The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia

Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.

Endogenous opioid peptides and brain development: Endomorphin-1 and Nociceptin play a sex-specific role in the control of oligodendrocyte maturation and brain myelination

The generation of fully functional oligodendrocytes, the myelinating cells of the central nervous system, is preceded by a complex maturational process. We previously showed that the timing of oligodendrocyte differentiation and rat brain myelination were altered by perinatal exposure to buprenorphine and methadone, opioid analogs used for the management of pregnant addicts. Those observations suggested the involvement of the μ-opioid receptor (MOR) and the nociceptin/orphanin FQ receptor (NOR). However, it remained to be determined if these receptors and their endogenous ligands could indeed control the timing of myelination under normal physiological conditions of brain development. We now found that the endogenous MOR ligand endomorphin-1 (EM-1) exerts a striking stimulatory action on cellular and morphological maturation of rat pre-oligodendrocytes, but unexpectedly, these effects appear to be restricted to the cells from the female pups. Critically, this stimulation is abolished by coincubation with the endogenous NOR ligand nociceptin. Furthermore, NOR antagonist treatment of 9-day-old female pups results in accelerated brain myelination. Interestingly, the lack of sex-dependent differences in developmental brain levels of EM-1 and nociceptin, or oligodendroglial expression of MOR and NOR, suggests that the observed sex-specific responses may be highly dependent on important intrinsic differences between the male and female oligodendrocytes. The discovery of a significant effect of EM-1 and nociceptin in the developing female oligodendrocytes and brain myelination, underscores the need for further studies investigating brain sex-related differences and their implications in opioid use and abuse, pain control, and susceptibility and remyelinating capacity in demyelinating disease as multiple sclerosis.

Novel role of the nociceptin system as a regulator of glutamate transporter expression in developing astrocytes

Our previous results showed that oligodendrocyte development is regulated by both nociceptin and its G-protein coupled receptor, the nociceptin/orphanin FQ receptor (NOR). The present in vitro and in vivo findings show that nociceptin plays a crucial conserved role regulating the levels of the glutamate/aspartate transporter GLAST/EAAT1 in both human and rodent brain astrocytes. This nociceptin-mediated response takes place during a critical developmental window that coincides with the early stages of astrocyte maturation. GLAST/EAAT1 upregulation by nociceptin is mediated by NOR and the downstream participation of a complex signaling cascade that involves the interaction of several kinase systems, including PI-3K/AKT, mTOR, and JAK. Because GLAST is the main glutamate transporter during brain maturation, these novel findings suggest that nociceptin plays a crucial role in regulating the function of early astrocytes and their capacity to support glutamate homeostasis in the developing brain.

Deregulated Ca2+ cycling underlies the development of arrhythmia and heart disease due to mutant obscurin

Obscurins are cytoskeletal proteins with structural and regulatory roles encoded by OBSCN. Mutations in OBSCN are associated with the development of hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). Specifically, the R4344Q mutation present in immunoglobulin domain 58 (Ig58) was the first to be linked with the development of HCM. To assess the effects of R4344Q in vivo, we generated the respective knock-in mouse model. Mutant obscurins are expressed and incorporated normally into sarcomeres. The expression patterns of sarcomeric and Ca2+-cycling proteins are unaltered in sedentary 1-year-old knock-in myocardia, with the exception of sarco/endoplasmic reticulum Ca2+ adenosine triphosphatase 2 (SERCA2) and pentameric phospholamban whose levels are significantly increased and decreased, respectively. Isolated cardiomyocytes from 1-year-old knock-in hearts exhibit increased Ca2+-transients and Ca2+-load in the sarcoplasmic reticulum and faster contractility kinetics. Moreover, sedentary 1-year-old knock-in animals develop tachycardia accompanied by premature ventricular contractions, whereas 2-month-old knock-in animals subjected to pressure overload develop a DCM-like phenotype. Structural analysis revealed that the R4344Q mutation alters the distribution of electrostatic charges over the Ig58 surface, thus interfering with its binding capabilities. Consistent with this, wild-type Ig58 interacts with phospholamban modestly, and this interaction is markedly enhanced in the presence of R4344Q. Together, our studies demonstrate that under sedentary conditions, the R4344Q mutation results in Ca2+ deregulation and spontaneous arrhythmia, whereas in the presence of chronic, pathological stress, it leads to cardiac remodeling and dilation. We postulate that enhanced binding between mutant obscurins and phospholamban leads to SERCA2 disinhibition, which may underlie the observed pathological alterations.

