Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic overhead athlete shoulder and elbow score (KJOC Score)

BACKGROUND

There are no validated outcome measures consistently used in the literature to report results of ulnar collateral ligament reconstruction in overhead athletes.

HYPOTHESIS

The Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow score (KJOC score) will correlate with other validated scores for upper extremity assessment but will be more accurate in evaluating ulnar collateral ligament reconstruction outcomes in professional baseball players.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Fifty-five professional baseball players who underwent ulnar collateral ligament reconstruction were asked to complete the KJOC score, the Disabilities of the Arm, Shoulder and Hand (DASH) score, and the DASH sports module. Players were separated into 3 categories-(1) playing without pain, (2) playing with pain, and (3) not playing because of pain-and compared with 123 asymptomatic throwers. Pearson (parametric) and Spearman rank (nonparametric) correlations among the 3 systems were conducted to validate the KJOC score. Means across categories were compared using a Wilcoxon rank-sum test, and a threshold score separating categories 1 and 3 was determined using receiver operator characteristic discrimination analysis.

RESULTS

Significant correlations were found between the KJOC score and the DASH (-.693, P < .0001), and the DASH sports module (-0.804, P < .0001). Only the KJOC score was able to discriminate between categories 2 and 3, as well as category 1 and the uninjured population. In addition, the KJOC score was the most sensitive and accurate method of discriminating category 1 from category 3, with a threshold score of 81.3.

CONCLUSION

The results of this study validate the use of the KJOC score for evaluation of overhead athletes undergoing ulnar collateral ligament reconstruction. The KJOC score is the most sensitive score for detecting subtle changes in performance in the throwing athlete.

The effect of pitching biomechanics on the upper extremity in youth and adolescent baseball pitchers

BACKGROUND

Increased pitch counts have been linked to increased complaints of shoulder and elbow pain in youth baseball pitchers. Improper pitching mechanics have not been shown to adversely affect the upper extremity in youth pitchers.

HYPOTHESIS

The correct performance of 5 biomechanical pitching parameters correlates with lower humeral internal rotation torque and elbow valgus load, as well as higher pitching efficiency, in youth and adolescent pitchers.

STUDY DESIGN

Descriptive laboratory study.

METHODS

In sum, 169 baseball pitchers (aged 9-18) were analyzed using a quantitative motion analysis system and a high-speed video while throwing fastballs. The correct performance of 5 common pitching parameters was compared with each pitcher's age, humeral internal rotation torque, elbow valgus load, and calculated pitching efficiency.

RESULTS

Motion analysis correlated with video analysis for all 5 parameters (P < .05). Youth pitchers (aged 9-13) performing 3 or more parameters correctly showed lower humeral internal rotation torque, lower elbow valgus load, and higher pitching efficiency (P < .05).

CONCLUSIONS

Youth pitchers with better pitching mechanics generate lower humeral internal rotation torque, lower elbow valgus load, and more efficiency than do those with improper mechanics. Proper pitching mechanics may help prevent shoulder and elbow injuries in youth pitchers.

CLINICAL RELEVANCE

The parameters described in this study may be used to improve the pitching mechanics of youth pitchers and possibly reduce shoulder and elbow pain in youth baseball pitchers.

Domino heart transplantation involving infants

Domino heart transplantation has been well described in adults, but has not previously been reported in infant patients. We report the successful transplantation of a 'domino' heart from a 3-month-old infant with primary pulmonary hypertension undergoing heart-lung transplantation, into a 3-month-old infant with complex congenital heart disease. Both infants have survived past 1 year post-transplant, and neither infant has experienced any clinically significant allograft-related complications. Echocardiography and cardiac catheterization of the domino heart have consistently demonstrated stable hypertrophy of the right ventricle (RV) and interventricular septum, but good right and left ventricular function. Domino heart transplant surgery may be an effective way to provide 'pre-conditioned' donor hearts to infants urgently in need of heart transplantation.

The Critical Role of Axillary Ultrasound and Aspiration Biopsy in the Management of Breast Cancer Patients with Clinically Negative Axilla

BACKGROUND

Sonographic evaluation of the axilla can predict node status in a significant proportion of clinically node-negative patients. This review focuses on the value of ultrasound followed by ultrasound-guided cytology in assessing the need for sentinel node mapping and conservative versus complete axillary dissections.

DESIGN

Breast primaries from 168 sentinel node candidates were prospectively assessed for clinicopathologic variables associated with increased incidence of axillary metastases. Patients were classified accordingly, and those at a higher risk underwent ultrasound of their axillae, followed by aspiration biopsy if needed. Sentinel node mapping was performed in all low-risk patients, and in high-risk patients with normal axillary ultrasounds or negative cytology. Final axillary status was compared in terms of nodal stage, number of positive nodes, and size of metastasis.

RESULTS

112 patients were at high risk for nodal disease (67%), with a statistically significant lower probability for remaining node-negative and a statistical significantly higher risk for having more than one positive node. All patients with more than three positive nodes were detected by ultrasound-guided cytology. High-risk patients with final positive axillae missed by ultrasound or ultrasound guided cytology had tumor deposits measuring </=5 mm.

CONCLUSION

Extent of axillary dissections can be decided based on the risk for axillary metastases: sentinel node mapping for low-risk patients; less-aggressive axillary dissections for high-risk patients with negative ultrasound and/or negative cytology; and a standard dissection for high-risk patients with positive cytology.

Dual direct lateral portals for treatment of osteochondritis dissecans of the capitellum: an anatomic study

PURPOSE

The purpose of this study was to quantify the distance of dual direct lateral (posterolateral radiocapitellar) arthroscopic portals to the lateral ligamentous structures and to report the percentage of capitellum accessible through these portals.

