma, Entomoplasma, Mycoplasma, and Acholeplasma

Cytoplasmic fractions from species of the Mollicutes genera Entomoplasma, Mesoplasma, Mycoplasma, and Acholeplasma were assayed for NADH oxidase (NADH ox), ATP- and PPi-dependent phosphofructokinase (PFK), ATP- and PPi-dependent deoxyguanosine kinase (dGUOK), thymidine kinase (TK), TMP kinase (TMPK), glucose-6-phosphate dehydrogenase (G6Pde), lactate dehydrogenase (LDH), malate dehydrogenase (MDH), phosphoenolpyruvate carboxylase, hypoxanthine-guanine phosphoribosyl transferase, dUTPase, and uracil-DNA glycosylase (UNG) activities. Membrane fractions were also examined for NADH ox activity. These activities were used as indicators of the presence and relative activities of major Mollicutes metabolic and DNA repair pathways. This was the first study to determine the presence of these enzymes in members of the genera Entomoplasma and Mesoplasma. Using the data obtained, we constructed a preliminary scheme for distinguishing genera of the class Mollicutes on the basis of the results of signature functional enzyme assays. This scheme includes phylogenetic relationships deduced from rRNA analyses, but is more informative with respect to metabolic potential. The criteria used include the presence of PPi-dependent PFK, urease, dUTPase, and dGUOK activities. Entomoplasma ellychniae ELCN-1T (T = type strain), Entomoplasma melaleucae M-1T, Mesoplasma seiffertii F7T, Mesoplasma entomophilum TACT, Mesoplasma florum L1T, Mycoplasma fermentans PG18T, and Acholeplasma multilocale PN525T were similar in most respects. NADH ox activity was localized in the cytoplasm of these organisms. These strains had ATP-dependent PFK, MDH, LDH, ATP- and PPi-dependent dGUOK, and UNG activities, but not dUTPase or G6Pde activities. In contrast, Acholeplasma equifetale C112T, Acholeplasma oculi 19LT, Acholeplasma hippikon C1T, Acholeplasma modicum PG49T, and Acholeplasma morum 72-043T had membrane-localized NADH ox activity, PPi-dependent PFK, G6Pde, and dUTPase activities, and significantly lower MDH and LDH activities and exhibited a faster rate with PPi than with ATP in the dGUOK reaction. All of the members of the Mollicutes tested had hypoxanthine-guanine phosphoribosyl transferase, phosphoenolpyruvate carboxylase, and (except for Mesoplasma entomophilum TAC(T)) UNG activities. All of the Acholeplasma strains except Acholeplasma multilocale PN525T had TK, TMPK, and UNG activities. Mesoplasma entomophilum TAC(T) was distinguished by having no detectable dUTPase, UNG, TK, and TMPK activities, indicating that there is a severe restriction in or an absence of a synthetic route to dTTP. Our data also suggest that A. multilocale PN525T is a member of an unrecognized metabolic subgroup of the genus Acholeplasma or is not an Acholeplasma strain.

Principles of conservative management for a non-orthotic tenodesis grip in tetraplegics

The effectiveness of a tenodesis grip is determined by the passive properties of the hand. An effective tenodesis grip can be achieved by encouraging a decrease in the resting length (i.e., adaptive shortening) of the flexor digitorum profundus and the flexor digitorum superficialis so that the fingers flex when the wrist is extended. Also, adaptive shortening of the flexor pollicis longus needs to be encouraged so that the thumb approximates the flexed fingers when the wrist is extended. The length of the adductor pollicis will in part dictate where along the radial side of the index finger the thumb will contact. Development of an effective tenodesis grip also requires that excessive metacarpophalangeal and interphalangeal joint stiffness of the fingers be prevented and that the interphalangeal joint of the thumb become stiff in extension. Careful management of the tetraplegic hand can ensure the development of the musculoskeletal changes necessary for an effective tenodesis grip.

