Epstein-Barr virus infection of renal proximal tubule cells: possible role in chronic interstitial nephritis

Chronic interstitial nephritis frequently accompanies renal diseases of different etiologies. Far less common is the entity of primary interstitial nephritis wherein the glomerular and vascular structures of the kidney are not the primary focus of the disease process. Using in situ hybridization and the polymerase chain reaction, we detected DNA from the Epstein-Barr Virus (EBV) exclusively in renal tissue of patients with the idiopathic variety of chronic interstitial nephritis. The EBV genome, but not that of cytomegalovirus or adenovirus, was detected primarily in renal proximal tubule cells. Furthermore, the CD21 antigen, which serves as the receptor for EBV in B lymphocytes, was detected by immunocytochemistry primarily on proximal tubule cells and was markedly upregulated in the EBV-infected tissue. Western blot analysis of primary cultures of normal proximal tubule cells identified a 140-kDa protein, confirming the expression of the CD21 antigen. Colocalization experiments using proximal and distal tubule markers confirmed that EBV DNA and the CD21 antigen are found primarily in proximal tubule cells. EBV infection of renal proximal tubular cells may participate in evoking a cellular immune response that results in a damaged renal interstitium.

[The impact of suboptimal animal husbandry practices on animal health and economic profitability using the example of tie-in and loose housing system of dairy cattle]

In this study of two common housing systems of dairy cattle, the tie-in system and the loose housing system, check lists were created to evaluate whether these husbandry systems fulfill the needs of the animals. Furthermore, a combination of questionnaires and interviews were employed to assess the qualification of dairy stockmen to handle the animals. These checklists should provide a useful tool for those persons involved in the examination of husbandry systems, both by providing a written record and by providing a clear outline of all the points that need to be covered during such an examination. The study, done in the way of an explorative analysis of data, included 22 farms (14 with tie-in systems and 8 with loose housing systems) and a total of 802 animals. With regard to the economic effects of poor management and housing conditions, several interesting and statistically noteworthy correlations emerged. TIE-IN SYSTEM: Positive correlations were found between severity of behavioural abnormalities (behave)and number of injuries due to husbandry system (injury); injury and number of inseminations per pregnancy (preg); injury and age of cow (age); preg and cell count of milk (cell). Negative correlations were found between cell and milk yield (milk) as well as between the qualification of stockmen (equal) and inappropriate technical design of the housing environment (tech). LOOSE HOUSING SYSTEM: Positive correlations existed between behave and injury, and between tech and injury. Negative correlations were found between milk and cell, equal and tech, and milk and age. The magnitudes of these correlations were quantified by means of linear regression analysis. Comparison of the two husbandry systems revealed that while the loose housing systems is associated with significantly more problems related to tech, it is associated with significantly fewer problems related to injury. It seems that in this housing system cows are better able to avoid injury since they are allowed to move freely. No significant differences in behavior were found between the two husbandry systems. The present study shows the importance of proper technical design of housing environments, both in relation to animal welfare and to economic profitability.

Prosthetic interposition arthroplasty for the palliative treatment of end-stage spastic hip disease in nonambulatory patients with cerebral palsy

We reviewed our experience in using a prosthetic arthroplasty for the treatment of painful degenerative arthritis in 11 nonambulatory patients (14 hips) with cerebral palsy. Age of the patients ranged from 11 to 20 years. Three patients had previously undergone a salvage procedure. Radiographic follow-up averaged 16 months (range, 4 months to 5 years). Ten of the hips remained located on the latest radiographs, and four of the hips dislocated within 4 months of the procedure. No patient exhibited migration or failure of the implants, although one patient exhibited periprosthetic osteolysis, which remained unchanged over a 4-year period. Clinical follow-up averaged 5 years (range, 2-6 years). Ten patients (13 hips) had complete relief of hip pain. Caretaker satisfaction was high for these patients, with all 10 caretakers stating that they would recommend the procedure. One patient continued to have persistent pain in the hip, and the caretaker stated that she would not recommend the procedure.

