Changes in refractive error over a 5-year interval in the Beaver Dam Eye Study

PURPOSE

To examine changes in spherical equivalent over a 5-year period in persons 43 to 84 years of age.

METHODS

All people 43 to 84 years of age and living in Beaver Dam, Wisconsin, in 1988 were invited for a baseline examination (1988-1990) and a 5-year follow-up examination (1993-1995). Refractions were determined according to the same protocol at both examinations. Aphakic and pseudophakic eyes were excluded as well as eyes with best corrected Snellen visual acuity of 20/40 and worse. After exclusions, refraction was obtained on 3007 right eyes and 3012 left eyes of the 3684 people participating in both examinations.

RESULTS

Right and left eyes behaved similarly. Spherical equivalent became more positive in the youngest subjects and more negative in older subjects. After adjusting for other factors, the 5-year change in spherical equivalent of those 45, 55, 65, and 75 years of age was +0.15, +0.18, +0.10, and -0.07D, respectively. Severity of nuclear sclerosis was related to the amount of change. Those with mild nuclear sclerosis at baseline had a change of +0.2 D, whereas those with severe nuclear sclerosis had a change of -0.5 D. The amount of change was also related to gender, diabetes, and age at onset of myopia. It was unrelated to education and baseline spherical equivalent.

CONCLUSIONS

Changes in spherical equivalent over a 5-year period were small. Before the age of 70, people became more hyperopic. After the age of 70, people became more myopic. Much of the myopic change may be related to increasing nuclear sclerosis.

Meningoencephalitis caused by a novel paramyxovirus: an advanced MRI case report in an emerging disease

Eleven abattoir workers in Singapore were infected in March 1999 by an outbreak caused by the Nipah virus. This newly discovered, Hendra-like paramyxovirus causes acute infection of the CNS. We present the magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (MRS) findings in a patient suffering from acute meningoencephalitis. Multiple small white matter lesions were detected on diffusion-weighted imaging (DWI) and T2-weighted images. There were no abnormalities detected on MRS. We believe this to be the first reported MRI findings in this novel zoonotic viral disease.

[Elevation of serum and urine tumor necrosis factor levels after transurethral resection of the prostate]

BACKGROUND

Recent studies have suggested that inflammatory cytokines are major mediator of the acute phase protein response after surgery. The aim of the present study is to investigate the relationship between the degree of surgical trauma and the change of serum and urine cytokine levels after transurethral resection of the prostate (TUR-P).

METHOD

Serum and urine concentrations of tumor necrosis factor-alpha (TNF), interleukin-6 (IL 6), and interleukin-1 (IL 1) were evaluated in 55 patients who underwent TUR-P and in 23 patients who underwent abdominal surgery. The samples were collected periodically before and after an intervention, and the concentrations of cytokines were measured by enzyme-linked immunosorbent assay.

RESULTS

The concentration of serum TNF was significantly increased 6 hours after TUR-P. Since serum TNF level was not increased after abdominal surgery, serum TNF level was significantly higher after TUR-P than after abdominal surgery. Serum IL 6 and IL 1 levels were not increased after TUR-P. Urine levels of TNF, IL 6 and IL 1 were significantly increased after TUR-P, meanwhile no significant elevation of urine cytokine levels was recognized in the patients who underwent abdominal surgery. The elevation of urine cytokine levels was thought to be caused by the increased production of cytokines at the surgically resected sites. The urine TNF level after TUR-P was increased related to the resected tissue volume and irrigation fluid volume. The preoperative urinary tract infection caused excessive elevation of the urine TNF level after TUR-P. The urine TNF level after TUR-P also tended to be increased depending on the degree of postoperative pyrexia.

CONCLUSION

These results indicate the unique response of TNF to TUR-P. Measurement of serum and urine TNF levels after TUR-P can be a useful index for evaluating the perioperative condition of the patients undergoing TUR-P.

Associations of performance-based and self-reported measures of visual function. The Beaver Dam Eye Study

OBJECTIVE

To describe and compare performance-based and self-reported measures of visual function and to evaluate how each varied with age and how the performance-based measures were associated with the responses to self-reported questions about visual function.

DESIGN

Population-based epidemiologic study.

PARTICIPANTS

Adults participating in the first follow-up of the Beaver Dam Eye Study (n = 3,722).

MAIN OUTCOME MEASURES

Performance-based measures of vision including current binocular, best-corrected and near visual acuities, sensitivity to light as measured by an automated perimeter, contrast sensitivity, and self-reported measures from a standardized interview.

RESULTS

All performance-based and self-reported visual functions decreased with increasing age (p < 0.0001 for each). On average, women did more poorly than men on all the performance-based measures (p < 0.0001 for each), and on some of the self-reported measures. For both genders, correlations among the performance-based measures ranged from 0.38 to 0.67. In general, individuals reporting good visual function or little difficulty with visual tasks scored better on performance-based measures compared to individuals whose questionnaire responses reflected limited visual function. Overall, about 39% of drivers reported that their vision caused them to limit their night driving. Correlations of performance-based with self-reported measures of visual function were greater for best-corrected, binocular and near visual acuity compared to correlations of visual sensitivity to light and contrast sensitivity. There were 1,285 persons whose best-corrected acuity was better than their current binocular acuity and there were 97 people with visual impairment considering only current binocular acuity whose vision improved to better than 20/40 after refraction.

CONCLUSIONS

Performance-based and self-reported measures of visual function were consistently and inversely related to age. Performance-based measures were, in general, more highly correlated between themselves than were self-reported measures. Self-reported visual functions were significantly positively correlated with all performance-based measures, but correlations were moderate. While high contrast measures are usually used in clinical settings and in many studies, the data suggest that in assessing function it is appropriate to measure several different aspects of vision, both performance-based and self-assessed. Our data give some indication of the impact these visual functions have on daily life as reflected by night driving and on near and distant visual acuity. New refractive corrections would likely improve the visual acuity in many older adults.