Structure of giant muscle proteins

Giant muscle proteins (e.g., titin, nebulin, and obscurin) play a seminal role in muscle elasticity, stretch response, and sarcomeric organization. Each giant protein consists of multiple tandem structural domains, usually arranged in a modular fashion spanning 500 kDa to 4 MDa. Although many of the domains are similar in structure, subtle differences create a unique function of each domain. Recent high and low resolution structural and dynamic studies now suggest more nuanced overall protein structures than previously realized. These findings show that atomic structure, interactions between tandem domains, and intrasarcomeric environment all influence the shape, motion, and therefore function of giant proteins. In this article we will review the current understanding of titin, obscurin, and nebulin structure, from the atomic level through the molecular level.

A randomised study of prophylactic G-CSF following MRC UKALL XI intensification regimen in childhood ALL and T-NHL

BACKGROUND

Despite the current widespread use of prophylactic G-CSF in children with solid tumours and leukaemia, its effectiveness has not been clearly demonstrated. This randomised study evaluates the role of G-CSF given after a 5-day intensification block in children with acute lymphoblastic leukaemia (ALL).

PROCEDURE

Forty-six children with ALL or T-Cell non-Hodgkins lymphoma (NHL) treated on MRC ALL 97, UKALL XI or UKCCSG 9504 NHL protocols were randomised to receive granulocyte colony-stimulating factor following either the first or the second block of intensive chemotherapy in a cross-over study to determine if the prophylactic administration of G-CSF could reduce the rate of readmission to hospital for management of febrile neutropenia.

RESULTS

There was a statistically significant difference in the rate of hospital admission in the group receiving prophylaxis, with 34 of 46 being admitted, compared to 42 of 46 patients in the control arm (74 vs. 91%; P=0.0386). There were no differences found in duration of hospital admission, haematological toxicity, neutrophil recovery or duration of supportive care between the two groups. There was no demonstrable cost benefit derived from the prophylactic administration of G-CSF.

CONCLUSIONS

This study shows that the prophylactic administration of G-CSF following intensification chemotherapy for childhood ALL and T-NHL produces a significant reduction in the rate of readmission to hospital for the management of febrile neutropenia.

Molecular markers for predicting prostate cancer stage and survival

OBJECTIVE

To assess several molecular markers (detected by immunohistochemistry, IHC) to determine whether they can be used to improve the prognostic value of histological grade alone in predicting the behaviour of prostate cancer.

PATIENTS AND METHODS

Tumour tissue was retrieved from 156 men in whom tumour grade, stage and survival were known. The outcome measures were: (i) local stage (T-stage, organ-confined vs extraprostatic); (ii) metastatic status (M-stage, bone metastasis vs no bone metastasis); and (iii) survival. The IHC markers used were chosen to provide a broad representation of various aspects of tumour biology, i.e. the androgen receptor (AR) and oestrogen receptor (ER), adhesion molecules (E-cadherin), proliferation markers (MIB-1), tumour-suppressor genes (TP53 and the retinoblastoma gene product, Rb) and other novel cancer-related proteins (cyclin D1 and the breast cancer susceptibility gene product, BRCA2). All factors were assessed using logistic regression and Cox proportional-hazards survival models for predictive value, after adjusting for effects.

RESULTS

MIB-1, ER, cyclin D1 and E-cadherin all showed close statistically significant univariate associations with histological grade. Univariate analysis also identified close statistically significant associations between T-stage and both MIB-1 and E-cadherin. Likewise, there were close univariate associations for both M-stage and survival, and MIB-1, cyclin D1 and ER. Logistic regression modelling identified MIB-1, cyclin D1 and ER as statistically significant predictors of M-stage and, once MIB-1 was entered into the model, the effects of grade no longer made a significant contribution. MIB-1 was a significant predictor for T-stage, but the effects of grade remained significant in this model. Cox proportional-hazards modelling identified MIB-1, cyclin D1 and ER as being statistically significant predictors of survival, after adjusting for grade. After adjusting for both grade and MIB-1, the effects of cyclin D1 and ER were no longer statistically significant. Excess MIB-1, cyclin D1 or ER expression tended to be present within the most poorly differentiated and advanced-stage lesions; this provides an inherent instability to the models described. TP53, Rb, AR and BRCA2 were of limited prognostic value.