Test-retest reliability of a procedure for measuring extensibility of the extrinsic finger flexor muscles

This study assessed the test-retest reliability of a procedure designed to provide torque-controlled measurements of the extensibility of extrinsic finger flexor muscles. The extensibility of the extrinsic finger flexor muscles of both hands of nine patients who had spinal cord injuries was measured on two consecutive days. On each day a total of three measurements were obtained for each hand. Intraclass correlation coefficients (ICCs) and percent close agreement scores were used to assess agreement between the mean measurements obtained on day 1 and those obtained on day 2. An ICC of 0.85 was obtained. Measurements obtained on day 1 were within 5 degrees of the measurements obtained on day 2 83% of the time. The procedure is therefore sufficiently reliable for many clinical and research applications.

Successful control of intractable nausea and vomiting requiring combined ondansetron and haloperidol in a patient with advanced cancer

Chemically induced nausea and vomiting is a common symptom of advanced cancer effected through stimulation of dopamine (D2) or serotonin (5-HT3) receptors located in the chemoreceptor trigger zone (CTZ). These may be blocked by therapeutic doses of haloperidol and ondansetron, respectively. This case, reporting on a single patient acting as her own control, establishes that combined blockade of these receptors is sometimes required to relieve intractable nausea and vomiting. It also demonstrates the value of clinical review, audit of care, and quality assurance in the palliative care setting.

Atypical presentation of Crohn's disease: severe, recurrent iron deficiency anemia dependent on blood transfusions

We report an unusual case of Crohn's disease. Our subject, a 43-yr-old lady, presented with severe iron deficiency anemia, hypoproteinemia and lymphocytopenia, but without any clinical manifestations of Crohn's disease either at presentation or during follow-up. She had recurrent episodes of severe iron deficiency anemia, repeatedly requiring blood transfusions (28 units in 20 months). She was found to have a short stricture with ulceration in the ileum due to Crohn's disease, and a blind loop with bacterial overgrowth above it. Resection of the affected area prevented further recurrence of anemia and corrected hypoproteinemia. We postulate that her anemia and hypoproteinemia were due to blood and protein (lymph) loss from the ulcerated area in the ileum. Such a presentation has not been described before.

The prevention of infection in open fractures: an experimental study of the effect of fracture stability

An experimental model of a contaminated open fracture has been developed. This model has been used to test the hypothesis that stable fixation of a contaminated open fracture will reduce its susceptibility to infection. The tibiae of male New Zealand white rabbits were fractured and then fixed with either a dynamic compression plate (stable group) or a loose-fitting intramedullary rod (unstable group). The fracture site was then inoculated with a standard inoculum of Staphylococcus aureus. There were 20 rabbits in the stable group and osteomyelitis developed in seven (35 per cent); in the unstable group 15 (71 per cent) out of 21 animals developed osteomyelitis. This difference in infection rates was statistically significant (P < 0.02). This experimental study supports the concept of stabilization of open fractures in man.

Fate of frozen intercalary allograft at one year after implantation with adjuvant chemotherapy treatment. A case report

The proximal humerus of a 21-year-old man was reconstructed with a frozen allograft combined with a Neer shoulder prosthesis. At graft retrieval one year later, the proximal end of the allograft had revascularized with some osteogenic activity, but distally neither vascular ingrowth nor osteogenic activity was seen. Allografts should not be used unsupported because of their potential weakness with time. Intramedullary stems should be used to support functional allografts which primarily facilitate soft-tissue reattachment.

Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up

From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.

Haemangiopericytoma of the larynx

Haemangiopericytoma is an uncommon vascular tumour which has rarely been recorded in the larynx. The diagnostic and histopathological difficulties are discussed. A total laryngectomy was performed because of the size and site of the tumour, the associated risk of local recurrence and the high metastatic rate.