Outpatient procedures for cervical dysplasia: a 3 year review of laser vaporisation and LEEP

A 3 year retrospective review (1995 to 1997) of 127 patients with cervical dysplasia who underwent Laser Vaporisation of the cervix and LEEP at the Gynaecological Cancer Centre, KK Women's & Children's Hospital, Singapore, was undertaken. Amongst the patients in the Laser Vaporisation group, the mean age was 37.7 years (SD 8.8), the mean operating time was 14.8 minutes (SD 8.5), 63.6% were given prophylactic antibiotics and the mean follow up period was 15.3 months (SD 12.0), whilst in the LEEP group, mean age was 40.3 years (SD 8.4), mean operating time, 11.8 minutes (SD 4.9), prophylactic antibiotic rate, 53.8% and mean follow up period was 19.1 months (SD 9.3). Mild and moderate haemorrhage post procedure were the only complications encountered, 10.2% (5/49) in the Laser group and 3.8% (3/78) in the LEEP group. 98% (48/49) and 97.4% (76/78) of the Laser and LEEP groups, respectively, were free of disease on follow up. None of the 3 patients with persistent or recurrent disease were diagnosed as having invasive cancer. Overall, there were no significant differences in the patient characteristics, histopathology, operating times, follow up period, the use of prophylactic antibiotics, and complications in the 2 groups. The low complication rate, high disease-free rate and the relatively short operating time of Laser Vaporisation and LEEP in our study suggests that, indeed, both the procedures can be done safely and efficiently in the outpatient setting. However the discrepancy between the histology of colposcopically directed biopsy and that of LEEP specimens suggests that colposcopically directed biopsy may not be as accurate as one might believe, and further studies analysing the concordance between colposcopically directed biopsy and LEEP biopsy histologies are needed.

Diabetes, cardiovascular disease, selected cardiovascular disease risk factors, and the 5-year incidence of age-related cataract and progression of lens opacities: the Beaver Dam Eye Study

PURPOSE

To describe the relationships of diabetes mellitus, cardiovascular disease, and selected cardiovascular disease risk factors to cumulative incidence of age-related cataract and to progression of lens opacities over a 5-year interval.

METHODS

A follow-up examination of the Beaver Dam Eye Study cohort was performed 5 years after the baseline evaluation. Ages at the census prior to baseline ranged from 43 to 84 years of age. Protocols for examination, lens photography, and grading were the same for both examinations.

RESULTS

Age at baseline was the most significant characteristic associated with incidence of nuclear, cortical, and posterior subcapsular cataract in those without diabetes (P < .001) for all cataracts. The positive association of age with cataract was found for nuclear and cortical cataract in the worse eye (P < or = .04) but not posterior subcapsular cataract in those with diabetes. Progression of nuclear sclerosis was common, occurring in about 70% of subjects when considering either eye. Incident cortical and posterior subcapsular cataracts (P < or = .001 for worse eye for each lesion) and progression of cortical and posterior subcapsular opacities were more common in those with diabetes (P < or = .001 for either eye for each lesion). Increased glycated hemoglobin level was associated with increased risk of nuclear and cortical cataracts in those with diabetes. Relationships of risk factors to posterior subcapsular cataracts, especially among those with diabetes, were often in the expected direction but lacked significance possibly due to small samples.

CONCLUSIONS

Diabetes mellitus is associated with incidence over 5 years of cortical and posterior subcapsular cataract and with progression of more minor cortical and posterior subcapsular lens opacities. These changes may be related to level of glycemia. Cardiovascular disease and its risk factors have little effect on incidence of any age-related cataract.

Creutzfeldt-Jakob disease presenting with visual blurring, diplopia and visual loss: Heidenhain's variant

Focal electroencephalographic abnormalities as described in Heidenhain's variant of Creutzfeldt-Jakob disease are uncommon. We report a 73-year-old male presenting with visual symptoms, right hemianopia and rapidly progressive dementia. Myoclonus was synchronous with generalised periodic epileptiform discharges on electroencephalography (EEG). In addition, there were periodic focal sharp waves at the left occipital region. Diffusion-weighted magnetic resonance brain images showed slightly increased signal intensity in the occipital parasagittal area, left more than right. 14-3-3 protein was detected in the cerebrospinal fluid. The patient died within 5 months of presentation.

Survival following alpha particle pituitary irradiation for diabetic retinopathy

The purpose of this study was to evaluate the mortality experience of persons with longstanding diabetes who had received pituitary irradiation for diabetic retinopathy compared to a matched group of persons with diabetes who had not had pituitary ablation. The irradiated cohort consisted of 167 patients treated at the Donner Pavilion (Lawrence Berkeley Laboratory, University of California, Berkeley), and the comparison cohort was the population evaluated in the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). Survival analyses were performed comparing the two cohorts using three different sets of matching criteria, each more restrictive than the previous analyses. The three different strategies were (1) matched only on severity of diabetic retinopathy; (2) matched on severity of retinopathy and age; and (3) matched on severity of retinopathy, age, gender, and hypertension status. Tests of comparison were the log-rank test, the Wilcoxon test, and the likelihood ratio test. For the model matching only on severity of retinopathy, mean survival was 8.3 years for the WESDR group and 9.4 years for the ablated group (p > 0.05 for all three statistical tests). For the model matched on retinopathy and age, mean survival was 8.9 years for the WESDR group and 9.2 years for the ablated group (p=0.05 log-rank test, 0.32 Wilcoxon test, and 0.06 likelihood ratio test). For the model matching on retinopathy, age, gender, and hypertension status, mean survival was 8.9 years for the WESDR group and 11.6 years for the ablated group (p=0.72 log-rank test, 0.08 Wilcoxon test, and 0.82 likelihood ratio test). These data are compatible with the notion that pituitary ablation, and therefore induced pituitary growth hormone deficiency, may not decrease survival in those with severe diabetic retinopathy.

Renal function abnormalities and incident cataract after a five-year interval: The Beaver Dam Eye Study

PURPOSE

To evaluate the relationship between renal function abnormalities and incidence of age-related cataract.

METHODS

In a population-based epidemiologic study of age-related eye disease, cataract was classified based on lens photographs. Standard methods of grading were used. Blood urea nitrogen, serum creatinine, and gross proteinuria were measured using standard protocols.

RESULTS

Cortical cataract was associated with increased BUN, but after controlling for age, this relationship was no longer significant. In those with diabetes, elevated BUN or elevated creatinine was associated with increased odds of posterior subcapsular cataract, but these relationships were not significant.

CONCLUSION

Renal function abnormalities were not significantly associated with incidence of cataract after controlling for age and gender. However, the power to test these associations was limited. Further longitudinal follow-up of this cohort as well as other studies designed to evaluate these associations are needed.

Incidence of age-related cataract: the Beaver Dam Eye Study

OBJECTIVE

To estimate the incidence of nuclear, cortical, and posterior subcapsular cataract in the Beaver Dam Eye Study cohort.

