Neurologic complications of surgery for anterior shoulder instability

Two-hundred eighty-two patients underwent anterior reconstruction for recurrent glenohumeral instability between 1981 and 1991. Twenty-three patients (8.2%) had a neurologic deficit after surgery. Seven had sensory disturbances only; 16 had sensorimotor neuropathies (8 having multiple deficits designated as a diffuse plexopathy and 8 having a more defined deficit in 1 or 2 cords or peripheral nerves). Complete resolution occurred in 18 of the 23 patients. Four patients had a residual deficit (1 patient was lost to follow-up). Three had persistent sensory disturbances; 1 had permanent biceps weakness. None of these patients underwent surgical exploration. Older age (P = .045) and a Bankart lesion (P = .029) were associated with a neurologic complication. At an average follow-up of 8.7 years, 252 patients responded to a questionnaire regarding shoulder outcome, including 20 of the 23 patients with nerve injuries. The difference in the median Rowe score of those with and without nerve injury was not significant (P = .072). Neurologic injuries after anterior shoulder surgery presumably arise as a result of traction. The prognosis for neurologic recovery is generally good. Neurologic injury did not interfere with the outcome of the stabilization procedure.

Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study

Concerns regarding the teratogenicity of fluoroquinolones have resulted in their restricted use during gestation. This is despite an increasing need for their use due to emerging bacterial resistance. The objectives of the present investigation were to evaluate pregnancy and fetal outcomes following maternal exposure to fluoroquinolones and to examine whether in utero exposure to quinolones is associated with clinically significant musculoskeletal dysfunctions. We prospectively enrolled and followed up 200 women exposed to fluoroquinolones (norfloxacin, ciprofloxacin, ofloxacin) during gestation. Pregnancy outcome was compared with that for 200 controls matched for age and for smoking and alcohol consumption habits. Controls were exposed to nonteratogenic, nonembryotoxic antimicrobial agents matched by indication, duration of therapy (+/- 3 days), and trimester of exposure. Rates of major congenital malformations did not differ between the group exposed to quinolones in the first trimester (2.2%) and the control group (2.6%) (relative risk, 0.85; 95% confidence interval, 0.21 to 3.49). Women treated with quinolones had a tendency for an increased rate of therapeutic abortions compared with the rate among women exposed to nonteratogens (relative risk, 4.50; 95% confidence interval, 0.98 to 20.57), resulting in lower live-birth rates (86 versus 94%; P = 0.02). The rates of spontaneous abortions, fetal distress, and prematurity and the birth weight did not differ between the groups. Gross motor developmental milestone achievements did not differ between the children of the mothers in the two groups. We concluded that the use of fluoroquinolones during embryogenesis is not associated with an increased risk of major malformations. There were no clinically significant musculoskeletal dysfunctions in children exposed to fluoroquinolones in utero. The higher rate of therapeutic abortions observed in quinolone-exposed women compared to that for their controls may be secondary to the misperception of a major risk related to quinolone use during pregnancy.

Comparative cost analysis of myringotomy with insertion of ventilation tubes in Ontario and British Columbia

OBJECTIVE

The purpose of this study was to conduct a comparative cost analysis of myringotomy with insertion of ventilation tube (MVT) for children performed at two regional paediatric centres: The Hospital for Sick Children, and the British Columbia Children's Hospital.

DESIGN

Comparative cost analysis.

SETTING

The Hospital for Sick Children (HSC), Toronto, and the British Columbia Children's Hospital (BCCH), Vancouver.

METHODS

The cost analysis was performed from a health system perspective using a treatment protocol developed through a review of the literature and input from staff from each of the study hospitals. MVT cost estimates were derived, including direct treatment costs and overhead costs.

RESULTS

Total costs per MVT case (in 1994 Canadian dollars: Cdn$ 1.00 approximately US$ 0.75) varied from $390.81 at BCCH to $455.63 at HSC. Regional variations in physician costs accounted for almost 70% of the difference in MVT case costs. The distribution of nonphysician MVT case costs were similar in each study hospital, with direct (nonphysician) surgical costs, preoperative assessment and recovery room costs, and administration accounting for 30%, 26%, and 44% of total nonphysician costs, respectively.