METHODS

Arthroscopy was performed on 10 fresh-frozen cadaveric elbows via a standard 6-portal approach. The portals included dual direct lateral portals created in the posterolateral soft spot. The arthroscope was placed through one direct lateral portal; an arthroscopic electrocautery device was placed through the other direct lateral portal and was used to mark all accessible areas of the capitellum. Open dissection allowed measurement of the distances of the portals from the lateral ligamentous structures, as well as determination of the percentage of capitellum accessible through these portals.

RESULTS

The more ulnar of the dual lateral portals averaged 9.1 mm from the lateral ulnar collateral ligament, 11.5 mm from the annular ligament, and 13.1 mm from the radial collateral ligament. The more radial of the dual lateral portals averaged 1.5 mm, 9.7 mm, and 7.0 mm from these ligaments, respectively. Seventy-eight percent of the capitellum was accessible for instrumentation with these portals.

CONCLUSIONS

Correct placement of dual direct lateral portals does not disrupt the lateral ligamentous complex and allows access to a large portion of the capitellum.

CLINICAL RELEVANCE

Use of dual direct lateral portals is safe and practical for arthroscopic treatment of capitellar osteochondritis dissecans.

Gone but not forgotten: declarative and nondeclarative memory processes and their contributions to resilience

Cognitive psychology research challenges traditional psychoanalytic understanding of memory. The memory of facts and events is now referred to as declarative memory. Nondeclarative memory systems, in contrast, process patterns of perception, emotion, and action without representing the past in terms of any consciously accessible content. The author examines the contributions of declarative and nondeclarative memory processes to resilience. Declarative memories can promote resilience through their capacity to evoke soothing emotional responses. Nondeclarative memory processes can foster resilience through underlying the capacity to elicit and maintain supportive relationships. The concept of nondeclarative memory has potential to inform the understanding of essential psychoanalytic phenomena, including transference, countertransference, and enactment.

Lateral thoracic expansion for Jeune's syndrome: midterm results

BACKGROUND

In 1995, we reported the use of lateral thoracic expansion in a patient with symptomatic Jeune's asphyxiating thoracic dystrophy. We have subsequently used lateral thoracic expansion 16 times on 10 patients during 7 years. This article reports our outcomes and provides surgical details.

METHODS

Charts of all patients undergoing lateral thoracic expansion were reviewed. Eight of the 10 patients had symptomatic Jeune's syndrome. The other 2 had similar thoracic deformities limiting thoracic capacity. In half of the patients the procedures were performed bilaterally.

RESULTS

All patients older than 1 year of age were symptomatically benefited by lateral thoracic expansion. Functional and anatomic measurements documented thoracic enlargement in several patients who had comparable preoperative and postoperative studies. However, 2 infants with significant underlying airway disease did not improve and went on to succumb to that aspect of their disease despite enlargement of the thorax. Fracture of the titanium ministruts has been a recurrent problem, and we now use larger struts.

CONCLUSIONS

Lateral thoracic expansion is a safe and effective procedure in selected patients with Jeune's syndrome older than 1 year of age as judged by short-term and midterm follow-up. More experience and longer follow-up are required to discern the place of the lateral thoracic expansion in the overall management of these patients.

Revising psychoanalytic interpretations of the past. An examination of declarative and non-declarative memory processes

The author reviews a contemporary cognitive psychology perspective on memory that views memory as being composed of multiple separate systems. Most researchers draw a fundamental distinction between declarative/explicit and non-declarative/implicit forms of memory. Declarative memory is responsible for the conscious recollection of facts and events--what is typically meant by the everyday and the common psychoanalytic use of the word 'memory'. Non-declarative forms of memory, in contrast, are specialised processes that influence experience and behaviour without representing the past in terms of any consciously accessible content. They operate outside of an individual's awareness, but are not repressed or otherwise dynamically unconscious. Using this theoretical framework, the question of how childhood relationship experiences are carried forward from the past to influence the present is examined. It is argued that incorporating a conceptualisation of non-declarative memory processing into psychoanalytic theory is essential. Non-declarative memory processes are capable of forming complex and sophisticated representations of the interpersonal world. These non-declarative memory processes exert a major impact on interpersonal experience and behaviour that needs to be analysed on its own terms and not mistakenly viewed as a form of resistance.

Duplex criteria for determination of 50% or greater carotid stenosis

Recently the North American Symptomatic Carotid Endarterectomy Trial investigators reported a benefit of carotid endarterectomy compared with medical therapy for symptomatic patients with 50% or greater carotid stenosis. This has necessitated the development of screening parameters for diagnosis of 50% or greater carotid stenosis on the basis of the reference standards used in the study by the North American Symptomatic Carotid Endarterectomy Trial. The duplex scans and arteriograms of 110 patients (210 carotid arteries) were reviewed by blinded readers. Duplex measurements of peak systolic velocity and end diastolic velocity were recorded, and the ratio of these velocities in the internal and common carotid arteries was calculated. The criteria determined for detection of 50% or greater stenosis were as follows: peak systolic velocity of the internal carotid artery greater than 170 cm/s (sensitivity, 92%; specificity, 90%; positive predictive value, 92%; negative predictive value, 90%; and accuracy, 91 %); end diastolic velocity of the internal carotid artery greater than 60 cm/s (sensitivity, 92%; specificity, 86%; positive predictive value, 95%; negative predictive value, 79%; and accuracy, 91 %); ratio of peak systolic velocity of the internal carotid artery to peak systolic velocity of the common carotid artery greater than 2 (sensitivity, 93%; specificity, 75%; positive predictive value, 83%; negative predictive value, 89%; and accuracy, 85%); and ratio of end diastolic velocity of the internal carotid artery to end diastolic velocity of the common carotid artery greater than 2.4 (sensitivity, 96%; specificity, 79%; positive predictive value, 88%; negative predictive value, 92%; and accuracy, 89%). It is concluded that 50% or greater carotid artery stenosis can be reliably determined by duplex criteria. The use of receiver operating characteristic curves allows the individualization of duplex criteria to the clinical situation.