CONCLUSIONS

MIB-1, ER and cyclin D1 provide prognostic information that is clearly independent of grade. However, their true clinical value is probably limited because they are expressed mainly in the most advanced lesions. Nevertheless, MIB-1 expression is of sufficient value to warrant inclusion in future prognostic models. Furthermore, the expression of cyclin D1 and ER may reflect aspects of tumour biology that individually are worthy of further investigation. However, none of the IHC markers used in this study can be recommended for use in routine histological preparations.

Proximal tibiofibular bifurcation synostosis for the management of longitudinal deficiency of the tibia

Three adults with severe longitudinal deficiency of the tibia (LDT), in which an unossified proximal tibial anlage was present, who had been treated with proximal tibiofibular bifurcation synostosis (PTFBS) in early childhood, were evaluated between 20 and 31 years after the index procedure. All three were found to be functioning well as below-the-knee (BK) amputees. Mediolateral stability and anteroposterior instability of the knee were present in all cases. Instrumented motion analysis revealed diminished loading characteristics of the prosthetic limb, similar to that described for BK amputees in general. The most significant gait deviations at the knee unique to this study group were a quadriceps-avoidance gait pattern and an increased dynamic varus alignment. Instrumented muscle testing suggested that these deviations were a consequence of ligamentous instability. This study supports the concept that the presence of a proximal tibial anlage in severe LDT is indication for a surgical strategy that preserves the biological knee joint. The PTFBS maintains the integrity of the knee-extensor mechanism, the fibular collateral ligament, the tibiofemoral joint capsule, and the medial collateral ligament, enhancing the long-term stability and function of the knee joint.

The Fasting Hyperglycaemia Study: I. Subject identification and recruitment for a non-insulin-dependent diabetes prevention trial

Subjects at increased risk for developing non-insulin-dependent diabetes mellitus (NIDDM) were encouraged via a public awareness campaign, general practitioners, or a direct approach (in the case of women with previous gestational diabetes) to attend one of three English and two French centers for fasting plasma glucose (FPG) measurement. Of 1,580 subjects (mean +/- SD age, 47 +/- 10 years), 29% were male, 56% had a diabetic relative, 20% had a history of elevated blood glucose or glycosuria, and 9% previously had gestational diabetes. Thirty-one percent (493) had an initial increased fasting glucose ([IFG] 5.5 to 7.7 mmol.L-1), 3% (41) a diabetic fasting glucose ([DFG] > or = 7.8 mmol.L-1), and 66% (1,046) a normal fasting glucose ([NFG] < 5.5 mmol.L-1). Four hundred forty-one of the 493 returned for a second FPG measurement, and 67% (293) of these had a similar value on repeat testing 2 weeks later. A 75-g, 2-hour oral glucose tolerance test (OGTT) in 223 of these subjects showed that 37% (83) had impaired glucose tolerance (IGT), 26% (58) diabetes mellitus (DM), and 37% (82) normal glucose tolerance (NGT). Seven percent of self-referred patients had NIDDM by World Health Organization (WHO) criteria. Eighty-eight percent of those with an initial DFG had an increased glycated hemoglobin (> 6.2%), and 75% an increased fructosamine (> 282 mumol.L-1). While these two glycemic measures provided good discrimination for diabetes, neither were reliable in detecting those with increased but not diabetic FPG values. In conclusion, 293 (19%) of 1,580 self-referred subjects were identified as having persistently increased FPG, and 227 have been entered into a randomized NIDDM prevention trial evaluating healthy-living advice and sulfonylurea therapy.

Telecommunications and disease management in the home environment: new strategies to improve outcomes

This article provides an overview of the issues and effects of principle-centered health care within organized systems of care; portrays a comprehensive disease management framework for home health care; and offers virtual health management, telecommunications, and mobile computing strategies to enable health management enterprises to achieve health and outcomes maximization accountability demands in managed care.

