Syme amputation for the treatment of fibular deficiency. An evaluation of long-term physical and psychological functional status

BACKGROUND

Syme amputation is an accepted treatment for fibular deficiency. With improvement in limb-lengthening procedures, there has been renewed interest in limb salvage for these patients. The purpose of the present study was to evaluate the physical and psychological results in ten young adults who had had a Syme amputation for the treatment of fibular deficiency when they were children.

METHODS

The evaluation consisted of physical examination, prosthetic assessment, psychological testing, and physical performance testing of knee extension and flexion with use of a Cybex-II dynamometer.

RESULTS

Five patients reported no difficulty with the involved limb since the Syme amputation, four had had minor secondary procedures (three medial distal femoral or proximal tibial hemiepiphyseodeses, one reconstruction with an autologous patellar ligament graft, one revision of the stump, and one tibial osteotomy) on the affected extremity, and one had mild instability of the knee that had been treated nonoperatively. All ten patients had an appropriate, functional Syme prosthesis, and none reported difficulty with walking or running. On psychological testing, this group generally did not differ from the norm with regard to occupational satisfaction, personal growth, relationships with family members and peers, and recreational behavior. The patients' overall assessment of self-reported quality of life and self-esteem was similar to that of normative adult samples. In general, these patients were leading active, productive lives and had always done so.

CONCLUSIONS

On the basis of the results of this study, we concluded that young adults who have had a Syme amputation apparently are not limited in their ability to pursue and achieve personal goals. In order to justify recommending limb salvage rather than early Syme amputation for the treatment of fibular deficiency, the results of multistaged lengthening and reconstruction would have to match the functional, psychological, and cost-effective results for the patients whom we studied, who had had a Syme amputation.

Impact of obstetric factors on cord blood donation for transplantation

Recent reports have shown that low nucleated cell dose significantly decreases survival after cord blood transplantation. Prior to starting clinical cord blood banking we investigated the impact of obstetric factors on cell dose and volume of cord blood donations. Cord blood was obtained from 114 normal full-term deliveries. Mean volume collected was 93.5 ml, mean total nucleated cell count (TNC) was 13.1 x 108. Statistical analysis was by backwards stepwise regression. Significant factors affecting nucleated cell yield were volume of blood collected (P < 0.001), length of gestation (P < 0. 0001), time from delivery of the infant to cord clamping (P = 0.018) and total length of labour (P = 0.002). In clinical cord blood banking we have successfully used these findings for pre-collection assessment of placentae. Out of 476 cord blood donations subsequently collected for banking, only 29 (6.1%) have been discarded due to low volume. The mean TNC of the 409 banked units following volume reduction was 10.1 x 108. Despite careful optimization of collection, processing and storage techniques, cell dose still limits cord blood transplantation to smaller recipients.

Incidence of inflammatory myopathies in Victoria, Australia, and evidence of spatial clustering

OBJECTIVE

To determine the incidence of idiopathic inflammatory myopathies (IIM) in Victoria, Australia, and look for evidence of space-time or spatial clustering.

METHODS

Cases of IIM diagnosed between 1989 and 1991 were identified by muscle biopsy and hospital discharge diagnosis review. Diagnosis was verified by medical record review and included if Bohan and Peter criteria for definite or probable disease were met. The pair-wise Euclidean distances between cases' residences were computed using grid references, and temporal distances were calculated between biopsy dates. The Mantel test for space-time clustering was computed. Each patient was also characterized by statistical local area (SLA) according to place of residence. For each SLA, the expected annual incidence of IIM was calculated, based upon its population distribution, and these were compared to the observed annual incidence. Confidence intervals for the true rate ratio (RR) for each SLA were calculated assuming a Poisson distribution, and the level of heterogeneity in the data was examined by calculation of a chi-squared for homogeneity.

RESULTS

Ninety-four cases met inclusion criteria for an annual incidence of 7.4 (95% CI 6.0-9.0) per million person-years. No space-time clustering was found (z = -0.434, p = 0.665), but there was evidence of spatial clustering. A total of 67 observed cases were distributed among 58 urban SLA. Four SLA had a greater than expected incidence of myositis (95% Poisson based CI excluded 1), accounting for 20 of the observed cases.