The self-assembly of a lipophilic guanosine nucleoside into polymeric columnar aggregates: the nucleoside strucutre contains sufficient information to drive the process towards a strikingly regular polymer

Lipophilic guanosine derivatives act as self-assembled ionophores. In the presence of alkali metal ions in organic solvents, these G derivatives can form tubular polymeric structures. The molecular aggregates formed by 3',5'-didecanoyl-2'-deoxyguanosine (1) have been characterised by SANS and NMR spectroscopy. The polymer is structured as a pile of stacked G quartets held together by the alkali metal ions that occupy the column's central channel. The deoxyribose moieties, with their alkyl substituents, surround the stacked G quartets, and the nucleoside's long-chain alkyl tails are in intimate contact with the organic solvent. In this polymeric structure, there is an amazing regularity in the rotamers around the glycosidic bond within each G quartet and in the repeat sequence of the G quartets along the columns. In hydrocarbon solvents, these columnar aggregates form lyomesophases of the cholesteric and hexagonal types.

Compression of the trachea by the innominate artery in a 2-month-old child

SUMMARY. We utilized improved methods for assessing airway structure and function to define the clinical significance of the innominate artery syndrome. Both infant pulmonary function tests (IPFT) and noninvasive controlled ventilation computed tomography (CVCT) were used, along with traditional diagnostic techniques in a 2-month-old child with compression of the trachea by the innominate artery. These tests provided objective documentation of functional impairment before surgery and improvement postoperatively. These tests should aid in the understanding of this controversial syndrome and help to further define treatment options.

Use of a low-prime circuit for bloodless heart transplantation in xenotransplant of 5-7 kilogram primates

There is a great effort to decrease blood product use during open-heart surgery in pediatrics. We were presented with a research challenge to accomplish heart xenotransplantation from donor cynomologous monkey (Macaca fascicularis) to recipient olive baboon (Papio anubis) of 5-7 kilograms without benefit of donor or banked blood products. The purpose of this study was to design and implement a practical, low-volume circuit to minimize hemodilution and avoid the use of blood products. A simple circuit was assembled using a low-volume oxygenator with hardshell venous reservoir, an 1/8-inch arterial line, an 1/4-inch venous line, and gravity drainage. Three xenotransplants were performed and evaluated. The mean recipient weights were 6.3 +/- 0.7 kg. Circuit prime volume was 228 +/- 5.8 mL, and bypass time was 85 +/- 6.7 min. Blood flow rates were 585 +/- 113 mL/min with postmembrane arterial line pressures of 344 +/- 81 mmHg, and patient mean arterial pressures (MAP) of 51.4 +/- 16.7 mmHg. Venous saturations were 63.7 +/- 8.0%. The hematocrit prebypass was 37.4 +/- 3.2, bypass 20.7 +/- 0.9, post-MUF 27.8 +/- 3.3, and 7 days postoperative 24.5 +/- 7.5%. Platelet count was 289 +/- 1.1 K/microL, 147 +/- 37.1 K/microL, and 322 +/- 292.7 K/microL prebypass, postbypass, and 7 days postoperative, respectively. Plasma-free hemoglobin prebypass was 7.5 +/- 4.4 mg/dL and postbypass 22.2 +/- 16.5 mg/dL with no noted hematuria during and after the procedure. All patients survived and were successfully weaned from cardiopulmonary bypass (CPB) with same day extubation. A low-prime circuit for bloodless heart surgery is possible. To achieve low reservoir levels, especially without the use of an arterial line filter (ALF), it is necessary to have a full armament of monitoring and alarm devices.

Guest and subunit exchange in self-assembled ionophores

[reaction: see text] Self-assembled ionophores, formed by hydrogen bonding of isoG 1 around a cation, are dynamic structures. Multinuclear NMR spectroscopy in CD(3)CN-CDCl(3) showed that cation exchange is >10(4) faster than exchange of isoG 1 ligand in (isoG 1)(10)-Cs(+) Ph(4)B(-). The cationic guest also affected the kinetic stability of the complex. 2D-EXSY NMR experiments in CDCl(3) showed that ligand exchange was 2 orders of magnitude faster for the Li(+)-decamer than for the Cs(+)-decamer.

Social/emotional intelligence and midlife resilience in schoolboys with low tested intelligence

Seventy-three inner-city boys with a mean IQ of 80 were followed prospectively from age 14 until age 65. Their adult adjustment was compared to a socioeconomically matched sample of 38 boys with a mean IQ of 115. Although childhood social disadvantage did not distinguish the groups with low and high IQs, half of the low-IQ men enjoyed incomes as high and had children as well-educated as did the high IQ men. These resilient low-IQ men were more likely to be generative, to use mature defenses, and to enjoy warm object relations than the high IQ group as a whole.

Magnetoencephalographic characterization of sleep spindles in humans

Sleep spindles in EEG recordings of adults are most prominent over the central and frontal midline regions. Early magnetoencephalographic recordings agreed with conventional EEG findings. However, more recent small-array magnetoencephalography and quantitative EEG studies suggest that the source areas for spindles are more widespread. We used a whole-head 122-channel biomagnetometer to characterize the sources of sleep spindles in four normal volunteers. Parallel interactive and automated multiple dipole spatiotemporal source modeling was conducted on the data sets of 10 spindles from each subject. Principal component analysis was used to estimate the number of sources in interactive source modeling, and singular value decomposition was used in automated dipole modeling. Spectral analysis of the epochs containing sleep spindles was performed. Principal component analysis and singular value decomposition suggested that all sleep spindles were made up of activity from multiple sources. Similarly, interactive and automated multiple dipole source modeling showed that three or more sources were present in 75% of spindle bursts. The sources for sleep spindles localized to all four cerebral lobes. Parietal and frontal lobes were the areas most frequently involved. Interactive source modeling resulted in more frequent temporal lobe than occipital dipole localizations; automated source modeling showed more frequent occipital than temporal sources. Spindle source localizations varied across subjects and across different spindles within subjects. Our results indicate that individual sleep spindles are generated by multiple cortical sources that are widespread within and across individuals.