Computer modeling of the pathomechanics of spastic hip dislocation in children

Spastic muscles about the hip cause subluxation, dislocation, and lead to acetabular dysplasia. Spastic hip disease occurs when the muscles about the hip exert forces that are too high or in the wrong direction or both. To determine the role of the hip forces in the progression of spastic hip disease and the effect of both muscle-lengthening and bony reconstructive surgeries, a computerized mathematical model of a spastic hip joint was created. The magnitude and direction of the forces of spastic hips undergoing surgery were analyzed preoperatively and postoperatively to determine which procedure is best suited for the treatment of spastic hip disease. The muscle-lengthening procedures included (a) the adductor longus, (b) the psoas, iliacus, gracilis, adductor brevis, and adductor longus, and (3) the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus. The bony reconstructive and muscle-lengthening procedures included (a) lengthening the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees , (b) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing neck-shaft angle from 165 to 135 degrees , and (c) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees and neck-shaft angle from 165 to 135 degrees . Results show that a child with spastic hip disease has a hip-force magnitude 3 times that of the a child with a normal hip in the normal physiologic position. Based on this mathematical model the best to normalize the magnitude of the hip-joint reaction force, the muscles to be lengthened should include the psoas, iliacus, gracilis, adductor brevis, and the adductor longus. To normalize the direction of the hip force, the extremity should be positioned in the normal physiologic position. The impact of decreasing the femoral anteversion or femoral neck-shaft angle or both had little additional effect on the direction or magnitude of hip forces.

Reduced tolerance to acute renal ischemia in mice with a targeted disruption of the osteopontin gene

BACKGROUND

Mice with a targeted disruption of the osteopontin gene through homologous recombination in embryonic stem cells have recently been generated and shown to be characterized by unaltered fertility and normal embryonic and postnatal development, including renal development, but altered osteoclastogenesis from spleen progenitors. The lack of detectable pathological manifestations in kidneys of mice with the targeted disruption of the osteopontin gene (opn -/-) makes them an excellent model for studies of pathophysiological processes that are thought to be accompanied by changes in renal osteopontin expression. It has previously been suggested that osteopontin may play an important role in the pathophysiology of acute renal failure, thus prompting this study.

METHODS

Wild-type and opn -/- mice were subjected to 30 minutes of renal ischemia and were studied 24 hours later.

RESULTS

Control opn +/+ mice showed a significant retention of blood urea nitrogen and creatinine, which is indicative of the development of ischemic acute renal dysfunction. This was accompanied by a 2.7-fold increase in the immunodetectable osteopontin compared with sham-operated control. Animals with the disrupted osteopontin gene exhibited ischemia-induced renal dysfunction, which was twice as pronounced as that observed in mice with the intact osteopontin response to stress. In addition, the structural damage to the ischemic kidneys obtained from opn -/- mice was more pronounced than that observed in similarly treated wild-type mice. This was associated with the augmented expression of inducible nitric oxide synthase and the prevalence of nitrotyrosine residues in kidneys from opn -/- mice versus wild-type counterparts. In vitro studies with proximal tubular cells subjected to hypoxia in the presence of OPN, but not OPN with deleted arginine-glycine-aspartic acid (RGD) domain, resulted in cytoprotection.

CONCLUSIONS

The comparative analysis of functional and morphological sequelae of acute renal ischemia in opn +/+ and opn -/- mice provides strong evidence of renoprotective action of osteopontin in acute ischemia.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy

A retrospective review of 107 patients with cerebral palsy who had undergone a posterior spinal fusion with unit rod instrumentation by the same two surgeons was done to determine what factors cause complications that lead to delayed recovery time and a longer than average hospital stay. The operative risk score was developed with scores for the child's ability to walk and talk, oral feeding ability, cognitive ability, and medical problems within the year prior to surgery. Operative risk score is primarily a measure of degree of neurologic involvement. The postoperative complication score (POCS) is a combined measure of all postoperative complications including factors for prolonged intubation, intensive care unit stay, hospital stay, and delayed feeding. The mean age at surgery was 14.3 years. The mean weight was 29.5 kg, with 89 of 107 patients below the fifth percentile for weight compared with age. The mean degree of spinal deformity was 75.2 degrees (range 43-120 degrees ). The mean weight for age was -1.96 SD below the normal. The mean operative time was 4.3 h, with estimated blood loss of 1.2 blood volumes. The mean length of hospitalization was 23 days 2 h, with 5 days 2 h in the intensive care unit. The operative risk score and weight for chronological age below the fifth percentile showed statistical significance (p = 0.05) in regard to increased POCS. The weight for height-age and deficient total lymphocyte count, both factors that measure nutritional status, showed no statistical significance (p > 0.05) compared with POCS. Curves with deformity of >70 degrees had statistically significant high POCS (p = 0.03). Complications for patients having a posterior and an anterior surgery versus those who had a posterior fusion alone were not statistically different (p > 0.05). The factors that led to a greater rate of complications were the severity of neurologic involvement, severity of recent history of significant medical problems, and severity of scoliosis.