CONCLUSION

The incidence of IIM in Australia is higher than most previous population based estimates. The finding of spatial clustering supports the hypothesis that environmental factors may be important in the pathogenesis of these diseases.

Polymorphism of the vitamin D receptor gene and corticosteroid-related osteoporosis

Corticosteroid therapy (CST) is associated with reduced intestinal calcium absorption, bone loss and increased fracture risk. As polymorphisms of the vitamin D receptor (VDR) gene may be associated with bone mineral density (BMD) and intestinal calcium absorption, we asked whether patients with a given VDR genotype receiving CST may be at increased or decreased risk for corticosteroid-related bone loss and osteoporosis. We measured areal BMD (g/cm2) by dual-energy X-ray absorptiometry in 193 women (50 premenopausal, 143 postmenopausal) and 70 men with rheumatoid arthritis (n = 44), obstructive airway diseases (n = 128) and other corticosteroid-treated diseases (n = 91). All patients received a cumulative dose greater than 1.8 g per year or a minimum of 5 mg daily of prednisolone or equivalent for at least 1 year. VDR alleles were typed by polymerase chain reaction assay based on the polymorphic BsmI and TaqI restriction sites. BMD in patients was expressed as a Z-score (mean +/- SEM) derived from age- and gender-matched controls. BMD was reduced in patients at the lumbar spine (bb, -0.52 +/- 0.12; Bb, -0.47 +/- 0.11; BB, -0.65 +/- 0.18 SD; p < 0.01), femoral neck (bb, -0.46 +/- 0.10; Bb, -0.34 +/- 0.10; BB, -0.54 +/- 0.14 SD; p < 0.01), Ward's triangle (bb, -0.44 +/- 0.10; Bb, -0.31 +/- 0.10; BB, -0.45 +/- 0.13 SD; p < 0.01), and trochanter (bb, -0.50 +/- 0.10; Bb, -0.30 +/- 0.10; BB, -0.44 +/- 0.14 SD; p < 0.01). However, there was no significant difference in the deficit in BMD in any of the genotypes, either before or after adjusting for age, sex, body mass index, disease type, age at onset of disease, disease duration, cumulative steroid dosage, smoking status and dietary calcium intake. Similarly, there were no detectable differences between the BsmI genotypes and the rate of bone loss in 79 patients with repeated BMD measurements at an interval of 4-48 months. The data suggest that the VDR genotypes may not be a means of identifying patients at greater risk of corticosteroid-related bone loss.

Principles of risk assessment for illness caused by foodborne biological agents. National Advisory Committee on Microbiological Criteria for Foods

The Risk Assessment Subcommittee of the National Advisory Committee on Microbiological Criteria in Foods has prepared a generic document on the principles of risk assessment as applied to biological agents that can cause human foodborne disease. Typical biological agents include bacteria, viruses, fungi, helminths, protozoa, algae, parasites, and the toxic products that these agents may produce. Basic principles elaborated to characterize food pathogen risks include the four broadly accepted components of risk assessment. The role of surveillance and investigational activities to link biological agents and their food sources to consumer illness is described as is the role of predictive modeling for food pathogens.

Evaluation of mechanism of increased intracranial pressure with insufflation

BACKGROUND

Previous studies have documented an increase in intracranial pressure with abdominal insufflation, but the mechanism has not been explained.

METHODS

Nine 30-35-kg domestic pigs underwent carbon dioxide insufflation at 1.5 l/min. Intracranial pressure (ICP), lumbar spinal pressure (LP), central venous pressure (CVP), inferior vena cava pressure (IVCP), heart rate, systemic arterial blood pressure, pulmonary arterial pressure, cardiac output, heart rate, respiratory rate, temperature, and end-tidal CO2 were continuously measured. Mechanical ventilation was used to maintain a constant pCO2. Measurements were recorded at 0, 5, 10, and 15 mmHg of abdominal pressure with animals in supine, Trendelenburg (T), and reverse Trendelenburg (RT) positions. Prior to recording measurements, the animals were allowed to stabilize for 40 min after each increase in abdominal pressure and for 20 min after each position change.