Granulocyte colony-stimulating factor in established febrile neutropenia: a randomized study of pediatric patients

PURPOSE

Infection in neutropenic patients is potentially life-threatening and carries important implications for hospital resource use. Prophylactic administration of cytokines may reduce the severity of neutropenia, but involves the treatment of all patients for the possible benefit of a minority. This study evaluates whether treatment with cytokines in the setting of established febrile neutropenia will influence outcome and be potentially more cost-effective.

PATIENTS AND METHODS

In a double-blind study, pediatric patients with fever and severe neutropenia were randomized to receive granulocyte colony-stimulating factor ([G-CSF] filgrastim; 5 microg/kg/d) or placebo, in addition to antibiotics. The study protocol required a resolution of fever and a neutrophil count > or = 0.2 x 10(9)/L for hospital discharge. Patients could be randomized for up to four independent febrile episodes. A total of 186 episodes of febrile neutropenia were investigated.

RESULTS

Patients randomized to G-CSF had a shorter hospital stay (median, 5 v 7 days; P = .04) and fewer days of antibiotic use (median, 5 v 6 days; P = .02). G-CSF-treated patients also had more rapid neutrophil recovery and higher neutrophil levels at discharge. The 2-day reduction in hospital stay reduced the median bed cost by 29% per patient admission (P = .04).

CONCLUSION

Under the clinical guidelines of our institution, the use of G-CSF in the treatment of established febrile neutropenia produced a small but significant reduction in the time that children required antibiotics and hospital admission, with possible cost savings.

Acute toxicity in pelvic radiotherapy; a randomised trial of conformal versus conventional treatment

BACKGROUND

A prospective, randomized clinical trial to assess the effect of reducing the volume of irradiated normal tissue on acute reactions in pelvic radiotherapy accured 266 evaluable patients between 1988 and 1993.

PURPOSE

This is the definitive analysis to assess the differences between the conformal and conventional arms of the trial.

MATERIALS AND METHODS

In both arms, patients were treated with 6 MV X-rays using a 3-field technique (in all but 5 cases) consisting of an anterior and two wedged lateral or posterior oblique fields; in the conventional arm, rectangular fields were employed, whereas in the conformal arm, the fields were shaped with customized blocks drawn according to the beam's-eye-view of the target volume. The most common dosage was 64 Gy in 2-Gy fractions 5 times a week, although a subgroup (of ca. bladder patients) were treated with 30-36 Gy in once-a-week 6 Gy fractions. Each patients completed a comprehensive acute toxicity scoring questionnaire concentrating on bowel and bladder problems, tiredness and nausea, before the start of treatment, weekly during and for 3 weeks after the end of treatment and then monthly for a further 2 months. compliance was excellent.

RESULTS

There were no differences between the patients in the two arms with respect to age, gender, tumour type (52% prostate, 41% bladder, 5% rectum, 2% other) fractionation/dosage, anterior field size, weight, or baseline symptoms. Substantial differences in normal-tissue volumes (rectum, bladder, etc.) were achieved: median high-dose volume (HDV) of 689 cm3 for the conformal technique versus 792 cm3 for the conventional. A clear pattern of an increase in symptoms during RT, followed by a decrease after RT, was observed for the patient group as a whole. However, a very extensive analysis has not revealed any (statistically) significant differences between the two arms in level of symptoms, nor in medication prescribed. The disparity between our findings and those of other, non-randomized studies is discussed.

CONCLUSIONS

The data on late effects must be collected and analyzed before any definite conclusions can be drawn on the benefits of conformal therapy in the pelvis.

Centers of excellence: a medical measurement or marketing myth?

Managed care organizations, physician groups and hospital systems are all increasingly pressured to identify new modes of treatment that produce verifiable outcomes while reducing the revolving door pattern of health care for the chronically ill. Providers are also faced with creating systems of care to differentiate themselves from the competition in the marketplace. Disease-specific health management programs are being used to address both issues. When used properly, they can be promising tools in the battle to maintain health care quality while containing costs. Skillful balancing of these two important factors can ensure maximum value for both patients and payers. Are centers of excellence the critical pathway of the future? Or are they merely a marketing ploy to generate incremental growth and profitability for savvy business executives and medical group management entrepreneurs? This article provides an overview of the center of excellence concept, addresses its misuse in the industry and discusses the strategic and marketing implications for organizations considering this approach as a tool to demonstrate full accountability and meritorious outcomes.