CONCLUSIONS

This study identified the magnitude and determinants of regional variations in the cost of MVT surgery. Such cost estimates serve as an important (but not the sole) ingredient in service cost-effectiveness deliberations and in the formulation of evidence-based care when health care resources are scarce.

Persistent allopeptide reactivity and epitope spreading in chronic rejection of organ allografts

The role of the indirect allorecognition pathway in acute allograft rejection has been documented both in organ recipients and in experimental models. However, it is unknown whether self-restricted recognition of donor alloantigens also contributes to chronic allograft rejection. The aim of this study was to determine the relationship between allopeptide reactivity, epitope spreading, and chronic rejection. Using synthetic peptides corresponding to the hypervariable region of 32 HLA-DR alleles, we have followed the specificity of self-restricted T cell alloresponses to the donor in a population of 34 heart allograft recipients. T cells from sequential samples of blood collected from the patients up to 36 mo after transplantation were studied in limiting dilution analysis for allopeptide reactivity. The incidence of coronary artery vasculopathy (CAV) was significantly higher in patients who displayed persistent alloreactivity late after transplantation than in patients who showed no alloreactivity after the first 6 mo after transplantation. Both intra- and intermolecular spreading of epitopes was observed with an increased frequency in patients developing CAV in less than 2 yr, compared with patients without CAV; this suggests that diversification of the immune response against the graft contributes to chronic rejection. These data provide a strategy for identifying patients at risk of developing CAV and a rationale for therapeutic intervention aimed to prevent the progression of the rejection process.

Postoperative analgesia reduces mortality and morbidity after esophagectomy

BACKGROUND

To study the influence of postoperative analgesia on morbidity and mortality after esophagectomy.

METHODS

The outcomes of 578 patients who underwent one-stage resection between 1986 and 1995 were analyzed. Patients who received either epidural morphine, patient-controlled analgesia, or continuous intravenous morphine infusion supervised by an anesthesiology-based acute pain service (group APS, n = 299) were compared with those for whom conventional intramuscular meperidine injections were used (group CON, n = 279).

RESULTS

For patients who underwent transthoracic esophagectomy, group APS (n = 226) had a lower incidence of pulmonary complications (13% versus 25%, P = 0.002), cardiovascular complications (21% versus 43%, P < 0.001), and hospital mortality (8% versus 14%, P = 0.038) when compared with group CON (n = 189). No similar difference was demonstrated in patients who underwent esophagectomy without thoracotomy. The hospital stay (days) was shorter in group APS than in group CON for both transthoracic esophagectomy (22 +/- 20 versus 30 +/- 37, P = 0.005) and nontransthoracic esophagectomy patients (19 +/- 13 versus 25 +/- 21, P = 0.029).

CONCLUSION

Adequate postoperative analgesia is associated with lower cardiopulmonary complications, lower mortality and reduced cost in patients undergoing transthoracic esophagectomy.

Economic consequences of multiple sclerosis for Canadians

OBJECTIVES

To estimate the total costs of multiple sclerosis (MS) for all Canadians in 1994.

METHODS

Prevalence-based study estimating disease-related societal costs for Canadians with MS in 1994. The human capital approach was used to estimate the value of lost productivity due to illness. Two components were revealed: first, direct costs, in terms of expenditures on hospital care, other institutions, physician services, other health professionals, drugs, and other expenditures; and second, indirect costs, in terms of lost productivity due to premature mortality and disability.

RESULTS

The total costs of MS for Canadians were $502.3 million in 1994, with direct and indirect cost components at $188.6 million and $313.7 million, respectively.

CONCLUSIONS

This study highlights the scope and magnitude of the economic consequences of MS for Canadians. The costs calculated may be used to provide guidance in the setting of national priorities for research and prevention activities.