RESULTS

The animals showed a significant increase in ICP (mmHg) with each 5-mmHg increase in abdominal pressure (0 mmHg: 14 +/- 1.7; 5 mmHg: 19.8 +/- 2.3, p < 0.001; 10 mmHg: 24.8 +/- 2.5, p < 0.001; 15 mmHg: 29.8 +/- 4.7, p < 0.01). The ICP at 15 mmHg abdominal pressure increased further in the T position (39 +/- 4, p < 0.01). Insufflating in the RT position did not significantly reduce the increase in ICP. The IVCP (mmHg) increased with increased abdominal pressure (0 mmHg: 11.5 +/- 6.2, 15 mmHg: 22.1 +/- 3.5, p < 0.01). This increase correlated with the increase in ICP and LP (r of mean pressures >/=0.95). There was no significant change in CVP.

CONCLUSIONS

This study suggests that care may be needed with laparoscopy in patients at risk for increased ICP due to head injury or a space occupying lesion. The mechanism of increased ICP associated with insufflation is most likely impaired venous drainage of the lumbar venous plexus at increased intraabdominal pressure. Further studies of cerebral spinal fluid movement during insufflation are currently underway to confirm this hypothesis.

Prognosis in malignant mesothelioma related to MIB 1 proliferation index and histological subtype

The aims of this study were to evaluate the use of the proliferation marker MIB 1 and histological subtype as indicators of prognosis in malignant mesothelioma. Sections from 41 cases of malignant mesothelioma were histologically subtyped on hematoxylin and eosin sections and stained immunohistochemically for the proliferation marker MIB 1. A proliferation index was derived and the results compared with patient survival data. A statistically significant difference was found between the survival of patients having a low and high MIB 1 index (P < .001). Patients with tumors having a low MIB 1 index lived significantly longer than those with a high MIB 1 index. Patients with the spindle cell histological subtype of malignant mesothelioma had significantly shorter survival times than those with the epithelioid or mixed tumors (P < .01). The MIB 1 proliferation index and histological tumor subtype are useful markers of prognosis in malignant mesothelioma.

Lack of association between polymorphisms in the 5-HT2A receptor gene and the antipsychotic response to clozapine

OBJECTIVE

The authors' goal was to determine whether either of two 5-HT2A receptor polymorphisms, 102-T/C and 452-His/Tyr, are associated with clozapine response.

METHOD

Brief Psychiatric Rating Scale (BPRS) ratings were obtained in 70 patients with schizophrenia or schizoaffective disorder to determine their response to clozapine compared with a typical neuroleptic. Patients were genotyped with the polymerase chain reaction and restriction fragment length polymorphism analysis.

RESULTS

Neither 102-T/C nor 452-His/Tyr was associated with clozapine response. There were no significant differences in BPRS scores among patients with different 5-HT2A genotypes at week 10 of clozapine administration.

CONCLUSIONS

Allelic variation in the 5-HT2A gene is not associated with individual differences in clozapine response.

Effects of alprazolam on pituitary-adrenal and catecholaminergic responses to metabolic stress in humans

Concurrent effects of benzodiazepines on stress-induced activation of the three classical "stress" systems: pituitary-adrenal, adrenomedullary, and sympathoneural systems have not been extensively investigated in humans. In the present study, the effects of alprazolam (1.5 mg) on plasma levels of adrenocorticotropin hormone (ACTH), epinephrine, norepinephrine, dihydroxyphenylglycol (DHPG, the intraneuronal metabolite of norepinephrine), and mood states were examined in 10 healthy volunteers undergoing glucoprivic stress. Glucoprivic stress was induced by intravenous administration of the glucose analog, 2-deoxyglucose (2DG), at a dose (50 mg/kg) that impairs cellular glucose metabolism and produces a state comparable to hypoglycemia. Alprazolam and 2DG were administered in a double-blind, placebo-controlled manner. 2DG produced robust elevations in plasma ACTH and epinephrine levels, modest elevations in plasma norepinephrine levels, and decreases in plasma DHPG levels. Alprazolam significantly attenuated the 2DG-induced increases in plasma ACTH and epinephrine, but did not significantly effect plasma norepinephrine and DHPG. These data suggest that benzodiazepines attenuate metabolic stress-induced activation of the pituitary-adrenal and adrenomedullary systems but do not effect 2DG-related effects on peripheral sympathoneural function. The possible mechanisms involved are discussed.