Gait analysis in rehabilitation medicine: a brief report

Gait analysis can be a powerful tool for rehabilitation research and clinical practice. However, there has been little coordinated effort to set goals for the application of gait analysis in rehabilitation. Therefore, a priority setting process was engaged to obtain the opinions of a diverse pool of experts related to human motion analysis. The primary goal of this process was to develop priorities for future research, development, and standardization in gait analysis. A multistep approach was used that included expert testimony, group discussions, individually developed priorities, and a ranking process. Several important priorities emerged from this activity. The highest priority was assigned to research on the efficacy, outcomes, and cost-effectiveness of gait analysis.

Technetium-99m-tetrofosmin imaging of lung cancer: relationship with histopathology

Tc-99m-tetrofosmin is an agent to delineate cancer. To elucidate the usefulness of Tc-99m-tetrofosmin scintigraphy, we analyzed the relationship between the uptake of Tc-99m-tetrofosmin and histopathology in patients with lung cancer. SPECT studies were conducted twice: 15 minutes (early scan), and 60 minutes (delayed scan), after intravenous injection of 740 MBq Tc-99m-tetrofosmin. We calculated the retention index in order to evaluate the degree of Tc-99m-tetrofosmin retention in the primary tumor. The retention indices were significantly lower in squamous cell carcinoma than those of small cell carcinoma or adenocarcinoma. As the retention indices of Tc-99m-tetrofosmin were different in each histopathology, the index might play a part as a tumor marker of lung cancer.

Shortening of a unit rod protruding into the hip joint: case report and description of a surgical technique

A unit rod is a well-accepted method of posterior spinal instrumentation in patients with cerebral palsy (CP). Several types of complications after the use of a unit rod were reported, including penetration through the medial wall of the pelvis. A patient who underwent anterior and posterior spinal fusion with unit-rod instrumentation was found to have penetration of the unit rod into a dysplastic hip joint. The pelvic limb of the rod was shortened with a burr through an anterolateral approach to the iliac bone. This procedure was associated with a lower blood loss than was previously reported for revisions of unit rods. There was no need for hardware removal and therefore no loss of correction. The unit rod may be shortened before surgery to prevent this problem. The described procedure is a simple way of correcting penetration of a unit-rod limb into the hip joint.

Pauci-immune rapidly progressive glomerulonephritis after nephrectomy in a renal donor

Idiopathic rapidly progressive glomerulonephritis (RPGN) is a clinicopathologic syndrome in which glomerular damage is accompanied by a rapid and progressive decline in renal function, usually resulting in irreversible renal failure in weeks or months. We report the occurrence of pauci-immune RPGN, more specifically microscopic polyarteritis nodosa (PAN), in a 60-year-old woman 15 months after donor nephrectomy, and 3 months after documentation of intact, residual renal function. The transplanted kidney continues to function well in the recipient, 6 years posttransplantation, and 4.5 years beyond destruction of the donor's contralateral kidney by RPGN. The donor underwent cadaveric renal transplantation after 2 years on dialysis, and at the 3-year mark has intact renal function. These intriguing observations strongly argue that host environmental factors, rather than intrarenal factors, play a major causative role in the pathogenesis of RPGN.

Comparison of oxygen consumption measurements in children with cerebral palsy to children with muscular dystrophy

Children with muscular dystrophy (MD) offer a unique opportunity to measure the effect of weakness on gait efficiency as they experience weakness not usually accompanied by other disabilities affecting gait. Oxygen consumption measurements were collected from eight patients with MD and eight patients with cerebral palsy (CP). A statistically significant difference in oxygen cost and oxygen consumption while walking between patients with CP and patients with MD was found despite their common inability to walk similar distances. Oxygen cost and oxygen consumption were elevated within the CP population, whereas all measurements for the MD population were within normal ranges. The measurements show that a patient can have normal oxygen cost and oxygen consumption while walking and yet be functionally limited because of weakness. Caution should be taken when using oxygen cost and oxygen consumption as sole outcome measures for patients with CP, because these measures may be insensitive to changes in strength.