Magnetic source imaging and brain surgery: presurgical and intraoperative planning in 26 patients

OBJECT

The availability of large-array biomagnetometers has led to advances in magnetoencephalography that permit scientists and clinicians to map selected brain functions onto magnetic resonance images. This merging of technologies is termed magnetic source (MS) imaging. The present study was undertaken to assess the role of MS imaging for the guidance of presurgical planning and intraoperative neurosurgical technique used in patients with intracranial mass lesions.

METHODS

Twenty-six patients with intracranial mass lesions underwent a medical evaluation consisting of MS imaging, a clinical history, a neurological examination, and assessment with the Karnofsky Performance Scale. Magnetic source imaging was used to locate the somatosensory cortex in 25 patients, the visual cortex in six, and the auditory cortex in four. The distance between the lesion and the functional cortex was determined for each patient. Twenty-one patients underwent a neurosurgical procedure. As a surgical adjunct, a frameless stereotactic navigational system was used in 17 cases and a standard stereotactic apparatus in four cases. Because of the results of their MS imaging examination, two patients were not offered surgery, four underwent a stereotactic biopsy procedure, 10 were treated with a subtotal surgical resection, and seven were treated with complete surgical resection. One patient deteriorated before a procedure could be scheduled and, therefore, was not offered surgery, and two patients were offered surgery but declined. Three patients experienced surgery-related complications.

CONCLUSIONS

Magnetic source imaging is an important noninvasive neurodiagnostic tool that provides critical information regarding the spatial relationship of a brain lesion to functional cortex. By providing this information, MS imaging facilitates a minimum-risk management strategy and helps guide operative neurosurgical technique in patients with intracranial mass lesions.

Neonatal intrapericardial teratomas: clinical and surgical considerations

Intrapericardial teratomas are rare primary cardiac tumors of infancy and childhood. We describe three neonates with intrapericardial teratomas diagnosed during fetal life and treated after birth. Clinical and anatomic considerations suggest that cardiopulmonary bypass provides for safe tumor dissection and complete excision of the tumor, thereby decreasing the risk of recurrence.

Magnetoencephalographic patterns of epileptiform activity in children with regressive autism spectrum disorders

BACKGROUND

One-third of children diagnosed with autism spectrum disorders (ASDs) are reported to have had normal early development followed by an autistic regression between the ages of 2 and 3 years. This clinical profile partly parallels that seen in Landau-Kleffner syndrome (LKS), an acquired language disorder (aphasia) believed to be caused by epileptiform activity. Given the additional observation that one-third of autistic children experience one or more seizures by adolescence, epileptiform activity may play a causal role in some cases of autism.

OBJECTIVE

To compare and contrast patterns of epileptiform activity in children with autistic regressions versus classic LKS to determine if there is neurobiological overlap between these conditions. It was hypothesized that many children with regressive ASDs would show epileptiform activity in a multifocal pattern that includes the same brain regions implicated in LKS.

DESIGN

Magnetoencephalography (MEG), a noninvasive method for identifying zones of abnormal brain electrophysiology, was used to evaluate patterns of epileptiform activity during stage III sleep in 6 children with classic LKS and 50 children with regressive ASDs with onset between 20 and 36 months of age (16 with autism and 34 with pervasive developmental disorder-not otherwise specified). Whereas 5 of the 6 children with LKS had been previously diagnosed with complex-partial seizures, a clinical seizure disorder had been diagnosed for only 15 of the 50 ASD children. However, all the children in this study had been reported to occasionally demonstrate unusual behaviors (eg, rapid blinking, holding of the hands to the ears, unprovoked crying episodes, and/or brief staring spells) which, if exhibited by a normal child, might be interpreted as indicative of a subclinical epileptiform condition. MEG data were compared with simultaneously recorded electroencephalography (EEG) data, and with data from previous 1-hour and/or 24-hour clinical EEG, when available. Multiple-dipole, spatiotemporal modeling was used to identify sites of origin and propagation for epileptiform transients.

RESULTS

The MEG of all children with LKS showed primary or secondary epileptiform involvement of the left intra/perisylvian region, with all but 1 child showing additional involvement of the right sylvian region. In all cases of LKS, independent epileptiform activity beyond the sylvian region was absent, although propagation of activity to frontal or parietal regions was seen occasionally. MEG identified epileptiform activity in 41 of the 50 (82%) children with ASDs. In contrast, simultaneous EEG revealed epileptiform activity in only 68%. When epileptiform activity was present in the ASDs, the same intra/perisylvian regions seen to be epileptiform in LKS were active in 85% of the cases. Whereas primary activity outside of the sylvian regions was not seen for any of the children with LKS, 75% of the ASD children with epileptiform activity demonstrated additional nonsylvian zones of independent epileptiform activity. Despite the multifocal nature of the epileptiform activity in the ASDs, neurosurgical intervention aimed at control has lead to a reduction of autistic features and improvement in language skills in 12 of 18 cases.

CONCLUSIONS

This study demonstrates that there is a subset of children with ASDs who demonstrate clinically relevant epileptiform activity during slow-wave sleep, and that this activity may be present even in the absence of a clinical seizure disorder. MEG showed significantly greater sensitivity to this epileptiform activity than simultaneous EEG, 1-hour clinical EEG, and 24-hour clinical EEG. The multifocal epileptiform pattern identified by MEG in the ASDs typically includes the same perisylvian brain regions identified as abnormal in LKS. When epileptiform activity is present in the ASDs, therapeutic strategies (antiepileptic drugs, steroids, and even neurosurgery) aimed at its control can lead to a significa

Neuromagnetic assessment of pathophysiologic brain activity induced by minor head trauma

BACKGROUND AND PURPOSE

Patients with mild traumatic brain injury (TBI) often show significant neuropsychological dysfunction despite the absence of abnormalities on traditional neuroradiologic examinations or EEG. Our objective was to determine if magnetic source imaging (MSI), using a combination of MR imaging and magnetoencephalography (MEG), is more sensitive than EEG and MR imaging in providing objective evidence of minor brain injury.