DESIGN

A population-based study of the prevalence of age-related eye diseases was conducted between 1988 and 1990 (n=4926), and a follow-up study was conducted between 1993 and 1995 (n=3684). The evaluations included photographic documentation of the lens. Slitlamp photographs were taken to assess nuclear opacity, and retroillumination photographs were taken to assess cortical and posterior subcapsular cataract. The grading of photographs was done in a masked manner by trained graders using the same protocols for baseline and follow-up photographs. The graders were the same for both evaluations.

PARTICIPANTS

Persons aged 43 to 86 years who were identified through a private census conducted from 1987 to 1988 of the population of Beaver Dam, Wis, were invited for a baseline examination held between 1988-1990 and again for a follow-up examination held between 1993-1995.

RESULTS

Incident nuclear cataract occurred in 13.1%, cortical cataract in 8.0%, and posterior subcapsular cataract in 3.4% of right eyes. The cumulative incidence of nuclear cataract in right eyes increased from 2.9% in persons aged 43 to 54 years at baseline to 40.0% in those aged 75 years or older. For cortical and posterior subcapsular cataract, the corresponding values were 1.9% and 21.8% and 1.4% and 7.3%, respectively. Women were more likely than men to have nuclear cataract even after adjusting for age.

CONCLUSIONS

Incident cataracts are common age-related problems, and incidence increases with increasing age at baseline. These data will help in planning for future care (eg, cataract surgery and change in spectacle correction) and in investigating the importance of risk factors.

Performance-based and self-assessed measures of visual function as related to history of falls, hip fractures, and measured gait time. The Beaver Dam Eye Study

OBJECTIVE

The purpose of the study is to report relationships between visual function parameters and falls, hip fractures, and gait time in adults.

DESIGN

Population-based study.

PARTICIPANTS

The 3722 persons who participated in the 5-year follow-up of the Beaver Dam Eye Study cohort.

MAIN OUTCOME MEASURES

The visual functions measured at the examination were best-corrected visual acuity, current binocular acuity, near acuity, contrast sensitivity, and visual threshold to light. Information on falls and hip fractures was obtained by structured interview. Gait time was measured by standardized protocol.

RESULTS

History of falls and hip fractures increased with age, as did time to walk a measured course. Falls were more commonly reported for all persons who had poorer visual function, although not all relationships were significant in persons less than 60 years of age. In persons 60 years of age and older, hip fractures after the age of 40 were significantly related to all measures of visual function. Time to walk a measured course was significantly related to all measures of visual function.

CONCLUSIONS

These data indicate a consistent relationship between falls, fractures, gait time, and visual functions. Longitudinal data are necessary to accurately determine temporal relationships and to determine the likelihood of a causal association. In the interim, these data suggest that improving visual function may have benefits such as decreased traumatic events and improved mobility.

[A case of spontaneous repair of the ureteral rupture caused by ureteral carcinoma]

We report a 47-year-old male patient with a spontaneous ureteral rupture caused by ureteral carcinoma. Drip infusion pyelography (DIP) and computerized tomography (CT) demonstrated the extravasation of contrast medium around the dilated upper ureter. Nephrostography showed the extinction of extravasation 4 days after the DIP. A total nephroureterectomy with the excision of a cuff of bladder was performed for the transitional cell carcinoma of the right lower ureter. Meticulous pathological examination of the specimen revealed discontinuity of the muscle layer, edema and fibrin deposition in the submucosal layers in the upper ureter indicating the site of the rupture. These findings suggest that the spontaneous rupture of the ureter caused by the ureteral carcinoma could be spontaneously repaired in a short period.

A two-component system in Ralstonia (Pseudomonas) solanacearum modulates production of PhcA-regulated virulence factors in response to 3-hydroxypalmitic acid methyl ester

Expression of virulence factors in Ralstonia solanacearum is controlled by a complex regulatory network, at the center of which is PhcA, a LysR family transcriptional regulator. We report here that expression of phcA and production of PhcA-regulated virulence factors are affected by products of the putative operon phcBSR(Q). phcB is required for production of an extracellular factor (EF), tentatively identified as the fatty acid derivative 3-hydroxypalmitic acid methyl ester (3-OH PAME), but a biochemical function for PhcB could not be deduced from DNA sequence analysis. The other genes in the putative operon are predicted to encode proteins homologous to members of two-component signal transduction systems: PhcS has amino acid similarity to histidine kinase sensors, whereas PhcR and OrfQ are similar to response regulators. PhcR is quite unusual because its putative output domain strongly resembles the histidine kinase domain of a sensor protein. Production of the PhcA-regulated factors exopolysaccharide I, endoglucanase, and pectin methyl esterase was reduced 10- to 100-fold only in mutants with a nonpolar insertion in phcB [which express phcSR(Q) in the absence of the EF]; simultaneously, expression of phcA was reduced fivefold. Both a wild-type phenotype and phcA expression were restored by addition of 3-OH PAME to growing cultures. Mutants with polar insertions in phcB or lacking the entire phcBSR(Q) region produced wild-type levels of PhcA-regulated virulence factors. The genetic data suggest that PhcS and PhcR function together to regulate expression of phcA, but the biochemical mechanism for this is unclear. At low levels of the EF, it is likely that PhcS phosphorylates PhcR, and then PhcR interacts either with PhcA (which is required for full expression of phcA) or an unknown component of the signal cascade to inhibit expression of phcA. When the EF reaches a threshold concentration, we suggest that it reduces the ability of PhcS to phosphorylate PhcR, resulting in increased expression of phcA and production of PhcA-regulated factors.

Cardiovascular disease, selected cardiovascular disease risk factors, and age-related cataracts: the Beaver Dam Eye Study

PURPOSE

To examine the associations of cardiovascular disease and selected cardiovascular disease risk factors with the prevalence of age-related cataract.

METHODS

We conducted a population-based prevalence study of adults aged 43 to 86 years (n = 4,926) in Beaver Dam, Wisconsin. An ocular examination including lens photographs, medical history, height and weight measurement, blood testing, and photograph grading was performed according to standard protocols.