Increased serum stromelysin-1 levels in systemic lupus erythematosus: lack of correlation with disease activity

OBJECTIVE

In view of evidence that stromelysin-1 and collagenase-1 are involved in tissue injury in inflammatory joint diseases, we sought to determine whether matrix metalloproteinases (MMP) are implicated in the pathophysiology of systemic lupus erythematosus (SLE).

METHODS

Seventy-three patients with SLE and 39 healthy subjects were evaluated. Serum levels of MMP and tissue inhibitor of metalloproteinases were measured.

RESULTS

Serum stromelysin-1 levels were significantly increased in patients with SLE (416+/-252 ng/ml) compared to healthy subjects (125+/-93 ng/ml). No correlation between serial measurements of stromelysin-1 and disease activity in SLE patients was noted. Serum collagenase-1, gelatinase A, and TIMP-1 levels were not increased in SLE.

CONCLUSION

Serum concentrations of stromelysin-1 are increased in SLE, but the levels do not correlate with disease activity.

Operative treatment for hallux valgus in children with cerebral palsy

All patients with cerebral palsy who had hallux valgus and bunion deformities surgically corrected between 1986 and 1995 were reviewed to determine whether techniques other than arthrodesis of the first metatarsophalangeal joint would adequately correct these deformities. Twenty-six feet of 17 patients were surgically corrected for their bunions and/or their hallux valgus deformity. The mean hallux valgus angle for all children was 30 degrees, preoperatively, with 70% correction achieved. Four techniques of surgical correction were used. A first metatarsophalangeal joint arthrodesis on eight feet gave excellent outcomes for all using the duPont Bunion Rating Score and a mean of 89% correction of the hallux valgus angle. A proximal first metatarsal osteotomy, distal soft tissue release, and exostectomy of the bunion on five feet gave three excellent and two fair outcomes, with a mean of 83% correction of the hallux valgus angle. A distal soft tissue release and exostectomy on eight feet gave four excellent outcomes, two good outcomes, and two fair outcomes, with a mean of 53% correction of the hallux valgus angle. An osteotomy of the first proximal phalanx, metatarosphalageal soft tissue release, and exostectomy on five feet gave three excellent outcomes, one good outcome, and one fair outcome with a mean of 36% correction of the hallux valgus angle. All patients who met the criteria for the procedures were satisfied with the outcomes; however, the first metatarosphalageal joint arthrodesis gave the best results with the highest percent correction and bunion score.

Variability of energy-consumption measures in children with cerebral palsy

Oxygen consumption measurements made on five repeated tests from five children with cerebral palsy (CP) and five nondisabled children of similar age and size were collected using the Cosmed K2 (Cosmed, Rome, Italy) oxygen-analysis system at free-walking velocity. Oxygen cost, oxygen consumption, and physiological cost index (PCI) were measured. There were no statistically significant differences in the percentage of variability of oxygen cost, oxygen consumption, or PCI between the disabled and nondisabled populations. Oxygen cost was the most reliable oxygen-use measurement with an average percentage of variability of 13.2% for the CP population and 13.9% for the nondisabled population. Physiological cost index was found be the least reliable measurement with the average percentages of variabilities of the disabled and nondisabled populations of 20.3 and 20.5%, respectively. Thus because of oxygen cost's relatively low variability, it was the most sensitive measurement of change in gait efficiency.

Wound infection after spinal fusion in children with cerebral palsy

One hundred and seventy-two children with cerebral palsy were operated on for neuromuscular scoliosis by spinal fusion with unit rod instrumentation between January 1988 and June 1996. There were 15 (8.7%) postoperative wound infections (seven deep, eight superficial) in 15 patients (five males, 10 females) who had a mean age of 13.9 years. The mean follow-up after diagnosis of infection was 3.3 years (range, 1-7.2). Twelve of the 15 infected cases, including all seven deep infections, occurred in the distal portion of the incision. In 14 patients, the wound infections were diagnosed within the first 2 months of the original spinal fusion. All the superficial wound infections were treated successfully by local wound care and intravenous antibiotics. The removal of hardware was necessary in the one late deep wound infection that occurred 2 years after the spinal fusion. The remaining six deep infections were treated by irrigation and debridement with the wound left open, allowing it to heal by secondary intention. One patient's wound was closed over suction-irrigation drains; however, due to a recurrent abscess, the wound was reopened and allowed to granulate. All the wound infections occurred in severely neurologically involved spastic quadriplegics who were nonambulatory and severely mentally retarded and had seizure disorders.