METHODS

Four subject groups were evaluated with MR, MSI, and EEG. Group A consisted of 20 neurologically normal control subjects without histories of head trauma. Group B consisted of 10 subjects with histories of mild head trauma but complete recovery. Group C consisted of 20 subjects with histories of mild head injury and persistent postconcussive symptoms. The 15 subjects included in group D underwent repeat examinations at an interval of 2 to 4 months.

RESULTS

No MR abnormalities were seen in the normal control group or the asymptomatic group, but five (20%) of the patients with persistent postconcussive symptoms had abnormal MR findings. EEG was abnormal for one subject (5%) from the normal control group, one (10%) from the asymptomatic group, and five (20%) from the group with persistent postconcussive symptoms. MSI was abnormal for one subject (5%) from the normal control group, one (10%) from the asymptomatic group, and 13 (65%) from the group with persistent postconcussive symptoms. There was a direct correlation between symptom resolution and MSI findings for the symptomatic head trauma group.

CONCLUSION

MSI indicated brain dysfunction in significantly more patients with postconcussive symptoms than either EEG or MR imaging (P < .01). The presence of excessive abnormal low-frequency magnetic activity provides objective evidence of brain injury in patients with postconcussive syndromes and correlates well with the degree of symptomatic recovery.

Valve sparing operation in a child with aneurysmal disease of the ascending aorta

We describe an aortic valve-sparing operation in a small child with an ascending aortic aneurysm and root dilatation. The operation avoids the need for a prosthetic valve and long-term anticoagulation. Thus, the procedure is an attractive alternative for young children in whom a Ross procedure is not feasible.

Spontaneous brain magnetic activity in schizophrenia patients treated with aripiprazole

This magnetoencaphalographic (MEG) study was conducted as part of a multicenter clinical trial to study the efficacy of aripiprazole. Participants included 5 DSM-IV schizophrenia subjects and 10 age-matched normal controls. The schizophrenia subjects underwent a second MEG recording after 8 weeks of open-label treatment with aripiprazole. Overall, control subjects showed no abnormal spontaneous magnetic brain activity. At washout, 3 patients showed increased delta and theta activity along with paraxosymal bitemporal slow waves. In 2 of these patients, the slow waves were generated in the superior temporal plane, as determined by dipole modeling. In the third patient, the slow waves appeared to have been generated at multiple regions throughout the temporal and inferior parietal lobes. As a group, schizophrenia patients, when compared with normal controls, demonstrated significant decreases in alpha peak frequency and power. Following treatment, aripiprazole had a significant normalizing effect on delta and theta activity. Patients on aripiprazole continued to demonstrate significant abnormalities in alpha frequency and power.

Differences between learning disability subtypes classified using the revised Woodcock-Johnson Psycho-Educational Battery

This study examined the characteristics of students with specific learning disabilities in either reading and spelling or arithmetic. Based on scores obtained using the revised Woodcock-Johnson Psycho-Educational Battery, students with a marked weakness in arithmetic relative to reading and spelling were designated as Group A. Group R-S showed the opposite pattern. Each group included 30 participants ranging in age from 7 to 16 years, with a mean age of 10 years. The boy-to-girl ratios were 16:14 and 19:11 in Group A and Group R-S, respectively. Comparisons using measures from the Wechsler Intelligence Scale for Children-Third Edition (WISC-III) indicated that Group A was weaker in nonverbal skills than Group R-S, despite equivalent overall IQ scores between the two groups. Group R-S showed a within-group strength in nonverbal versus verbal skills. Group A students were more likely than Group R-S students to have counseling provided as part of their Individualized Education Program, suggesting greater socioemotional difficulty among Group A students. The present study supports the connection between nonverbal skills and socioemotional functioning noted by previous researchers, and generalizes findings from earlier studies to more current test editions.

Cellular retinoic acid-binding protein(II) presence in rat uterine epithelial cells correlates with their synthesis of retinoic acid

Vitamin A (retinol) and retinoic acid are necessary for the maintenance of the female reproductive system of higher animals. Our previous work has demonstrated cell specific expression of cellular retinoic acid-binding protein (CRABP) and cellular retinoic-acid binding protein(II) [CRABP(II)] in the uterus of the rat. CRABP(II) expression was shown to be induced in the uterine surface epithelial cells by treatment of prepubertal rats with pregnant mare serum gonadotropin (PMSG). Here we report that, after PMSG treatment, collected uteri had markedly higher levels of retinoic acid than did the uteri of prepubertal rats treated with the control vehicle. Smooth muscle, stromal, and epithelial cells were then cultured from uteri from such animals and provided with retinol or with the retinol/retinol-binding protein complex. Retinoic acid production, analyzed by high-performance liquid chromatography, was observed for the epithelial cells from the uteri of prepubertal animals treated with PMSG, cells previously shown to express CRABP(II) and confirmed here to continue to express it in culture. Little or no retinoic acid was produced by cultured epithelial cells from the prepubertal uteri [shown previously to be negative for CRABP(II)] or by smooth muscle and stromal cells taken from uteri of prepubertal or PMSG-treated rats (shown previously to express CRABP). Retinoic acid production by uterine epithelial cells [and CRABP(II) expression] was also observed if the prepubertal rat was treated with estrogen before cell collection. At no time did cells expressing CRABP exhibit significant retinoic acid synthesis. Thus, this system revealed an important difference in retinoid metabolism between cells expressing CRABP and CRABP(II) and suggests CRABP(II) may participate in retinoic acid production and/or secretion.