RESULTS

Age and sex influenced most of the relationships between risk variables and cataract. Many relationships apparent in univariate analyses were not significant when controlling for confounders. In multivariate models, higher glycated hemoglobin was significantly and consistently associated with increased risk of nuclear cataract in women. For cortical cataract, higher serum high density lipoprotein cholesterol was associated with decreased risk in women. For posterior subcapsular cataract, men with higher ratios of total to high-density lipoprotein cholesterol were at increased risk. History of cardiovascular disease was not associated with cataracts in persons with or without diabetes after controlling for additional risk indicators.

CONCLUSIONS

Some risk factors for cardiovascular disease were associated with increased frequency of age-related lens opacities. Age and sex influenced these relationships but did not entirely explain them. Longitudinal follow-up is necessary to determine antecedent-consequent relationships that may suggest causal associations.

Standardized problem list generation, utilizing the Mayo canonical vocabulary embedded within the Unified Medical Language System

VOCABULARY: The Mayo problem list vocabulary is a clinically derived lexicon created from the entries made to the Mayo Clinic's Master Sheet Index and the problem list entries made to the Impression/ Report/Plan section of the Clinical Notes System over the last three years. The vocabulary was reduced by eliminating repetition including lexical variants, spelling errors, and qualifiers (Administrative or Operational terms). Qualifiers are re-coordinated with other terms, at run-time, which greatly increased the number of input strings which our system is capable of recognizing.

IMPLEMENTATION

The Problem Manager is implemented using standard windows tools in a Windows NT environment. The interface is designed using Object Pascal. HTTP calls are passed over the World Wide Web to a UNIX based vocabulary server. The server returns a document, which is read into Object Pascal structures, parsed, filtered and displayed.

STUDY

This paper reports the results of a recent Usability Trial focused on assessing the viability of this mechanism for standardized problem entry. Eight clinicians engaged in eleven scenarios and responded as to their satisfaction with the systems performance. These responses were observed, videotaped and tabulated. Clinicians in this study were able to find acceptable diagnoses in 91.1% of the scenarios. The response time was acceptable in 92.5% of the scenarios. The presentation of related terms was stated to be useful in at least one scenario by seven of the eight participants. All clinicians wanted to make use of shortcuts which would minimize the amount of typing necessary to encode the concept they were searching for (e.g. Abbreviations, Word Completion).

CONCLUSIONS

Clinicians are willing to choose a canonical term from a suggested list (as opposed to their own wording). Clinicians want an "intelligent" system, which would suggest terms within a category (e.g. Types of "Migraine"). They are able to make functional use of our system, in its current state of development. Finally, all clinicians appreciate the value of encoding their problems in a standardized vocabulary, toward improved research, education and practice.

Changes in visual acuity in a population. The Beaver Dam Eye Study

PURPOSE

To describe the change in visual acuity over a 5-year period in persons participating in a large population-based study.

METHODS

Best-corrected visual acuity was measured, after refraction, with logMAR charts using a modification of the Early Treatment Diabetic Retinopathy Study protocol in 3684 persons living in Beaver Dam, Wisconsin, who ranged in age from 43 to 86 years at the time of a baseline examination from 1988 to 1990, and at a follow-up examination from 1993 to 1995.

RESULTS

The change in the number of letters read correctly over the 5-year period varied from 0.4 +/- 4.9 (mean +/- standard deviation) in people between 43 and 54 years of age to -5.2 +/- 15.4 in people 75 years of age or older at baseline. Over the 5-year period, vision became impaired (20/40 or worse in the better eye) in 2.9% of the population and severely impaired (20/200 or worse in the better eye) in 0.3%. The visual angle doubled in 1.7% of the population, and 2.4% had improved vision. People 75 years of age or older at baseline were 12.5 times (95% confidence interval [Cl], 8.6-18.2; P < 0.001) more likely to have impaired vision, 9.7 times (95% Cl, 5.9-16.0; P < 0.001) more likely to have doubling of the visual angle, and 78 times more likely (95% Cl, 9.9-614.1; P < 0.001) to have severe visual impairment than people younger than 75 years of age at baseline. People 75 years of age or older who were living in nursing homes or group homes were 3.8 times more likely to have impaired vision, 3.3 times more likely to have severely impaired vision, and 5.7 times more likely to have a doubling of the visual angle than those not residing in a nursing home or a group home.

CONCLUSION

These data provide precise population-based estimates of incidence of visual loss over a wide spectrum of ages and show that decreased visual acuity in people 75 years of age is a common finding, especially in those who are in nursing homes or group homes.

The incidence of hypertension in insulin-dependent diabetes

BACKGROUND

There are few epidemiologic data describing the long-term incidence of hypertension in people with diabetes.

METHODS

In a population-based study performed in southern Wisconsin, 765 individuals diagnosed as having diabetes when they were younger than 30 years and taking insulin participated in baseline, 4-year, and 10-year examinations. Blood pressure was measured by standardized protocols,and hypertension was defined as a mean systolic blood pressure of 160 mm Hg or more ( > or = 140 mm Hg in those younger than 25 years) and/or mean diastolic blood pressure of 95 mm Hg or more ( > or = 90 mm Hg in those younger than 25 years) and/or history of hypertension with the use of antihypertensive medication.

RESULTS

The prevalence of hypertension at baseline was 17.3%. The 10-year incidence of hypertension was 25.9%. The incidence of hypertension was greater with older age, longer duration of diabetes, higher glycosylated hemoglobin level, proteinuria, more severe retinopathy, and male gender. After other risk factors were controlled for, the 10-year incidence of hypertension was significantly related to higher glycosylated hemoglobin level (odds ratio, 1.23 per percentage increase; 95% confidence interval, 1.13 to 1.34) presence of gross proteinuria (odds ratio, 3.64; 95% confidence interval, 2.26 to 5.85), longer duration of diabetes (odds ratio, 1.03 per year of diabetes; 95% confidence interval, 1.01 to 1.04), and being male (odds ratio, 1.93; 95% confidence interval, 1.34 to 2.77).

CONCLUSION

These data suggest that control of hyperglycemia and prevention of gross proteinuria may lead to a reduction in the long-term incidence of hypertension.

Prevalence of self-reported erectile dysfunction in people with long-term IDDM

OBJECTIVE

The purpose of this report is to examine the prevalence of erectile dysfunction and relationships to other characteristics in men with younger-onset diabetes.

RESEARCH DESIGN AND METHODS

In a population-based cohort study in southern Wisconsin, prevalence of erectile dysfunction was measured based on self reports in men who were 21 years of age or older, were < 30 years of age at diagnosis of diabetes, had 10 or more years of diabetes, and were taking insulin (n = 365).

