Comparison of two methods of predicting outcome in perinatal asphyxia

In a follow-up study of 122 full-term infants in whom postasphyxial encephalopathy occurred the incidence of death or severe handicap was 1 in 1000 deliveries. The abilities of two methods of diagnosing intrapartum asphyxia to predict outcome at a median age of 2.5 years were compared. A decision matrix calculation was undertaken to assess the sensitivity and specificity of low Apgar score and postasphyxial encephalopathy. A 10 min Apgar score less than or equal to 5 was the most sensitive of six different Apgar ratings in predicting adverse outcome (sensitivity 43%, specificity 95%) but even this was much less sensitive than the presence of moderate or severe encephalopathy in predicting death or severe handicap (sensitivity 96%).

Gastric carcinoma: 30-year review

The records of 1030 patients with gastric carcinoma seen between 1941 and 1970 were analysed. A 10-year follow-up was available for 1024. The overall operability and resectability rates were 80.9% and 53.5% respectively, and in the two decades 1951 to 1960 and 1961 to 1970, the rates increased significantly, as did the subtotal gastrectomy rate of 46.9%. Subtotal resection for cure was done in 59.5%, and for palliation in 40.5%. Fifty-six patients underwent a total gastrectomy. There was no significant increase in consecutive decades in either overall 5-year survival or survival following subtotal gastrectomy. The 5- and 10-year survival rates of 15.1% and 6.6%. Of the 5-year survivors, 54% had no lymphnode involvement and 35.2% had nodes positive for tumour spread. Gastroesophagectomy was associated with a high morbidity and extremely low survival. Of 56 patients having a total gastrectomy, 37 lived 1 year or more while only 5 survived 5 or more years. Linitis plastica occurred with equal frequency in men and women. Operability and resectability rates were lower and there was a 90.6% 1-year death rate.

Painful subluxation of the carpometacarpal joint of the thumb in Ehlers-Danlos syndrome

Two cases of subluxation of the carpometacarpal joint of the thumb in children with Ehlers-Danlos syndrome are presented. Although hand involvement is not universally appreciated, the carpometacarpal joint of the thumb may be particularly susceptible to weakened ligamentous constraints in Ehlers-Danlos syndrome.

Agenesis of the corpus callosum and macrocephaly in siblings

A brother and sister with developmental delay, relative macrocephaly and agenesis of the corpus callosum are described. The brother also had unilateral cerebellar hypoplasia and malrotation of the large bowel. Published cases of familial agenesis of the corpus callosum are reviewed and the value of ultrasonography in demonstrating agenesis of the corpus callosum in the neonate is emphasised.

Toe-to-hand transfer based on the medial plantar artery

Two patients had toe-to-hand transfers based on the medial plantar artery system. The dorsalis pedis and first dorsal metatarsal arteries were absent in both cases. Although the procedure is slightly more complicated than currently described techniques for toe-to-hand transfers based on the dorsal system, the procedure was performed in both cases without complication.

Severe pseudoachondroplasia with parental consanguinity

A boy who showed features of the severe form of pseudoachondroplasia, whose parents were first cousins, is reported. Published reports supporting the existence of an autosomal recessive form of this disorder are reviewed.

Gouty tenosynovitis in the hand

Gouty tenosynovitis can present as an infection, tendon rupture, nerve compression, or digital stiffness. In ten patients, extensive urate deposition was encountered in the extensor tendons at both the wrist and digital levels in addition to involvement of the flexor tendons in the carpal canal and digital theca. Direct nerve or muscle involvement was not observed in the hand. Medical therapy, which is now the cornerstone of treatment for most aspects of gout, may not be the best treatment for tophaceous deposits in the hand. Operative treatment may be required to debulk tophaceous deposits, improve tendon gliding, decompress nerves, allow increased range of motion of joints, and ameliorate pain.

Embolotherapy in the treatment of congenital arteriovenous malformations of the hand: a case report

This article describes the treatment of a painful ulcerating congenital arteriovenous malformation in the hand of a 39-year-old woman. Preoperative transcatheter embolotherapy was used to diminish vascularity and engorgement. Operative treatment consisted of a resection of angiomatous material and coverage with a pedicle flap. Preoperative transcatheter embolization of small feeder vessels may offer some advantage over the operative approach alone in treating congenital arteriovenous malformations of the hand.

Blood vessel implantation into ischemic bone

Blood vessel implantation, core decompression, and core decompression plus cancellous bone grafting were compared in 36 adult mongrel dogs to evaluate their relative effectiveness in revascularizing an ischemic femoral head. Each of the methods resulted in a reversal of the ischemic changes to varying degrees. Blood vessel implantation resulted in increased new bone formation at the site of vessel implantation but no significant revascularization in the peripheral portion of the femoral head. The method of creating avascular necrosis of the femoral head of the canine, as described by Hori, was studied in a controlled fashion. Although ischemic changes were noted in our hands, the model failed to produced findings consistent with avascular necrosis.