The prevention of infection in open fractures. An experimental study of the effect of antibiotic therapy

Using an experimental rabbit model of a contaminated open fracture of the tibia that was fixed with an intramedullary pin, we assessed the effect of a single dose of cephradine in preventing post-traumatic osteomyelitis in which the infecting organism was Staphylococcus aureus. We paid particular attention to the effect of a delay in giving the antibiotic. The frequency of osteomyelitis in the animals in a control group (no antibiotic) was 91 per cent. When a single injection of cephradine was given one hour before inoculation with the bacteria, the rate was 30 per cent, a statistically significant reduction (p less than 0.01). When cephradine was not administered until one to four hours after inoculation with the bacteria, the average rate of osteomyelitis was 51 per cent, a 40 per cent reduction compared with the rate for the control group. The effect of the antibiotic therefore persisted even when the initial dose was delayed for four hours after bacterial inoculation.

Topically applied vidarabine sodium phosphate in genital herpes infection

One hundred and thirty-four patients with recurrences of genital herpes were randomized in a double-blind trial to receive self-applied topical therapy with either vidarabine sodium phosphate in an aqueous gel or placebo gel. No significant differences were noted between the two groups in the duration of viral shedding, in the time to healing of the treated recurrence, in the interval between recurrences, or in the number of recurrences.

An experimental model of post-traumatic osteomyelitis in rabbits

An experimental model of a contaminated open fracture, using the tibia of male New Zealand white rabbits, is described. Post-traumatic osteomyelitis can be reliably induced in this model, with no systemic ill-effects. The characteristic bacteriological, radiological and histological findings are described. Inoculation of the fracture site with Staphylococcus aureus in a concentration of 10(6) bacteria caused osteomyelitis in two out of five rabbits. When the concentration of inoculum was increased to 10(7) organisms, osteomyelitis was seen in four out of five rabbits. No cases of infection were seen in the control animals. This is a simple and reliable model for studies into the prevention and treatment of post-traumatic osteomyelitis.

Screening for osteomalacia in elderly patients with femoral neck fractures

In this study 201 elderly patients with femoral neck fractures were compared with 30 osteomalacic patients with the same injury. Hypocalcaemia and a raised alkaline phosphatase level are common biochemical abnormalities in elderly patients with femoral neck fractures. In only a minority of patients, however, were they associated with histologically proven osteomalacia. By using the combination of hypocalcaemia and a raised alkaline phosphatase it is possible to identify a subgroup (approximately 10% of all admissions) in whom osteomalacia is relatively likely.

Chondrogenic neoplasms of the nasal cavity

Chondrogenic neoplasms of the nasal cavity are rare. Clinically, presentation is often late, with expansion and destruction of the middle facial skeleton. Local radical surgical excision is the preferred treatment, with regular life-long follow-up. Risk of local recurrence and distant metastases may occur many years after initial treatment. All chondrogenic tumours should be carefully followed up because the natural course of the disease may not match the histological differentiation.

Osteomalacia and femoral neck fractures in the elderly patient

In a series of over 1000 elderly patients with femoral neck fracture, who were routinely screened by iliac crest bone biopsy, a 2% prevalence of osteomalacia was found. This low figure suggests that osteomalacia is not a significant predisposing factor in the development of these fractures and that routine screening is not cost-effective.

Evaluation of the bronchial stump following pulmonary resection

Bronchoscopic and conventional bronchographic examinations are reliable methods to evaluate the integrity of a sutured bronchial stump. However, sometimes the critical condition of the patient makes these diagnostic procedures impractical. We present here a simpler method to achieve this purpose. This requires minimal invasiveness, no disturbance to the therapeutic support, and no transportation of the patient.

Chondroid osteosarcoma of the maxilla

A case of chondroid osteosarcoma of the maxilla is reported. This is itself a rare lesion but in this instance diagnosis was made more difficult for 2 reasons. On presentation, there was little radiological evidence of bone destruction and also, during follow-up and before biopsy-proven diagnosis, the lesion showed considerable evidence of repair on 2 occasions.