Intrathoracic cystic hygroma: a report of three cases

Cystic hygromas are relatively uncommon benign tumors of the lymphatic system. The lesions frequently are apparent at birth, and more than 90% are detected before the end of the second year of life. Most commonly, cystic hygroma presents as a soft tissue mass in the posterior triangle of the neck, and only rarely does it extend into the mediastinum. Isolated intrathoracic hygromas are exceedingly rare and have been reported infrequently among children. Herein the authors review three cases of intrathoracic cystic hygroma, spanning a period of 30 years at their institution.

Regulation and localization of cellular retinol-binding protein, retinol-binding protein, cellular retinoic acid-binding protein (CRABP), and CRABP II in the uterus of the pseudopregnant rat

Three members of the superfamily of small intracellular carrier proteins for lipophilic compounds are cellular retinol-binding protein (CRBP), cellular retinoic acid-binding protein (CRABP), and cellular retinoic acid-binding protein II (CRABP II). Retinol-binding protein (RBP) is a secreted protein that binds and solubilizes vitamin A for transport. Here we report the coordinate regulation of RBP, CRBP, retinol, and CRABP II in the uterus of the pseudopregnant rat. In the proliferative stage of the uterus, which was induced by PMSG, the messenger RNA (mRNA) and protein levels of RBP and CRBP as well as retinol levels significantly decreased. This pattern of regulation was duplicated by estrogen treatment of prepubertal rats. In addition, CRBP and RBP were found to be colocalized to the stromal cells of the rat uterus by immunohistochemistry and [35S]methionine-labeled affinity chromatography, respectively, and were not detected in other cell populations. CRABP II mRNA and protein expression were up-regulated in the proliferative phase of the uterus brought about by PMSG injection or, alternatively, by estrogen treatment of prepubertal rats. CRABP II was localized to the surface epithelium, but was not seen elsewhere, including glandular epithelium. Immunolocalization of CRABP showed staining of the smooth muscle and stromal cells of the uterus. The appearance of CRABP in the stroma of the uterus also correlated with PMSG injection as well as estrogen treatment. Although estrogen induced the appearance of both binding proteins, CRABP mRNA levels peaked between 4-24 h postestrogen treatment, whereas CRABP II mRNA levels continued to rise 48 h postestrogen treatment. These data demonstrate an important role for vitamin A and retinoid-binding proteins in rat uterine physiology.

Determination of duplex Doppler ultrasound criteria appropriate to the North American Symptomatic Carotid Endarterectomy Trial

BACKGROUND AND PURPOSE

The North American Symptomatic Carotid Endarterectomy Trail (NASCET) demonstrated the benefit of carotid endarterectomy for symptomatic patients with > or = 70% carotid stenosis. Screening for detection of significant carotid occlusive disease has relied on duplex Doppler imaging. However, traditional duplex categories (50% to 79%, 80% to 99%) are not directly applicable to NASCET. We sought to evaluate duplex criteria for determination of > or = 70% carotid stenosis.

METHODS

Duplex scan and arteriograms of 110 patients (210 carotids), performed within 1 month of each other, were reviewed by blinded readers. Arteriographic stenosis was determined by the NASCET method. Duplex measurements of peak systolic and end-diastolic velocity (PSV, EDV) were recorded, and ratios of velocities in the internal and common carotid arteries (ICA, CCA) were calculated. Receiver-operator characteristic (ROC) curves of sensitivity, specificity, positive and negative predictive values (PPV, NPV), and accuracy were determined.

RESULTS

Interobserver agreement for measurement of arteriographic stenosis was "almost perfect" (kappa=0.86). The criteria chosen for detection of > or = 70% stenosis were PSVICA>210 cm/s (sensitivity, 94%; specificity, 77%; PPV, 68% NPV, 96% accuracy, 83%) EDVICA>70 cm/s (sensitivity, 92%; specificity, 60%; PPV, 73%; NPV, 86%; accuracy 77%), PSVica/PSVCCA >3.0 (sensitivity, 91%; specificity, 78%; PPV, 70%; NPV, 94%; accuracy, 83%), and EDVICA/EDVCCA>3.3 (sensitivity, 100%; specificity, 65%; PPV, 65% NPV, 100%; accuracy, 79%).

CONCLUSIONS

We conclude that > or = 70% carotid stenosis can be reliably determined by duplex Doppler ultrasound. Individual vascular laboratories must validate their own results.

Population requirements for capitation planning in pediatric cardiac surgery

OBJECTIVE

To determine the population number necessary to generate a sufficient volume of pediatric cardiac surgeries to allow accurate prediction of resource utilization.

DESIGN

All pediatric cardiac surgical patients receive care in our institution by means of only four clinical pathways that are based on acuity, not diagnosis or procedure. This allows accurate tracking of resource utilization. Based on available information, 750 consecutive surgically treated patients were retrospectively assigned to a pathway. They were subsequently subdivided into study groups of decreasing sizes from 150 to 35. Variability of pathway distribution from group to group was examined as a measure of the ability to predict resource utilization based on group size. Pediatric cardiac statistics from the state of Ohio were then used to extrapolate to the population base necessary to generate each group size.

SETTING

A regional pediatric cardiac referral center.

PATIENTS

All sequential patients who underwent pediatric cardiac surgery between July 1991 and January 1994.

RESULTS

Statewide statistics showed that a population base of 1 million people generates 100 pediatric cardiac operations. Groups of 100 patients or greater had minimal variation in pathway distribution from group to group, allowing accurate prediction of hospital charges. This was not true for groups of 50 patients or less.

CONCLUSIONS

Resource utilization for pediatric cardiac surgery can be accurately predicted in a capitated setting for populations of 1 million covered lives (100 procedures) or greater. For populations of 500 000 covered lives or less, variability of case mix is great enough to suggest the need for a more individualized payment mechanism.

Transfusion patterns in pediatric open heart surgery

BACKGROUND

Transfusions in pediatric open heart surgery were analyzed to determine the percentage of patients transfused, the types and volumes of blood components used, and the relationships among transfusions, patient characteristics, surgeon, and surgical procedure.