RESULTS

Of the study group, 20% reported a history of erectile dysfunction. The prevalence of erectile dysfunction increased with increasing age (from 1.1% in those 21-30 years of age to 47.1% in those 43 years of age or older, P for trend < 0.0001) and with increasing duration of diabetes (P for trend < 0.0001). Erectile dysfunction was associated with presence of severe diabetic retinopathy, a history of peripheral neuropathy, amputation, cardiovascular disease, a higher glycosylated hemoglobin, use of antihypertensive medications, and higher BMI.

CONCLUSIONS

These data suggest that tighter glycemic control and careful selection of antihypertensive medications might prove beneficial.

Thyroid function test changes with adjuvant tamoxifen therapy in postmenopausal women with breast cancer

PURPOSE

While tamoxifen has been shown to alter concentration of many hormones and their binding globulins, there have been conflicting results regarding its effects on thyroid function tests. We sought to clarify these effects by studying subjects in a controlled clinical trial.

PATIENTS AND METHODS

We evaluated a subset of postmenopausal women who had participated in a longitudinal, double-blind, randomized, placebo-controlled toxicity study of tamoxifen 10 mg orally, twice daily. There were 14 subjects in both the tamoxifen and placebo groups. Measurement of thyroid-binding globulin (TBG), thyroxine uptake (T-Uptake), thyroxine (T4), and thyroid-stimulating hormone (TSH), and an indirect estimate of the free T4 index (FTI), were made for each subject before and after 3 months of treatment.

RESULTS

For T-Uptake, T4, and TBG, there were significant increases in the mean change from baseline to 3 months in the tamoxifen group compared with the placebo group (P = .02, .0001, and .003, respectively), while there were no significant changes in the measured TSH and in the calculated FTI.

CONCLUSION

We conclude that tamoxifen therapy in postmenopausal women results in increased TBG, with secondary increases in measured T-Uptake and T4 following. However, TSH and FTI levels are unchanged, and treated women remain eumetabolic.

[Long-term results and complications of intravesical instillation of bacillus Calmette-Guerin for prophylaxis of bladder cancer recurrence]

Since 1982, we treated 22 patients with superficial bladder cancer via intravesical bacillus Calmette-Guerin (Tokyo 172 strain) for prophylaxis against tumor recurrence. To determine the long-term efficacy and complications of BCG therapy, retrospective analysis was performed. The BCG therapy was initiated one to two weeks after complete transurethral resection of visible tumors. One hundred twenty mg or 80 mg of BCG suspended in 40 ml of 0.9% NaCl solution was instilled into the bladder once a week for 6 times, then monthly for 10 times. Of 22 patients, 10 tumor recurrences were recognized in 4 patients (mean followup 74 months). Recurrent free rate at 5 years was 78.5%. Common side effects were low grade fever and bladder irritability. Although these side effects were self-limiting, 15 patients (68%) refused instillation of BCG before completion of our protocol because of the bladder irritation. No relationship was observed between total dose of BCG instilled and tumor recurrence. Severe side effects such as permanent structural or functional alterations of the bladder or mycobacterial infection of other organs were not observed. Intravesical administration of Tokyo 172 strain of BCG seemed to be safe and useful for long-term prophylaxis of superficial bladder cancer recurrence.

The relationship between tumor size and chemosensitivity of murine bladder cancer

The relationship between tumor size and antitumor efficacy of chemotherapy was quantitated using an i.d. bladder cancer in C3H mice. The fundamental hypothesis was that tumor microenvironmental factors progressively changed with tumor growth, which then influenced the cell killing activity of agents. For all five chemotherapeutic agents examined, the antitumor efficacy progressively decreased as the tumor became larger ("volume effect"). The change in antitumor efficacy was expressed as the treatment delay (days) to cause a 50% reduction in antitumor efficacy (designated as volume effect/50, VE50). The VE50 value of Adriamycin (ADM) was 25.1, cisplatin was 10.4, carboplatin was 5.7, vinblastine was 4.7, and cyclophosphamide (CP) was 3.2 to 4.1 days; indicating the antitumor effect of ADM was least and CP was most influenced by tumor size at the time of treatment.

Allotransplantation of rat islets into the cisterna magna of streptozotocin-induced diabetic rats

Islets were isolated from the pancreata of Sprague-Dawley rats and transplanted into streptozotocin-induced diabetic outbred Wistar rats. The effect of transplantation of islets into the cisterna magna on the diabetic state of the recipients was compared with that of the conventional transplantation of islets into liver via the portal vein. After successful intraportal (IP) transplantation, rejection took place between days 7 and 15 in all diabetic recipients. All of the eleven rats surviving after stereotaxic implantation of islets into the cisterna magna returned to normoglycemia within 7 days after transplantation. Nine of the recipients with intra-cisterna magna (IM) islet allografts were still normoglycemic at 210 days after transplantation. The glucose disappearance rate of the IM transplant rats was slower than that of the IP transplant rats, and blood glucose returned to the normal basal level within 5 hr following glucose administration. Although the insulin levels were almost undetectable in cerebrospinal fluid before IM transplantation, the insulin levels were markedly increased after IM transplantation and twice as great in CSF than blood. Thus, these findings indicate that the cisterna magna can serve as an immunologically privileged site for implantation of allogeneic pancreatic islets, and islets in CSF can regulate and maintain normal glucose homeostasis via secretion of insulin across the blood-brain barrier.

Comparison of six microcomputer dietary analysis systems with the USDA Nutrient Data Base for Standard Reference

We compared the general operating features and nutrient databases of six microcomputer dietary analysis systems. A 3-day food record with 73 food items was entered into each program; nutrient averages were compared with the US Department of Agriculture Nutrient Data Base for Standard Reference (USDA NDB), full version, release 9, for microcomputers. The six programs were found to vary widely in cost, number of foods and nutrients in the database, use of non-USDA data and imputation of data for missing values, number of print/export options, time to analyze the 3-day food record, and overall ease of use. Although all of the microcomputer dietary analysis systems were within 7% of the USDA NDB for energy, protein, total fat, and total carbohydrates, the proportion of other nutrients varying more than 15% from the USDA NDB varied considerably between programs. Variance among programs for 3-day food record nutrient values occurred because of differences in the number of food items included in the database (leading to varying degrees of substitution), the recency of the nutrient data (whether or not the most recent USDA releases had been incorporated), and the number of missing values (the degree to which non-USDA sources or estimated calculations were used to fill in the blanks from the USDA standard). Our results demonstrate that it is important for each dietitian to carefully choose a microcomputer dietary analysis system that is suitable to specific and predetermined needs.