Mechanism of liver allograft rejection: the indirect recognition pathway

Transplant rejection is mediated by the direct and indirect pathways. To explore the role of the indirect recognition pathway in the rejection of liver allografts, T cells obtained from peripheral blood were expanded in medium containing IL-2 and tested in LDA for reactivity to synthetic peptides corresponding to the hypervariable regions of the mismatched HLA-DR antigen(s) of the donor. Serial investigations of 17 recipients showed that T-cell reactivity to donor HLA-DR peptides was strongly associated with acute rejection episodes. In recipients carrying a graft that was mismatched by two HLA-DR alleles, a single donor antigen was targeted during primary rejection, although allopeptide reactivity against the second HLA-DR antigen was observed during subsequent episodes of acute rejection. The finding that allopeptide reactivity occurs early following transplantation and is predictive of rejection is consistent with the notion that processing of donor alloantigens by recipient APCs activates the indirect T-cell recognition pathway that plays a major role in initiating and amplifying allograft rejection.

Suppurative myositis in children

Three cases are reported of pyogenic (non-tuberculous) myositis involving the ilio-psoas and/or iliacus muscles in children presenting to John Hunter Hospital, Newcastle, Australia, in a 12-month period. In one, cultures grew Haemophilus influenzae type B and in the other two Staphylococcus aureus was isolated. Biopsy of the abscess cavity from the second child confirmed an antecedent haematoma as the underlying cause. The third had underlying sacroiliac septic arthritis with a history of antecedent trauma. The classification, investigation, and treatment of myositis is discussed.

Monitoring of soluble HLA alloantigens and anti-HLA antibodies identifies heart allograft recipients at risk of transplant-associated coronary artery disease

The development of accelerated transplant-related coronary artery disease (T-CAD) is the major obstacle to long-term survival of cardiac allografts. We have investigated the role of various demographic and immunologic parameters as prognostic indicators of T-CAD in a population of 274 heart allograft recipients. Our data demonstrate that patients who experience more than 1 episode of acute rejection per year and/or develop antidonor HLA antibodies are at increased risk of developing T-CAD. Using HLA-A2 as a marker for the release of soluble HLA antigens from the donor, we established that recipients displaying circulating donor alloantigens for more than 26 weeks following transplantation are at increased risk of developing T-CAD (P=0.008). This association suggests that the release of alloantigens from the allograft is indicative of chronic injury and/or that it stimulates chronic rejection via the indirect allorecognition pathway. Our findings indicate that patients at risk of developing T-CAD can be identified by monitoring the release of donor alloantigens and production of antidonor HLA antibodies following transplantation.

Additive value of immunologic monitoring to histologic grading of heart allograft biopsy specimens: implications for therapy

BACKGROUND

Currently the sole method available for diagnosis of heart allograft rejection is endomyocardial biopsy. Although this procedure offers important criteria for treatment, it cannot always discriminate between mild episodes of rejection which might be self-limiting and forms which may progress. In an effort to monitor rejection, we have implemented a cellular monitoring strategy aimed at identifying episodes of rejection in biopsy specimens which may evolve into higher grades of rejection. The lymphocyte growth assay is based on the capacity of interleukin-2 receptor-positive T cells to expand in the presence of interleukin-2 and antigen provided by the biopsy fragment. In this study we investigated whether a positive lymphocyte growth assay correlated with and was predictive of subsequent histologic allograft rejection and the development of anti-human leukocyte antigen antibodies.

METHODS

Lymphocyte growth assay was performed on 437 biopsy specimens from 76 patients. Patients with mild allograft rejection defined as grade 2 rejection were randomized to treatment according to the results of the lymphocyte growth assay. Anti-human leukocyte antigen antibodies was also measured monthly. Cells grown from the biopsy specimens were tested against the donor cells and allopeptides derived from the donor human leukocyte antigen-DR.

RESULTS

A highly significant correlation was observed between the histologic grade of rejection and growth of graft infiltrating cells (p < 0.0001). Lymphocyte growth occurred in 10% of grade 0 versus 60% of grade 3A biopsy specimens. Only 4% of histologically negative cases with negative lymphocyte growth assay progressed to rejection in the next month. In the randomized study in which treatment was based on the lymphocyte growth assay results, progressive rejection occurred in three of four cases with positive lymphocyte growth assay versus only 1 of 11 with a negative lymphocyte growth assay (p < 0.001). A highly significant correlation was found between a positive lymphocyte growth assay and subsequent development of antihuman leukocyte antigen antibodies (p < 0.0006). This finding indicates that cellular rejection evidenced by lymphocyte growth assay ultimately results in humoral antihuman leukocyte antigen antibody mediated rejection. Limiting dilution analysis showed that although the direct recognition pathway prevails in early rejection, cells participating in the indirect pathway also proliferate vigorously in the graft during rejection.