STUDY DESIGN AND METHODS

In a 9-month period, 122 patients, aged 12 or less (median, 1 year; 31% <4 months old), underwent 126 procedures (37 routine, 60 complex, 29 repeat operations). Bypass circuit size and priming solution, target intraoperative hematocrit, heparinization, protamine reversal, and transfusion indications and doses were standardized. The number of full "adult" units of packed red cells (RBCs), units of fresh-frozen plasma (FFP), and platelet concentrates (PCs) transfused in the operating room through postoperative Day 3 were tabulated.

RESULTS

RBCs, FFPs, and PCs were transfused in 98, 54, and 58 percent of cases, respectively. Twenty-two percent of components were transfused postoperatively. The average numbers of components transfused for complex procedures (3.4 RBCs, 6.1 total) and repeat operations (4.0 RBCs, 8.1 total) were greater than those for routine procedures (1.8 RBCs, 2.1 total) (p<0.01). The average total number of components transfused did not correlate with surgeon or patient age; patients <4 months old used the largest mean numbers of RBCs and total components of all types. For four procedures, preoperative crossmatch and directed-donation collection orders that would be expected to produce acceptable utilization rates and a <15-percent chance of needing additional components were determined.

CONCLUSION

Blood order protocols for pediatric open heart surgery can be procedure-specific, should address the use of non-red cell components, and should cover early postoperative transfusions.

Anomalous course of the left main coronary artery in tetralogy of Fallot

An extremely rare coronary artery anomaly where the left main coronary artery arose anteriorly from the right coronary sinus and coursed in front of the right ventricular outflow tract was present in a patient with tetralogy of Fallot. Preoperative angiocardiography was interpreted as normal. Operative recognition was prevented by dense adhesions and a partial intramural course. Division of the vessel at repair resulted in death of the patient. The angiographic pattern associated with this anomaly is very unusual, and in many views looks deceptively normal. Details are presented.

Determination of sixty percent or greater carotid artery stenosis by duplex Doppler ultrasonography

PURPOSE

The Asymptomatic Carotid Atherosclerosis Study, demonstrating the benefit of carotid endarterectomy for symptom-free patients with 60% or greater carotid artery stenosis, has given rise to the need for development of screening parameters for detection of these lesions. Traditional duplex categories (50% to 79%, 80% to 99%) are not applicable. We sought to develop duplex criteria for determination of 60% or greater carotid artery stenosis by comparison with arteriography.

METHODS

The duplex scans and arteriograms of 110 patients (210 carotid arteries), obtained within 1 month of each other, were reviewed by blinded readers. Arteriographic stenosis was determined by the method of the Asymptomatic Carotid Atherosclerosis Study. Duplex measurements of peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded, and ratios of velocities in the internal and common carotid arteries (ICA, CCA) were calculated. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), and accuracy were determined, and receiver-operator characteristic curves were generated.

RESULTS

Interobserver agreement for measurement of arteriographic stenosis was "almost perfect" (kappa = 0.86). The criteria determined for detection of 60% or greater stenosis were as follows: PSVICA > 170 cm/sec (sensitivity 98%, specificity 87%, PPV 88%, NPV 98%, accuracy 92%), EDVICA > 40 cm/sec (sensitivity 97%, specificity 52%, PPV 86%, NPV 86%, accuracy 86%), PSVICA/PSVCCA > 2.0 (sensitivity 97%, specificity 73%, PPV 78%, NPV 96%, accuracy 76%), EDVICA/EDVCCA > 2.4 (sensitivity 100%, specificity 80%, PPV 88%, NPV 100%, accuracy 88%). If all of the above criteria were met, 100% accuracy was achieved.

CONCLUSION

It is concluded that 60% or greater carotid artery stenosis can be reliably determined by duplex criteria. The use of receiver-operator characteristic curves allows the individualization of duplex criteria appropriate to specific clinical situations of patient screening for lesions (high sensitivity and NPV) or use as a sole preoperative imaging modality (high PPV). Individual vascular laboratories must validate their own results.

Hydrolysis of the GlcNAc oxazoline: deamidation and acyl rearrangement

The specific deamidation of 2-acetamido-1,3,4,6-tetra-O-acetyl-alpha-D-glucopyranose is achieved by p-toluenesulfonic acid-promoted hydrolysis of 2-methyl-(3,4,6-tri-O-acetyl-1,2-dideoxy-alpha-D-glucopyrano)-[2,1 -d]-2- oxazoline 2 to give quantitative formation of the 1,3,4,6-tetra-O-acetyl-2-amino-2-deoxy-alpha-D-glucopyranose p-toluenesulfonate (5d). This two-step procedure provides an amino sugar which may be readily acylated to give novel glycoconjugates. Alternatively, base-catalyzed O-1-->N-2 acyl rearrangement of the amino tosylate 5d gives the 2-acetamido-3,4,6-tri-O-acetyl-2-deoxy-D-glucopyranose 4 as a 9:1 mixture of alpha and beta anomers. Thus, hydrolysis of GlcNAc oxazoline 2 gives the amino-ester 5 as the kinetic product and the amido-alcohol 4 as the thermodynamic product.

Primary aortoesophageal fistula caused by an atherosclerotic thoracoabdominal aortic aneurysm: a case report and review of the literature

A 55-year-old woman suffered an episode of massive hematemesis caused by an aortoesophageal fistula from an atherosclerotic thoracoabdominal aortic aneurysm. In situ grafting of the thoracic portion of the aneurysm was followed by sepsis and a sinus tract between the mid-esophagus and the aortic prosthesis. Graft removal, aortic closure, esophageal closure and axillobifemoral bypass allowed clearing of the sepsis and recovery. Severe hypertension followed aortic closure and extra-anatomic bypass and resulted in the eventual death of the patient 16 months later from dissection of the ascending aorta with pericardial tamponade. There are very few treated cases of aortoesophageal fistulas caused by atherosclerotic aneurysms reported in the literature. Furthermore, there are no reported cases where the aorta was closed at the level of the subclavian artery with extra-anatomic bypass to restore blood flow to the lower half of the body.