Longitudinal deficiency of the fibula. Operative treatment

We reviewed the results of early amputation and prosthetic fitting in twenty-five children (thirty-one extremities) who had longitudinal deficiency of the fibula and were managed between 1977 and 1992. The median age at the time of the initial operation was thirteen months (range, eight months to nine years and eight months). The median duration of follow-up was eight years and ten months (range, two years and six months to sixteen years and eleven months). A Syme amputation was performed on fifteen extremities (thirteen children), and a modified Boyd amputation (which included resection of the distal tibial physis) was performed on sixteen extremities (thirteen children). (One child had a Syme amputation on one side and a Boyd amputation on the other and is thus included in both groups). In twenty-seven extremities, simultaneous excision of the fibular anlage was performed to prevent the development of a deformity secondary to the potential tethering effect. In twelve extremities, a diaphyseal osteotomy of the tibia also was performed to correct tibial bowing and to improve the mechanical alignment of the extremity. At the time of follow-up, the patients who had had a Syme amputation had more problems related to reformation of the calcaneus, instability of the heel pad, prosthetic suspension, and excessive length of the residual extremity. The modified Boyd amputation improved the function of the heel pad and the prosthetic suspension and provided the optimum length of the residual extremity. We also found that an early diaphyseal osteotomy of the tibia to correct severe bowing improved prosthetic fitting. This study did not support the concept that early resection of the fibular anlage or a diaphyseal osteotomy of the tibia prevents the development of hypoplasia of the lateral femoral condyle and associated genu valgum deformity.

Operative treatment of bone overgrowth in children who have an acquired or congenital amputation

Fifty-three children who were less than thirteen years old were followed for a median of seven years and ten months (range, two years and nine months to fourteen years and six months) after operative treatment for overgrowth of the tibia or humerus after amputation. During the thirty-one years in which these children were managed, three operative techniques were used in successive periods. Thus, the fifty-three children could be divided into three groups: thirty-one who had had a resection and revision, nine in whom the bone had been capped with a synthetic device, and thirteen in whom the bone had been capped with an autogenous tricortical bone graft from the iliac crest. A retrospective review was performed to determine the result and complications associated with each of these techniques. Survival analysis revealed that subsequent procedures were performed in twenty-six (84 per cent) of the thirty-one patients who had had a resection and revision, in seven of the nine in whom the bone had been capped with a synthetic device, and in four of the thirteen in whom the bone had been capped with an autogenous bone graft. The estimated mean survival time (that is, the time to a subsequent procedure) was five years in the group that had had the bone capped with an autogenous graft and three years and six months in the group that had had resection and revision; the difference is significant (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Symptoms and health problems in pregnancy: their association with social factors, smoking, alcohol, caffeine and attitude to pregnancy

This paper describes the prevalence and correlates of symptoms and health problems in pregnancy using data from a prospective population study in London. Data on the prevalence of 11 symptoms and 12 health problems were obtained at three points in pregnancy from a consecutive sample of 1513 white women. Relationships were examined between these symptoms and a range of psychosocial factors including social class, education, marital status, income, smoking, alcohol, caffeine, attitude to pregnancy and whether the pregnancy was planned. Most women reported nausea and breast tenderness in early pregnancy. Heartburn, backache, constipation and headaches were also common. The prevalence of symptoms tended to increase with gestation except for nausea and vomiting. Women with manual occupations, minimum education, low income, single marital status and unplanned pregnancy reported more of most symptoms except nausea which was associated with higher social status. A negative attitude to pregnancy was associated with more headaches but was unrelated to nausea. Women who smoked reported more 'nerves and depression' but less nausea. In general, nausea and vomiting showed a different pattern of associations from all other symptoms.

Local anaesthetic agents in surgery for ingrown toenail

To determine the most effective local anaesthetic for ingrown toenail surgery, 100 procedures were performed after patients had been randomized to receive lignocaine, bupivacaine or hyaluronidase and bupivacaine. The effect of each anaesthetic was monitored and 80 patients returned a follow-up questionnaire. There was no significant difference in the time for the local anaesthetic to take effect, or in the pain caused by its injection or the procedure. Significant differences were found between treatments with respect to pain at discharge from hospital and significantly fewer patients who received bupivacaine experienced pain 24 h after surgery (P = 0.002). Bupivacaine provides quick-acting and long-lasting anaesthesia and should be used in preference to lignocaine.