A method of dynamic foot-pressure measurement for the evaluation of pediatric orthopaedic foot deformities

Dynamic foot-pressure measurements are time-sensitive measurements of the pressures under the foot while walking. Historically, many methods are used to measure these pressures; however, current medical literature does not contain a method suitable for the evaluation of pediatric orthopaedic foot deformities. A method for the measurement of dynamic foot pressure for the treatment of pediatric orthopaedic foot deformities was defined in this study. We established the dynamic foot-pressure pattern of a normal population using this method. Dynamic foot-pressure measurements were collected from 54 normal subjects (108 feet). These measurements were divided into the following five segments: the heel, the lateral midfoot, the medial midfoot, the lateral forefoot, and the medial forefoot. Standard tables and graphs were created describing the normal progression of pressure across each segment of the foot while walking. These standard tables and graphs can be used as a reference with which clinical measurements can be compared. This method may be useful as a diagnostic measure of foot deformities and may increase the clinician's ability to measure changes in foot deformity resulting from treatment intervention.

The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation

In 1995, our department of anesthesiology established an airway team to assist in treating unanticipated difficult endotracheal intubations and an airway quality improvement (QI) form to document the use of emergency airway techniques in airway crises (laryngeal mask airway [LMA], flexible fiberoptic bronchoscopy, retrograde intubation [RI], transtracheal jet ventilation [TTJV], and cricothyrotomy). Over a 2-yr period, team members and staff anesthesiologists completed airway QI forms to document the smallest peripheral SpO2 during an airway crisis, the number of direct laryngoscopies (DL) performed before using an emergency airway technique, and the emergency airway technique that succeeded in rescue ventilation. Team members agreed to use the LMA as the first emergency airway technique to treat the difficult ventilation/difficult intubation scenario. A SpO2 value < or =90% during mask ventilation defined difficult ventilation. Inability to perform tracheal intubation by DL defined difficult intubation. An increase in the SpO2 value >90% defined rescue ventilation. Review of airway QI forms from October 1, 1995 until October 1, 1997 revealed 25 cases of difficult ventilation/difficult intubation. Before airway rescue, the median SpO2 was 80% (range 50%-90%), and there were four median attempts at DL (range one to nine). The LMA had a success rate of 94% (95% confidence interval [CI] 77-100). Flexible fiberoptic bronchoscopy, TTJV, RI, and surgical cricothyrotomy had success rates of 50% (95% CI 0-100), 33% (95% CI 0-100), 100% (95% CI 37-100), and 100% (95% CI 37-100), respectively. LMA insertion as the first alternative airway technique was useful in dealing with unanticipated instances of simultaneous difficulty with mask ventilation and tracheal intubation.

IMPLICATIONS

Twenty-five cases of simultaneous difficulty with mask ventilation and tracheal intubation occurred after the induction of general anesthesia during the study period. The laryngeal mask was used in 17 cases, and it provided rescue ventilation without complication in 94% of these cases (95% confidence interval 77-100).

A method for normalization of oxygen cost and consumption in normal children while walking

Measurement of oxygen use is helpful in determining energy consumption in children with walking abnormalities; however, no statistically valid measurements of nondisabled children have been established using a telemetric system. Data from 94 nondisabled children, ages 5-15 years, were collected using the Cosmed K2 oxygen analysis system. Oxygen cost, measured in milliliters O2/kg/m walked, and oxygen consumption, measured in milliliters O2/kg/min, were correlated to inverse body surface area (IBSA) measured in meters(-2). Linear relationships between oxygen cost and IBSA and between oxygen consumption and IBSA were best described by the following equations: oxygen cost = 0.256 (IBSA) + 0.052 (r = 0.806) and oxygen consumption = 17.635 (IBSA) + 4.956 (r = 0.758). From these data, equations were derived to calculate predicted oxygen cost and predicted oxygen consumption for each child. Indices were developed to express the difference between a measurement and the predicted mean in reference to the normal variation. These equations and indices can help quantify the variation of energy use of children with walking abnormalities when compared with their nondisabled peers. Additionally, the indices enable multiple tests from one subject to be compared, regardless of a change in age, height, and weight between measurements.