Standardizing care delivery for infants and children with common congenital cardiac lesions

The emergence of managed care is influencing the practices of pediatric cardiology and cardiac surgery. The need for efficiencies brought about by standardizing care whenever possible has led to the development of care guidelines and clinical pathways. Care guidelines are general algorithms mapping the care of a specific problem. They are patient oriented and cover all aspects of care from diagnosis onward. National task forces have recently published guidelines for the care of children with specific congenital cardiac defects, and some of these are reviewed. Clinical pathways are more specific to an episode of inpatient or outpatient care. They consist of expected defined outcomes of care, including all tests, monitoring, and intervention. In other fields, clinical pathways have been developed for specific diagnoses or procedures. However, in pediatric cardiac surgery, the variety of conditions and operations is so great that two different methods of acuity-based, rather than disease-based, clinical pathway methodologies were developed that have been shown to decrease lengths of stay and hospital charges. Refinement of the system will require more sophisticated data, including the delineation of actual costs rather than charges, along with refinement and standardization of outcomes measurements. With fundamental changes in the delivery system, the roles of the specialist and the primary care physician have undergone changes that will continue to evolve. Vigilance on the part of all providers will be necessary to assure quality of care in this new milieu.

Lateral thoracic expansion for Jeune's asphyxiating dystrophy: a new approach

A new procedure is described for thoracic expansion in Jeune's asphyxiating dystrophy. The chest wall is enlarged by division of ribs and underlying tissue in a staggered fashion so that either rib or periosteum covers the lung. New bone formation has been demonstrated so that a viable enlargement has been obtained. The clinical result is excellent to date.

Hypoplasia of the eustachian valve and abnormal orientation of the limbus of the foramen ovale in hypoplastic left heart syndrome

We examined the eustachian valve and the limbus of the foramen ovale in 42 hearts with hypoplastic left heart syndrome (HLHS) and in 16 normal hearts. In HLHS, only 4.8% of the eustachian valves were moderately to well developed, whereas the remaining 95.2% were abnormal (p < 0.001): 92.9% of the eustachian valves were absent or markedly hypoplastic, and 2.4% had an abnormally redundant and enlarged eustachian valve. The eustachian valve was well developed in 87.5% of normal hearts. In addition, the lesser development of the eustachian valve seemed to correlate with lesser development of the left side of the heart. The limbus was well developed in 100% of the normal hearts and moderately to well developed in only 33.3% of the HLHS group (p < 0.001). Most hearts in the HLHS group had marked hypoplasia of the limbus, which was rotated and deviated so as to be close to the superior vena caval entrance.

Clinical pathways can be based on acuity, not diagnosis

The standardization of medical practice is gaining acceptance as a technique for controlling length of stay and hospital charges, while maintaining quality. Most clinical pathways address specific diagnoses or procedures, but we have developed a new approach in which pathways for cardiac care are based on acuity. All congenital cardiac surgical care rendered at Columbus Children's Hospital now falls within one of four such clinical pathways. This simplified approach is easy to use and has been well accepted. Our experience in a group of 107 consecutive patients treated in this fashion is described. The results of variance analyses, along with length of stay and charge data, are presented to demonstrate the degree to which resource utilization can be standardized in this widely variable group of patients whose problems were made cohesive by classification according to acuity level. We conclude that the resultant standardization offers considerable advantages for the managed care environment.

Retinol processing by the peritubular cell from rat testis

The cells that surround and support the seminiferous epithelium of the tubules in the testis, i.e., the peritubular or myoid cells, are known to contain relatively high amounts of cellular retinol-binding protein (CRBP). This suggests that they may play an important role in the movement or metabolism of retinol (vitamin A alcohol), which is required for the maintenance of spermatogenesis. Peritubular cells in culture, isolated from the testes of the 20-day-old rat, maintained high levels of CRBP and had the ability to internalize retinol from retinol-binding protein (RBP), the blood transport protein for retinol, in a manner suggesting a receptor-mediated process. Little of the internalized retinol was esterified, in contrast to what occurs in other cell types that contain high amounts of CRBPs, and very little, if any, lecithin-retinol acyltransferase activity was present in microsomes obtained from the cultured cells. The cells did, however, have the ability to synthesize and release their own RBP to the medium. This suggests that retinol from the blood may actually reach the seminiferous epithelium by passing across the peritubular cell, released on a new molecule of RBP, rather than by entering into the tubule bound to the preexisting RBP present in the interstitial fluid.

Inhibition of crossed caudal interneurons by lateral interneurons in lamprey spinal chord during fictive locomotion

Templates of the membrane potential profiles from lateral (LI) interneurons and motoneurons during glutamate- and N-methyl-D-aspartate (NMDA)-induced fictive locomotion showed pronounced plateau phases. In contrast, crossed caudal (CC) interneurons had a less obvious and steeper plateau region that was followed by a clear notch coinciding with the end of the lateral interneuron plateau phase. These results indicate a significant inhibitory input from LI to CC interneurons.

Coronary artery fistula in the pediatric age group: a 19-year institutional experience

Ten patients with coronary artery fistulae were identified from records at Columbus Children's Hospital between 1974 and 1993. Clinical presentations of patients were quite variable, from 1 day to 20 years of age. Symptoms ranged from none to severe cardiorespiratory failure requiring extracorporeal membrane oxygenation. Long term follow-up revealed one sudden death and one spontaneous closure of the fistula. This lesion should be ruled out in patients who present as extracorporeal membrane oxygenation candidates. Patients with mild forms of this lesion may be followed up medically if the left to right shunt is inconsequential, because spontaneous closure is a possibility. Because of the risk of sudden death, close long-term follow-up is mandatory even for operated patients, and antiplatelet therapy should be considered for these patients.