An individualized, comprehensive asthma care treatment program

In the conclusion of a three-part series on patient-centered asthma care, the authors describe the program developed at National Jewish Center for Immunology and Respiratory Medicine. Beginning at the time of diagnosis, the interdisciplinary intervention team works in tandem with the patient and family to build confidence, skill, and motivation in self-management.

Asthma care map for decision making

In the second part of a three-part series on patient-centered asthma care, the authors describe the eight critical elements of multidisciplinary care management for patients with moderate to severe asthma.

Patient-centered asthma care: a community-based multidisciplinary model

In this first part of a three-part series, the authors discuss a treatment program for patients with chronic, severe asthma. Of all chronic diseases, asthma has proven to be one of the most expensive--financially, physically, and psychologically. Although the symptoms are usually reversible, they can be severe if left untreated. Physicians, nurses, and case managers across the country are recognizing the total value of treatment at "centers of excellence." In referring their toughest asthma cases to these centers, health care professionals and patients alike are experiencing the positive benefits received from a patient-centered, multidisciplinary approach.

Treatment of slipped capital femoral epiphysis with a spica cast

Thirteen patients who had seventeen slipped capital femoral epiphyses were managed with a spica cast between 1984 and 1986. The average time in the plaster cast was three months. Complications were noted in fourteen of the hips. Three pressure sores developed in two patients. Further slipping developed in three hips once the cast had been removed, and chondrolysis developed in one of these hips. Chondrolysis developed in eight additional hips, and the lesion was transient in four of them. Degenerative changes developed in all nine hips with chondrolysis, regardless of whether the chondrolysis was transient or permanent. The degenerative changes were Iowa Grade I in three of these hips, Grade II in two hips, and Grade III in four. Chondrolysis developed in six of the eight black patients and in four of the five black boys. Chondrolysis developed in six of the nine hips that had a Grade-II or III slip. These findings have led us to abandon the use of a spica cast as a mode of treatment for slipped capital femoral epiphysis.

Results of surgical treatment of talipes equinovarus congenita

A series of 153 feet in 103 patients were surgically treated for idiopathic clubfeet (mean follow-up period of 10.3 years). Thirty-four percent had prior surgery before referral to the authors' institution. Functional results were excellent in 28.7%, good in 37.9%, fair in 13.1%, and unsatisfactory in 20.3%. The complication rate was 7.4%. Serious complications included translocation of os calcis, avascular necrosis of the talus, and injuries to neurovascular structures. Pain after strenuous activities was noted in 11.3% of the feet. In 9.8% of feet, limitation of activities was noted by the patients. Translocation of the hindfoot was associated with extensive subtalar release and often resulted in poor function. At operation, extensive subtalar release should only be performed with caution after failure of correction from release of other medial and posterior structures.

Congenital longitudinal deficiency of the tibia

Fifty-seven patients (seventy-one limbs) who had congenital longitudinal deficiency of the tibia (tibial hemimelia) were retrospectively categorized according to radiographic type (Types 1 through 4, as described by Jones et al.). At an average follow-up of nine years, fifty-six of fifty-seven patients walked independently. An ablative surgical procedure was performed on sixty-one of the seventy-one lower extremities. According to the classification of Jones et al., fifty-four limbs had a Type-1 (a or b) or Type-2 deficiency. In twenty-two of these extremities, disarticulation of the knee was performed; in twenty-five, a Syme amputation; and in one, a Chopart amputation. The ipsilateral foot was retained in six extremities that had a severe Type-1 or Type-2 deficiency. Medial transfer of the fibula (the Brown procedure) generally yielded less than satisfactory results; in ten of fourteen extremities, one or more additional operations were needed. Seventeen extremities were classified as having a Type-3 or Type-4 deficiency; Syme amputation was done in nine and Chopart amputation, in four. Despite satisfactory reconstruction of the ankle, a Syme amputation was necessary in most extremities that had a Type-4 deficiency because a major leg-length discrepancy was projected. In four limbs that had a Type-3 or Type-4 deficiency, the foot was retained.