[Comparison between clinical response and in vitro chemosensitivity of solid tumors in the succinic dehydrogenase inhibition test]

We describe our experience with succinic dehydrogenase inhibition (SDI) test for solid tumors as a chemosensitivity test using 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide. Specimens were obtained from 76 surgical resected tumors, including 32 colon cancers, 24 stomach cancers and 16 lung cancers. Following enzymatic dissociation of scissors-minced tumors, viable cells were cultured in serum free medium (S-Clone SF-B) for 4 days with eight drug concentrations obtained by 2-fold dilution of drugs. Among 76 specimens tested, 48 specimens including 15 colon cancers, 18 stomach cancers and 15 lung cancers were successfully evaluated. For the purpose of judgement, 50% inhibitory concentration (IC50) was calculated in each case. Tumor specimen was regarded as sensitive to a given agent when the IC50 value was the same or smaller than the cut-off concentrations (1 microgram/ml for mitomycin C, 5 micrograms/ml for cisplatin, 2 micrograms/ml for adriamycin and 50 micrograms/ml for 5-fluorouracil), and was regarded as resistant when it was larger than these levels. In vitro vs in vivo drug sensitivity was successfully evaluated in 23 cases. The overall predicting accuracy rate was 78% (18/23), with one true positive, 5 false positive and 17 true negative cases. This test appeared to be useful to tailor effective agents for patients because of its relatively high successful and predictive rates.

Influence of high-energy shock waves and cisplatin on antitumor effect in murine bladder cancer

The potential application of high-energy shock waves (HESW) for control of experimental bladder cancer was investigated. Subcutaneous 3-d murine bladder cancer (MBT-2) in C3H mice were exposed to HESW alone (250 to 1,500 shocks) or in combination with cisplatin (5 to 10 mg/kg, i.p.). Although HESW alone showed no influence on tumor growth, HESW/cisplatin combination therapy suppressed tumor growth more than cisplatin alone. Subsequent studies revealed that an air-fluid interface relative to tumor location played a pivotal role for the chemosensitizing effect of HESW. HESW treatment was able to enhance the cisplatin cytotoxicity only when the tumors were placed adjacent to the air-fluid interface.

Cortisone inhibition of tumor angiogenesis measured by a quantitative colorimetric assay in mice

A simple and quantitative angiogenesis assay was developed. Using this assay, the angiostatic effect of cortisone acetate (CA) on three murine tumors was studied. Tumor cells were inoculated i.d. into the syngeneic or heterogeneic hosts (day 0) and the degree of angiogenesis was quantitated on day 3 by measuring the tumor vascular volumes using an Evan's blue perfusion technique. CA treatment (250 mg/kg for 3 days) significantly suppressed tumor angiogenesis; however, the degree of angiostatic effect was influenced by the tumor types and by the mouse strain used. MBT-2 bladder cancer angiogenesis was suppressed by 77%-80% of controls in C3H/HeN and C57B1/6 mice, whereas MBT-2 angiogenesis in BALB/c mice was significantly less suppressed by CA (65% inhibition) as compared with values obtained for C3H mice. B16 melanoma or Line-1 lung-cell carcinoma-induced angiogenesis was suppressed by 57%-66% in their syngeneic or heterogeneic hosts. The combined administration of CA and heparin (Sigma; 1,000 units/ml in drinking water) did not influence the outcomes. The data suggest that host factor(s) and tumor factor(s) influenced the expression of CA angiostatic activity. This colorimetric assay enabled a quantitative estimation of the degree of angiogenesis in mammalian animals.

Effect of systemic glutathione depletion by buthionine sulfoximine on sensitivity of murine bladder cancer to cytotoxic agents

The effect of systemic glutathione (GSH) depletion on sensitization of bladder cancer cells to various antineoplastic agents was investigated using murine model, MBT-2. Subcutaneous injection(s) of buthionine sulfoximine (BSO) significantly depleted the GSH content in the tumor and organs. BSO pretreatment produced significant enhancement in the antitumor effect of cyclophosphamide (CY), though it failed to sensitize the tumors to doxorubicin hydrochloride (Adriamycin), cisplatin, mitomycin C, JM-8, methotrexate, vinblastine, and tumor necrosis factor. Mice tolerated cytotoxic agents alone and in combination with BSO except for cisplatin in combination with BSO. A 29 percent (4/14) mortality rate was observed in mice treated with BSO and divided schedule of cisplatin.

Improved use of buthionine sulfoximine to prevent cisplatin nephrotoxicity in rats

Male Sprague Dawley rats were treated with buthionine sulfoximine (BSO) and cisplatin in different doses and schedules to optimize the chemoprotective effect of BSO against cisplatin nephrotoxicity. BSO at 4 mmol/kg, administered s.c. 2 h prior to cisplatin, resulted in normal blood urea nitrogen (BUN) levels in rats treated with 3 or 4 mg/kg cisplatin, and modestly, but significantly reduced the toxicity of cisplatin at 5 mg/kg. Administration of BSO (4 mmol/kg) at intervals ranging from 0 to 16 h prior to cisplatin (5 mg/kg) resulted in a significant reduction in BUN values. A BSO dose as low as 0.04 mmol/kg was found to be as effective as 4 mmol/kg against nephrotoxicity associated with cisplatin at 4 mg/kg. Repetitive injections of BSO (1 mmol/kg every 12 h, four times, beginning 2 h prior to cisplatin) significantly inhibited elevations of BUN associated with higher-dose cisplatin (6 mg/kg), whereas a single BSO injection of 4 mmol/kg was ineffective. The degree and duration of renal glutathione depletion was related to the dose of BSO. Renal glutathione content following 4 mmol/kg BSO was 38% of control at 2 h and 40% at 24 h; following 0.04 mg/kg, glutathione was 47% at 2 h and almost 100% at 24 h. Simultaneous in vitro administration of BSO did not inactivate cisplatin cytotoxicity as measured by the colony-forming ability of MBT-2 cells in soft agar. These data indicate that repeated injections of BSO, beginning prior to cisplatin administration, would improve the nephroprotective effect without compromising the chemotherapeutic efficacy of cisplatin. It is suggested that the ability of BSO to reduce cisplatin nephrotoxicity may not correlate with the degree of renal glutathione depletion and that the mechanism of action is unlikely to involve direct inactivation of cisplatin.