Loco-Regional Recurrence and Survival after Wide Local Excision, Radiotherapy and Axillary Clearance for Early Breast Cancer

After breast conservation for early breast cancer which comprised wide local excision, axillary clearance and radiotherapy to the breast, 145 women have been followed prospectively for a median of 42 months. Local recurrence occurred in 11 (7%) and axillary recurrence in three (2%). Distant recurrence has occurred in 32 and accounted for 80% of all first recurrences.

Local treatment failure has occurred in three women and would not have been prevented by mastectomy. Loco-regional recurrence in the absence of preceding or synchronous distant disease was unusual and did not pose a significant clinical problem.

Limbic system abnormalities identified in schizophrenia using positron emission tomography with fluorodeoxyglucose and neocortical alterations with deficit syndrome

A hypothesis of psychosis localization in schizophrenia was derived from studying metabolic alterations in rat brain in response to phencyclidine hydrochloride administration. Since phencyclidine and its selective agonist dizocilpine maleate (MK801) induced overlapping and long-lasting metabolic alterations predominantly in limbic areas, the hypothesis developed that schizophrenic patients with psychosis would evidence functional abnormalities in limbic circuits compared with normal controls. Accordingly, 12 actively psychotic, drug-free patients with schizophrenia and matched normal controls underwent functional brain scans using positron emission tomography and fluorodeoxyglucose. Regions of interest were identified on five matched axial slices in each patient and control subject, and average metabolic rates were calculated. Patients with schizophrenia showed a significantly lower regional cerebral metabolic rate of glucose in the hippocampus and the anterior cingulate cortex than did normal controls, but not in neocortical areas or in the extrapyramidal system. When the group of schizophrenic patients was divided into deficit and nondeficit types, a preliminary exploratory analysis suggested thalamic, frontal, and parietal cortical hypometabolism in the deficit subgroup, with normal metabolism in the nondeficit patient group in those areas; in contrast, hippocampal and anterior cingulate cortical metabolism was reduced in both deficit and nondeficit subtypes. These results suggest that the limbic system, especially the hippocampus, is functionally involved in schizophrenic psychosis and that different manifestations of schizophrenia may involve different neuronal circuits.

In vitro vs in vivo corrosion analyses of two alloys

The in vitro and in vivo corrosion characteristics of two alloys, cast Co-Cr-Mo (ASTM F75) and wrought Ni-Cr-Mo, were evaluated using electro-chemical corrosion analysis. Two in vitro electrolytic solutions were utilized, an isotonic saline solution consisting of 0.9 w/o NaCl in distilled water and an isotonic saline solution with 10 v/o sterile calf serum. The in vivo environment was created by implanting cylindrically shaped specimens of each alloy into the back muscles of New Zealand white rabbits. Cyclic anodic and cathodic polarization curves were generated for the three test conditions and subsequently were compared. Anodic curves conducted using the isotonic saline and isotonic saline plus serum electrolyte solutions were very similar to the anodic curves generated for the implanted alloy specimens for both alloys. The corrosion rates predicted from the in vitro and in vivo cathodic polarization curves were not statistically different for the three test conditions. Overall, the corrosion data generated using the in vitro environmental conditions adequately predicted the in vivo corrosion behavior of the cast Co-Cr-Mo and wrought Ni-Cr-Mo alloys.

Sarcomatoid variant of anaplastic large-cell Ki-1 lymphoma

Although anaplastic large-cell Ki-1 lymphomas can mimic a variety of tumors, a correct diagnosis is usually not difficult to reach if it is recognized that lymphoma cells can assume bizarre and pleomorphic appearances and that the pattern of growth can be purely sinusoidal. We report a unique case of a 45-year-old man presenting with a leg lesion that showed sarcomatoid growth patterns. The subcutaneous/dermal tumor displayed a myxoid stroma reminiscent of myxoid malignant fibrous histiocytoma. In a subsequent lymph node biopsy, a well-developed storiform pattern was formed by interweaving fascicles of plump spindle and oval neoplastic cells, reminiscent of pleomorphic/storiform type of malignant fibrous histiocytoma. The lymphoid nature of the tumor cells was documented by immunoreactivity for leukocyte common antigen, Ki-1 antigen, and the T-cell marker UCHL1. We conclude that the presence of a storiform or myxoid pattern does not disqualify the diagnosis of lymphoma; this possibility should always be pursued in pleomorphic tumors because the treatment is substantially different from that for sarcoma, carcinoma, or melanoma.