Hydrocortisone inhibits mucin secretion from guinea pig gallbladder

We studied the effects of hydrocortisone, an inhibitor of phospholipase A2, on the secretion of mucin and release of prostaglandins from guinea pig gallbladder explants. We measured mucin using [3H]glucosamine as a precursor and prostaglandins by radioimmunoassay of 6-keto-prostaglandin F1 alpha. Mucin secretion and prostaglandin release were studied under basal conditions and after arachidonate stimulation. Hydrocortisone sodium succinate reversibly inhibited basal secretion of mucin by 24% at 10(-5) M (P less than 0.05 compared with control) and 34% at 10(-4) M (P less than 0.01). Hydrocortisone, 10(-4) M, also reversibly inhibited arachidonate-stimulated secretion of mucin (P less than 0.01 compared with controls incubated with arachidonate alone). Release of prostaglandin F1 alpha was significantly inhibited by hydrocortisone under basal (P less than 0.01) and arachidonate-stimulated (P less than 0.01) conditions. The inhibitory effect of hydrocortisone was mediated by inhibition of hydrolysis of arachidonate from membrane phospholipids, suggesting that exogenous arachidonate is incorporated into membrane phospholipids prior to conversion to prostaglandins.

Role of gallbladder mucin in pathophysiology of gallstones

A critical step in the formation of cholesterol gallstones in nucleation (i.e., the formation of cholesterol monohydrate crystals from supersaturated bile). The rate of nucleation of cholesterol depends upon a critical balance between pronucleating and antinucleating factors in bile. Mucin, a high molecular weight glycoprotein secreted by the gallbladder and biliary duct epithelium, is a pronucleating agent in experimental and human gallstone disease. Gallbladder mucin shares with other epithelial mucins the ability to bind lipids and bile pigment. The hydrophobic binding sites in the polypeptide core of mucin may provide a favorable environment for nucleation of cholesterol monohydrate from supersaturated bile. In nearly all animal models of cholelithiasis, mucin hypersecretion is prominent. The stimulus for gallbladder mucin hypersecretion appears to be a component of lithogenic bile. Prostaglandins regulate mucin release in gallbladder epithelium in vitro and probably in vivo. In the cholesterol-fed prairie dog, blockage of mucin release with aspirin inhibits gallstone formation. These findings suggest that inhibition of mucin release may prevent cholesterol stone formation during high-risk periods or after dissolution therapy with bile salts.

Colorectal cancer. Risk factors and screening strategies

Colorectal cancer is common in the United States and frequently discovered too late for cure. Epidemiologic studies suggest a complex relationship between animal fat intake, fecal flora, and risk of development of colorectal cancer, but the actual mechanism of carcinogenesis is still unknown. Early detection might increase the proportion of patients who could be cured of the disease. Screening of asymptomatic subjects over the age of 40 years for fecal occult blood seems to detect cancers before they become invasive. Efforts are needed to ensure that all subjects with positive tests for occult blood are completely examined. We prefer colonoscopy as a single test in that it is both diagnostic and curative early in the disease. The cost-effectiveness of mass screening and its ability to reduce colorectal cancer mortality in our society require further prospective study.

Localized nodular tenosynovitis: experience with 115 cases

One hundred fifteen cases of localized nodular synovitis (giant cell tumor of the tendon sheath) were reviewed. The optimal treatment for these lesions is unknown, and a high recurrence rate exists. Growths arose from most of the synovial sites of the hand, including joints, capsular ligaments, and tendon sheaths. Deformation of the bone surface was commonly seen; however, bone invasion was uncommon. The histologic features may vary, but the lesions are always benign and do not metastasize. Treatment consisted of thorough local excision and adjacent joint exploration when appropriate. Recurrence occurred in 10 cases (9%) with one to five additional surgical procedures needed to eradicate the lesion.

Dental Education and Dental Practice

This paper relates recent modes of dental practice to changes that the public and government are likely to ask the health care professions to make in the future. As usual they are asking for the best of all worlds. First, that we maintain the clinical model to the highest standards of personal dental care based and tested against the best research at our disposal, whilst we ensure there is no reduction in the high technical standards for which british dentists have a reputation. Second, that the profession is required to consider ways of providing care on the medicosocial model for the whole community at an economic level the country will afford. The broad changes in dental education have been reviewed, from the technical apprenticeship to the establishment of strong university departments in teaching hospitals. The importance of a sound biomedical foundation and of research both to education and the credibility of dental practice as a primary health care profession is stressed if the profession is to retain its position as a sister to medicine and not slide down to that of a technical ancillary.

Manifesting heterozygosity in sex-linked spastic paraplegia?

An unusual form of hereditary spastic paraplegia is described. Affected females have a late-onset slowly progressive spastic paraparesis. Affected males show oligophrenia with a rapidly progressive spastic quadriplegia. The mode of inheritance is consistent with sex-linkage, with partial manifestation in female carriers.

Spondylocostal dysostosis

A female child with multiple vertebral and rib abnormalities is described.

The efficacy of free tissue transfer in the treatment of osteomyelitis

We evaluated the efficacy of free tissue transfer in the treatment of osteomyelitis in thirty-three patients who were followed for an average of 41.4 months (range, twenty-four to fifty-nine months). The bone lesions were classified in two ways: first, according to whether there had been drainage for less or more than six months and second, according to whether the lesion was Type I, II, or III. The thirty-three patients underwent a total of thirty-seven free tissue transfers, and thirty (79 per cent) of the transfers survived. Major complications were encountered after 41 per cent of the surgical procedures, consisting of failure of the free tissue transfer in seven patients (21 per cent) and recurrent sepsis in six (20 per cent) at follow-up. Four of the seven patients in whom the free tissue transfer failed underwent an amputation. Six of the patients with a failed transfer and nine of the ten with recurrent sepsis had a Type-III lesion. Previously published reports have suggested that free tissue transfer is an extremely successful and reliable procedure for the treatment of osteomyelitis. In our series limited success was achieved in patients with a Type-I or II lesion, but six of the patients with a Type-III lesion had recurrence of infection despite a successful transfer.