Interleukin 2 suppression of a murine bladder cancer implanted into kidney, bladder and skin; its organ specificity

Little is known about organ associated tumor response to systemic interleukin 2 (IL2) therapy. The effect of IL2 on bladder cancer growth in the skin and in the genitourinary tract was investigated. C3H mice were implanted with the syngeneic transitional cell carcinoma, MBT-2, intradermally (i.d.), beneath the left renal subcapsular area, and in one experiment, simultaneously in the bladder. IL2 (human recombinant form; Biogen Research Co) was given i.p. at 5000 U thrice daily for 5 consecutive days commencing on Day 3, or for 10 to 11 days commencing on Day 10 with some doses omitted at signs of toxicity. For comparison, mice bearing 3-d and 10-d tumors in the skin and subcapsular kidney were treated with chemotherapy (cisplatin, 6 mg./kg. X 3; mitomycin C, 3 mg./kg. X 3; cyclophosphamide, 75 mg./kg. X 1). IL2 therapy mediated growth suppression of 10-d tumors in the genitourinary organs and skin at a similar rate. In contrast to IL2, systemic chemotherapy mediated tumor suppression in an organ specific manner; renal subcapsular tumors responded to the chemotherapy, whereas i.d. tumors were insensitive. Three-day tumors (both i.d. and renal subcapsular tumor) responded relatively well to each treatment compared to 10-d tumors. These data suggest that in systemic immunotherapy with IL2, anatomic location of the tumor is less important for inducing an antitumor response than in chemotherapy.

Interferon sequence homology and receptor binding activity of ovine trophoblast antiluteolytic protein

Sequencing of the 40 N-terminal amino acids of the blastocyst protein responsible for blocking corpus luteum regression in early pregnancy in sheep revealed a 37% homology with human alpha-interferon; 28% of the remaining amino acid changes were conservative. 125I-Labelled human alpha-interferon bound to membrane receptors from sheep uteri with an approximate Kd of 4 x 10(-11) M; binding was inhibited by unlabelled alpha-interferon or purified blastocyst antiluteolytic protein. The blastocyst antiluteolytic protein therefore closely resembles the interferon-alpha family of antiviral proteins.

Effect of intravesical administration of tumor necrosis serum and human recombinant tumor necrosis factor on a murine bladder tumor

The effect of intravesical administration of tumor necrosis factor (TNF) on the implantability and growth of bladder cancer was studied using the murine tumor model, MBT-2. Crude TNF was prepared from serum (TNS) of BCG infected rats after injection of endotoxin or the recombinant product of human TNF-alpha was used. Treatment was begun 24 hr. or seven days after tumor instillation and repeated three times. Tumor implantability and tumor weight were determined on day 21. Low dose TNF (200 U), given in the form of TNS, failed to suppress the growth of established tumors (seven-day tumor). It did, however, significantly reduce tumor implantability. The growth of seven-day tumors was significantly suppressed by administration of higher dose of TNF (3,700 U) given in recombinant form.

Reduction of bladder cancer growth in mice treated with intravesical Bacillus Calmette Guerin and systemic interleukin 2

The effect of systemic administration of Interleukin 2 (IL2) on intravesical Bacillus Calmette-Guerin (BCG) therapy was studied in an established murine bladder tumor, MBT-2. BCG (100 micrograms.) was administered intravesically on days 7 and 14 after seeding bladders with MBT-2 cells. IL2 (5,000 U/injection) was given intraperitoneally every eight hours for 10 times (days seven through 10 and 14 through 17). BCG or IL2 therapy alone failed to reduce incidence of tumor implantation and tumor weight; whereas, combined treatment with BCG and IL2 reduced tumor weight significantly compared to saline or BCG treated mice. Cytotoxicity was assessed in a four-hour 75Semethionine-release assay. Augmentation of natural killer cell activity was only observed in mice treated with BCG plus IL2. MBT-2 target cells were not lysed by spleen cells from mice treated with BCG or saline. IL2 therapy produced lymphokine-activated killer cell activity, though combining BCG with IL2 suppressed this activity after each course of treatment. The results suggest that combined treatment with IL2 enhances the therapeutic effect of BCG therapy. However, this enhancement of antitumor activity is not clearly explained by augmentation of natural killer or in vivo-generated lymphokine-activated killer cells.

Inhibition of cisplatin-induced nephrotoxicity in rats by buthionine sulfoximine, a glutathione synthesis inhibitor

DL-Buthionine-(S,R)-sulfoximine (BSO), a glutathione-depleting agent, was found to diminish the nephrotoxic effect of cisplatin (cis-diamminedichloroplatinum). Pretreatment of rats with BSO (4 mmol/kg s.c.) 2 h prior to cisplatin, either as a single dose of 5 mg/kg or at a daily dose of 2.5 mg/kg for 3 consecutive days, resulted in diminished elevations of plasma BUN concentration and decreased cisplatin-induced inhibition of renal gamma-glutamylcysteine synthetase and gamma-glutamyl transpeptidase activity measured 6 days following treatment. Administration of BSO prior to cisplatin at 7.5 mg/kg did not significantly alter the effect of cisplatin on either BUN concentration or enzyme activity. The influence of BSO pretreatment on the antitumor activity of cisplatin was studied using implantation of a murine bladder cancer (MBT-2) in C3H mice. Pretreatment of mice with BSO (5 mmol/kg) did not influence cisplatin antitumor efficacy.

Effect of rotation and conservation tillage of earthworms in a red-brown earth under wheat

The effects of two rotation and two tillage systems on earthworm populations have been studied in a red-brown earth under wheat. At the time of sampling, the earthworm population under direct drill was nearly double that under conventional cultivation. The total number of worms was not affected by crop rotation with pasture or lupins, but following pasture there were significantly more large worms. It is suggested that at this site the earthworm population may be responding rapidly to alterations in food supply and water stress under the different agricultural systems.

[Effect of metoclopramide on gastric distension and lethal toxicity of cisplatin in mice]

Mice treated with cisplatin (cDDP), were found to have considerably bloated stomachs presumably resulting from paralysis of gastric emptying without appetite suppression and emesis. Repeated administration of metoclopramide (MCP) not only reduced gastric distension, but also the number of toxic deaths after 13 mg/kg of cisplatin i.p. The mechanism of action by which MCP increased the resistance of mice to cDDP seemed to be alleviation of systemic dehydration by means of enhanced gastric emptying.