CONCLUSIONS

Monitoring of rejection with lymphocyte growth assay is a simple method which provides prognostic information on the outcome of cardiac allografts. Lymphocyte growth assay correlates with histologic rejection and is predictive of future histologic rejection episodes. Lymphocyte growth assay also predicts subsequent development of antihuman leukocyte antigen antibodies and thus may provide a useful method for ascertaining the onset of chronic rejection.

Ontario patients' acceptance of waiting times for knee replacements

OBJECTIVE

To determine waiting times for an initial orthopedic consultation and subsequent knee replacement surgery in Ontario and patients' acceptance of these waiting times.

METHODS

Mailed patient survey to 185 randomly selected knee replacement recipients discharged from 5 Ontario hospitals between 1985 and 1990, with telephone followup after 2 mailings, implemented between May and July, 1992. Patients were asked about waiting times for their initial orthopedic consultation and subsequent knee replacement surgery and their acceptance of these waiting times.

RESULTS

Of the 185 patients, 40 were excluded because they were deceased, unable to respond, or not traceable. Of the 145 eligible patients, 127 or 87.6% responded. The median waiting times for an initial consultation and for knee replacement surgery were 4.0 and 9.5 weeks, respectively. Waiting times did not change significantly over the 5-year study period (Pearson correlation coefficients: 0.07, p = 0.53, for consultation, and -0.08, p = 0.44, for surgery). The waiting times for consultation and surgery were acceptable to 93.2% (95% confidence interval: 88.7-97.7%) and 88.1% (95% confidence interval: 82.3-93.9%) of respondents, respectively. The average acceptable surgical waiting time of 13.2 weeks was significantly shorter than the not acceptable average of 34.3 weeks (p < 0.001).

CONCLUSION

The average waiting periods for an initial orthopedic consultation and subsequent knee replacement surgery were relatively short, and the majority of patients considered their waiting times acceptable.

Waiting times for knee-replacement surgery in the United States and Ontario

BACKGROUND

Canada, which has universal single-payer health insurance, is often criticized for waiting times for surgery that are longer than those in the United States. We compared waiting times for orthopedic consultations and knee-replacement surgery and patients' acceptance of them in the United States and in the province of Ontario, Canada.

METHODS

A stratified random sample of 1486 Medicare recipients (629 from the U.S. national sample, 428 from Indiana, and 429 from western Pennsylvania) and 516 people from Ontario who had been hospitalized for knee replacement between 1985 and 1989 were surveyed by mail in 1992. Patients were asked how long they had waited to see an orthopedic surgeon and to have surgery, the acceptability of these waiting times, and their overall satisfaction with surgery.

RESULTS

About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The median waiting time for an initial orthopedic consultation was two weeks in the United States and four weeks in Ontario. The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada. In the United States, 95 percent of patients in the national sample considered their waiting time for surgery acceptable, as compared with 85.1 percent in Ontario. Overall satisfaction with surgery ("very or somewhat satisfied") was 85.3 percent for all U.S. respondents and 83.5 percent for Canadian respondents.

CONCLUSIONS

Waiting times for initial orthopedic consultation and for knee-replacement surgery were longer in Ontario than in the United States, but overall satisfaction with surgery was similar.

Stenotic bicuspid aortic valve associated with a ventricular septal defect in an adult presenting with congestive heart failure: a rare observation

This report is concerned with an adult presenting with stenotic bicuspid aortic valve associated with a ventricular septal defect (VSD). The association between aortic regurgitation (AR) and VSD has often been described, but that between a stenosed aortic valve and VSD has been rarely observed, although bicuspid aortic valves and ventricular septal defects are probably the two most common congenital heart defects. The development of congestive heart failure in the presented case was considered to be due to an increase in the left to right shunt through the VSD. This was attributable to a progressive elevation in left ventricular pressure as a result of the development, with age, of stenosis of the bicuspid aortic valve.