The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use

Echogenic venous emboli accompany tourniquet deflation during total knee arthroplasty. Two types of echogenic emboli appear in the central circulation: small venous emboli (miliary emboli) and large venous emboli (masses of echogenic material superimposed on miliary emboli). Presumably, medullary cavity trespass releases small and large echogenic emboli. However, patients undergoing lower extremity procedures with a tourniquet have large echogenic emboli regardless of medullary cavity invasion. Avoiding tourniquet inflation may decrease the release of large venous emboli. Thirteen patients undergoing total knee arthroplasty without pneumatic tourniquet received intramedullary guides and 11 patients received tibial extramedullary guides. Recordings of hemodynamic variables, mixed venous oximetry, end-tidal CO2, and echocardiographic images were made after the induction of anesthesia and for 15 min after femoral prosthesis cementing. Mean arterial pressure did not change during the study, and mean pulmonary arterial pressure increased minimally. Large venous emboli appeared in eight patients, small venous emboli appeared in 12 patients, and no emboli appeared in four patients. Compared with previous investigations of large venous emboli during total knee arthroplasty with a pneumatic tourniquet, multiple logistic regression analysis discloses a 5.33-fold greater risk of large venous embolism accompanied the use of a tourniquet during total knee arthroplasty.

IMPLICATIONS

One third of knee replacements performed without a tourniquet demonstrated large emboli. Reducing marrow cavity invasion did not decrease the release of large emboli. Compared with knee replacement without tourniquet, tourniquet use places patients at a 5.33-fold greater risk of having a large emboli.

Lateral femoral scan: an alternative method for assessing bone mineral density in children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP), often nonambulatory and/or on anticonvulsants, are at increased risk for fractures. Bone mineral density (BMD) measured by the conventional techniques of dual-energy X-ray absorptiometry (DXA) often cannot be reliably or easily measured in these patients.

OBJECTIVE

To find an alternative site to whole body, spine and hip that can be conveniently used to measure BMD in CP patients.

MATERIALS AND METHODS

Having observed that CP patients prefer to lie on their sides, we explored measuring BMD at the distal femur in the lateral projection. A total of 92 scans were performed without sedation in 34 children and adolescents with CP, aged 4-19 years. Four femoral shaft subregions were created: two trabecular and two cortical.

RESULTS

The coefficients of variation (CV %) were generally higher for opposite-side comparisons (n = 12 patients) than for same-side comparisons (n = 16 patients). For intra- and interobserver analyses, CV % were higher for cortical regions than for trabecular regions. Overall, the CV % were similar to those for hip and spine.

CONCLUSION

This peripheral site in the femur should be considered as an alternative for patients with CP when whole-body, hip and spine DXA are not practical.

Rapid skeletal turnover and hypercalcemia associated with markedly elevated interleukin-6 levels in a young black man

A 24-year-old black man presented with diffuse musculoskeletal pain and shotty lymphadenopathy. Laboratory studies revealed hypercalcemia and hyperphosphatemia, very high serum alkaline phosphatase activity, diffuse but intense uptake of radionuclide on a bone scan, urinary N-telopeptide excretion 30 times the upper limit of normal, and serum interleukin-6 100 times the upper limit of normal. An extensive workup for etiologies of the disorder was negative. A bone biopsy revealed intense osteoclastic resorption coupled with rapid bone formation and/or remodeling. This case appears to represent a new entity. Treatment with bisphosphonates produced symptomatic and biochemical improvement.