The immunoperoxidase-specific IgE assay in the otolaryngologic center

The debate between the skin testing allergist and the in vitro testing allergist goes on. Clearly, the in vitro methods of allergy testing are here to stay. In vitro testing is less limiting and offers a number of advantages to both the allergist and the patient.

Infantile cortical hyperostosis with intramedullary lesions

A case report of an infant with the clinical, radiological, and histological presentations of infantile cortical hyperostosis is presented. Besides the classically described subperiosteal thickening, the present patient radiographically also had well-circumscribed intramedullary lytic lesions in both proximal tibial metaphyses, which subsequently disappeared in 3 months. These lesions have not been previously described in the literature. Resolution of these lesions suggests they may be part of the radiological picture of infantile cortical hyperostosis and probably may be managed by observation.

Phosphate excretion and reabsorption in the conscious dog

When normal conscious dogs were given small doses of (NH4)2HPO4 by stomach tube to increase their plasma PO4, the rate of excretion of PO4 increased without change in creatinine clearance. After eating meat, increased PO4 excretion was accompanied by increase in both creatinine clearance and plasma PO4. The calculated rate of tubular reabsorption of PO4 did not change significantly after (NH4)2HPO4 administration, but there was a significant increase in PO4 reabsorption after meat; in comparison there was no change in SO4 reabsorption. Similarly, administration of certain amino acids, which caused an increase in creatinine clearance, also caused a significant increase in PO4 reabsorption. Administration of SO4 with PO4 had no significant effect on PO4 reabsorption. It appears from the results, that PO4 has an apparent tubular maximum rate of reabsorption (Tm) when plasma PO4 alone is varied; but this Tm is not a real maximum because PO4 reabsorption increases above this value after the administration of meat or amino acids, both of which cause an increase in glomerular filtration rate. There is no evidence to suggest that there is any inhibition of PO4 reabsorption by SO4 or amino acids.

Tuberculosis presenting as carpal tunnel syndrome

A 44-year-old man presented with typical symptoms, signs, and laboratory findings of carpal tunnel syndrome. Mycobacterium tuberculosis was cultured from the flexor tenosynovium excised at surgery. Tuberculosis should be considered in the differential diagnosis of carpal tunnel syndrome with unexplained chronic synovitis. The diagnosis may be missed unless a tissue specimen is analyzed specifically with acid-fast stain and culture. Therapy should include excision of involved synovium, early postoperative mobilization, and appropriate chemotherapy.

Effect of freezing on histologic and biomechanical failure patterns in the rabbit capital femoral growth plate

Ten pairs of proximal femora were harvested from 8-week-old New Zealand white rabbits. Experimental shear fractures were then created in vitro, and load-displacement curves were recorded. One specimen from each animal was tested within 4 h of death, whereas the contralateral specimen was frozen for 10 to 20 days and thawed prior to testing. Histologic sections of the fractured specimens were studied. No statistically significant differences could be demonstrated between the fresh and the frozen/thawed specimens in either the histologic patterns or the shear load or stress to failure.

Histologic patterns of capital femoral growth plate fracture in the rabbit: the effect of shear direction

Growth plate fractures were produced in vitro in the rabbit capital femoral physis by applying shear loading parallel to the physeal complex in four different directions. Load-displacement curves were recorded and histologic sections were prepared from each specimen. Different histologic patterns were observed with different directions of shear loading. The histologic level within the growth plate through which the fracture propagated varied with each specimen and with the different directions of shear loading. The "classical" pattern of failure through the hypertropic cellular zone of the physis was not uniformly seen. The mechanical patterns of failure also varied with the direction of shear loading. The shear strength of the physeal complex was significantly greater with anterior to posterior loading than with posterior to anterior loading. The possible factors contributing to this mechanical anisotropy are discussed, and the literature on related studies is reviewed.

Dimensions of the rabbit femur during growth

In the rabbit, the femur grew rapidly in length during the first 4 weeks of life of the animal. Growth continued at a slower rate up to 8 to 10 weeks of age and then reached a plateau. A similar growth pattern (rapid increase followed by a plateau) was seen for the dimensions of the femoral head, neck, and shaft. Significant growth differences between the left and right femurs did not occur.

Shear fractures through the capital femoral physis of the skeletally immature rabbit

Shear fractures were created through the capital femoral physes of rabbits 2, 4, 6, 10, and 14 weeks of age. Biomechanically, the load to complete failure (i.e., fracture) increased with maturation. The load to failure increased with increasing area of the capital femoral physis. The shear stress increased with age and then began to plateau at 10 weeks of age. Histologically, the zone of failure involved the columnar zone in the specimens from rabbits 2-6 weeks old, progressed to the junction of the columnar and hypertrophic zones in the specimens from 10-week-old rabbits, and occurred within the zone of hypertrophy in the specimens from 14-week-old rabbits. Fractures progressed from a type I physeal fracture in the specimens from rabbits 4-6 weeks old to a type II physeal/metaphyseal fracture in the specimens from older animals, with the metaphyseal fragment increasing in size with increasing chondroosseous maturation of the specimen.

Proximal femoral epiphysiolysis in the neonate

Seven neonates with eight proximal femoral epiphysiolyses were reviewed. Pain elicited by leg motion was the common diagnostic finding in all. Radiography showed lateralization of the shaft similar to congenital hip dysplasia. However, the acetabular index was normal in all but one child. Arthrography confirmed the diagnosis, showing a located proximal femoral epiphysis and a laterally displaced, externally rotated proximal metaphysis. Treatment usually consisted of traction followed by abduction splinting. The long-term results were excellent in six fractures. Growth complications included angular deformation (bowing) in one patient and coxa vara due to localized premature epiphysiodesis in one patient. Duplication of the lesion in stillborn cadavers showed that the fracture was usually a type 1 physeal injury traversing the entire physis beneath both the capital femur and the greater trochanter. The periosteal sleeve was intact posteriorly and still attached to the proximal physis. However, in two instances there was comminution (rather than crushing) of the epiphysis, physis, and metaphysis medially, which might explain the residual varus deformation and premature growth arrest seen infrequently as complications of this particular proximal femoral injury. An experimental animal model also duplicated these morphologic observations.