Evaluation of bronchoconstriction induced by neurokinins and its inhibition by selective nonpeptide antagonists in conscious guinea pigs, using a double-chamber plethysmograph technique

Bronchoconstriction induced by inhaled neurokinins, leukotriene D4 (LTD4), and histamine was examined in conscious guinea pigs, using a double-chamber plethysmography. The reliability of the plethysmograph was established by obtaining stable baseline values of key pulmonary parameters, including specific airway resistance, over a 4-day period. As well, the usefulness of the setup was confirmed using LTD4 and the LTD4 antagonist MK-571. Aerosols of MK-571 inhibited the bronchoconstriction induced by LTD4 (0.3 microM, 3 min aerosol) with an IC50 value of 65 +/- 16 nM. Inhaled neurokinin A (NKA), substance P (SP), [beta Ala8]NKA(4-10), or [Sar9,Met(O2)11]SP at concentrations up to 10 microM had no bronchoconstrictive effect, unless the guinea pigs were pretreated with the neutral endopeptidase inhibitor thiorphan (0.2 mg/mL, 5 min aerosol). The rank order of bronchoconstriction potency was LTD4 > [beta Ala8]NKA(4-10) approximately NKA > [Sar9,Met(O2)11]SP approximately SP >> histamine. Hyperresponsiveness to NKA-induced bronchoconstriction was evident after 1 day and lasted for 4 days. The response to NKA was not inhibited by mepyramine, indomethacin, or MK-571 but was significantly reduced by atropine and hexamethonium, suggesting the involvement of a cholinergic mechanism. Aerosols of SR-48,968 a selective NK2 antagonist, had potent effects on the bronchoconstriction induced by NKA (1 microM, 3 min aerosol), with an IC50 value of 17 +/- 3 nM. SR-48,968 was also active when administered intraperitoneally. The NK1 antagonist CP-99,994 (0.1 microM, 10 min aerosol) inhibited the responses to SP by 70% but had no effect on NKA-induced responses at concentrations up to 10 microM.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-idiotypic antibodies specific for HLA in heart and kidney allograft recipients

Chronic rejection is the major threat to both heart and renal allograft survival. We have explored the possibility that some patients with anti-donor HLA antibodies (Ab1) develop specific anti-idiotypic antibodies (Ab2) which suppress the production of Ab1, and subsequently, the progression of chronic rejection. Analysis of Ab2 in sera obtained from Ab1 producers showed that 22% of heart and 18% of kidney recipients produced Ab2. The 4- and 5-year actuarial graft survivals in Ab2 producers were 100% and 83%, respectively, compared to 57% in patients who formed Ab1 but not Ab2 (p < 0.004). Patients carrying the DR2 alleles, DRB1*1501, *1502 or *1601 were at a lower risk of producing anti-donor HLA antibodies.

Effect of recipient gender and race on heart and kidney allograft survival

Study of long-term survival of heart allografts shows that AA males and females have lower graft survival rates than those observed in NAC recipients. Primary kidney allografts in AA males, but not females, also display lower 5-year survival rates compared to those observed in the corresponding populations of NAC. Comparison of graft survival in the overall population of male and female recipients of kidney allografts shows that females have higher graft survival rates, probably as a result of better HLA matching. The level of alloantibody activity in posttransplantation sera is similar in the two populations, suggesting that factors other than HLA mismatching may contribute to the higher degree of graft failure in AA recipients.

Effect of anti-HLA and anti-idiotypic antibodies on the long-term survival of heart and kidney allografts

Long-term survival of heart and kidney allografts is threatened by the development of chronic rejection. Analysis of the relationship between reversible acute rejection episodes and actuarial survival at 5 years showed an inverse correlation suggesting that early cellular events may trigger antibody-mediated chronic rejection. In both heart and kidney allograft recipients producing anti-HLA antibodies we found a significant decrease in the 5-year graft survival rate. However, there was heterogeneity among anti-HLA antibody producers with respect to the development of anti-idiotypic antibodies. The actuarial 5-year graft survival was significantly higher in patients with Ab2 compared to patients without.