Anterior hip dislocation in children with cerebral palsy

This is a report of 27 hips with anterior dislocation in 17 children with cerebral palsy. Type 1 consists of patients with extension-external rotation and adduction contracture of the hip and extension contracture of the knee; type 2 consists of patients with extension-external rotation and abduction contracture of the hip and flexion contracture of the knee; and type 3 consists of patients without contractures. All children with types 1 and 2 were unable to sit and were forced into an almost full-time lying position. No child with type 3 pattern had sitting troubles. Hip pain was present in 50% of patients. All children with type 1 pattern and half of children with types 2 and 3 developed a thoracolumbar kyphosis. Standard radiographic hip measurements were inconsistent, and only three-dimensional computed tomography scans were useful in fully assessing the deformity. Indications for hip surgery were inability to sit or hip pain or both. Reconstruction was performed by anterior superior acetabular reconstruction and varus-shortening femoral osteotomy or proximal femur resection as a salvage procedure. Although three of the 13 children required two procedures, 11 of 13 children who underwent 16 hip procedures had stable and painless hips at the time of follow-up.

Protein profiles and identification of high performance liquid chromatography isolated proteins of cancer cell lines using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOFMS) has been used to rapidly profile the protein content of human cell lysates from MCF-10 cell and variant lines. The method was used to study the protein profiles of these cells as they progressed from normal breast epithelium to fully malignant cells. Distinct differences in the protein profiles were observed with progression, and specific proteins associated with carcinogenesis (p53, c-myc, and c-erbB-2) were heavily expressed in these cells as detected by MALDI-TOFMS. These proteins were also isolated using non-porous reversed-phase high performance liquid chromatography (NP-RP-HPLC) and mass analyzed by MALDI-TOFMS to provide molecular weight information without interference from other proteins in the whole cell lysates, and to avoid suppression effects in mixtures of proteins detected by MALDI-TOFMS. In order to confirm the identity of these oncoproteins, the cell lysates were subjected to one-dimensional (1-D) gel separation and subsequently electroblotted onto a poly(vinylidene difluoride) (PVDF) membrane for further analysis. Trypsin and cyanogen bromide digestions were performed on these proteins eluted from excised PVDF bands which were then analyzed by MALDI-TOFMS. The identity of these proteins was confirmed by database matching procedures.

Radiographic evaluation of breech presentation: is it necessary?

The purpose of this study was to evaluate the use of ultrasound in identifying fetal position and cervical spine flexion in breech presentations. Radiographic and ultrasonographic determinations of the type of presentation (frank, complete or incomplete) and degree of cervical spine flexion in 52 breech presentations were compared. The angle of flexion was defined as the angle between the fetal mandible and main axis of the cervical spine and categorized as full flexion, military, partial extension and full extension. Ultrasound was concordant with radiographic assessment of the type of presentation in 77% and the angle of flexion in 64% of the subjects and was even more accurate in those in labor. All cases predicted as having full flexion (< 90 degrees C) of the cervical spine by ultrasound had an angle of flexion < or = 90 degrees C on radiographic assessment. Of subjects in labor, ultrasound accurately identified the type of breech presentation in all cases. In addition, sonographic identification of full flexion of the cervical spine excludes cases of fetal neck extension and precludes the need for radiographic assessment prior to a trial of labor.

When to recommend compulsory versus optional CME programs? A study to establish criteria

When should remedial continuing medical education (CME) be compulsory for family physicians? When should it be optional? Should it be structured or not? In 1993-1994, the authors addressed this need for criteria by conducting a study that used reports on 14 physicians who had undergone a structured oral interview (SOI) at the College of Physicians of Quebec. (The SOI is a day-long encounter during which two specially trained physician-interviewers present a physician with standardized clinical cases that focus on ten specific aspects of a family physician's competence.) The 14 SOI reports were reviewed by 12 external physician-judges in an attempt to see how consistently they could link the ten aspects of competence, as shown in the reports, to five particular types of recommended remedial CME programs (the strictest being "compulsory program with suspended license" and the most lenient being "simple suggestions for improvement"). There was substantial agreement among the judges when choosing between compulsory and optional programs (kappa = 0.63, p < .05). The main criteria used when recommending an optional program were overall strengths and the quality of clinical reasoning. The same two criteria were also used for recommending a compulsory program, but the judges also considered three additional factors: the physician's ability to recognize his or her limits and how he or she handled referrals and prescribed medications. Many of the criteria used by the judges were based on unique information that came out of observations and interactions during the SOIs, such as quality of argumentation, sustaining a train of thought, sense for the case as a whole, or awareness of one's limits. Finally, the external judges corroborated the decisions previously made by the College of Physicians of Quebec concerning the appropriate CME programs for the 14 physicians.