Multiple osteotomies with Zickel nail fixation for polyostotic fibrous dysplasia involving the proximal part of the femur

Involvement of the proximal part of the femur by polyostotic fibrous dysplasia is a progressive and disabling condition that leads to deformity. Morbidity is high in terms of recurrent fracture and deformity. Conventional methods of treatment have been ineffective in controlling these problems. The cases of four patients were reviewed to determine the natural history of polyostotic fibrous dysplasia involving the proximal part of the femur. In six femora, multiple osteotomies with fixation using a Zickel nail was utilized to provide definitive control of deformity and recurrent fracture and to allow the patients to return to normal activities.

Dermoid cyst of the spine in childhood

A 1 year, 10-month-old boy presented with a history of meningitis, a recent neurologic deficit, and myelographic evidence of a thoracic, extradural compressive lesion. The lesion was subtotally totally excised at surgery and found to be a dermoid cyst. Treatment of this uncommon tumor is facilitated by its early recognition and excision before onset of infection. Incomplete removal can result in regrowth.

Foam bones. Experimental teaching aid

The teaching of surgical anatomy is an important aspect of an orthopedic training program. The fabrication of polyurethane bones by the authors' staff has proved to be a simple, inexpensive, and rapid means of duplicating bones, permitting the orthopedic surgeons to experiment with new surgical techniques as well as to teach surgical skills. Polyurethane bones may be purchased commercially but are much less costly and more instructive when made by staff members.

Emergicenters. Opportunity or threat?

Political, social, and economic pressures on the healthcare industry are resulting in the development of new approaches to the delivery of quality health care to consumers. One of the newest responses to these change forces has been the development and proliferation of freestanding emergency centers. This article examines the underlying causes behind their development, describes the distinct services and strengths of the "emergicenter" concept, and shows how medical group practices can turn a potential competitive threat into an opportunity for future growth.

Proximal femoral focal deficiency: a 50-year experience

The case histories of 91 patients (54 male, 37 female) with proximal femoral focal deficiency identified measurements which allow the physician to predict ultimate growth and pelvo-femoral stability early in the patient's life. For unilateral patients, the classification correlated with percentage of femoral inhibition, acetabular index, shelf index and acetabular dysplasia, enabling prediction to be made within the first two years of life. A constant percentage of femoral inhibition was confirmed in both unilateral and bilateral patients, and the effects of classification and associated anomalies were determined. Bilateral proximal femoral focal deficiency occurred twice as frequently among males, and function at maturity was primarily dependent upon leg-length differential, foot position and associated anomalies, and secondarily upon absolute leg-length and pelvo-femoral stability.

Acid-base and metabolic responses to anion infusion in the anesthetized dog

This study evaluated the acid-base and metabolic effects of several organic anions which might have application in the correction of metabolic acidosis during hemodialysis. Anesthetized dogs were infused intravenously with the sodium salts of either chloride, bicarbonate, acetate, lactate, or pyruvate. Acetate perturbated metabolism more than any of the other organic anions infused. These perturbations included hypoxemia, reductions in serum potassium and phosphorus, a decrease in plasma, glucose, and increases in intermediary metabolites such as lactate, acetoacetate and beta-hydroxybutyrate. Transferance of our findings to hemodialysis suggests that acetate would compromise the ability of dialysis to reduce body burdens of potassium and phosphorus and provide proper base repletion. Pyruvate would appear superior to acetate as a base substitute by virtue of its lesser effects on oxygen consumption and electrolyte distribution and its capacity to produce glucose. However, the significant production of lactate with pyruvate infusion, coupled with diffusive losses of bicarbonate during dialysis and the possible instability of pyruvate in solution, would still hinder proper base repletion. Bicarbonate generation with lactate infusion was too slow to provide a practical alternative for base repletion in hemodialysis. Bicarbonate infusion caused minimal alterations in intermediary metabolism. This, in conjunction with obviating diffusive losses, suggests the use of bicarbonate would allow more appropriate base repletion during hemodialysis.

Proximal femoral focal deficiency: natural history and treatment

The leg-length discrepancy in patients with proximal femoral focal deficiency is difficult to treat and is often unmanageable except by amputation. To identify candidates for ablative and nonablative surgery and to outline a rational treatment program, 91 patients (120 femurs) were retrospectively analyzed to determine the relationship of absolute femoral length, relative femoral length, and pelvofemoral stability to the functional effects at maturity of various operative and nonoperative management. The direct relationship of function to Aitken classification was documented and correlated with percent femoral inhibition (p less than 0.01), and pelvofemoral stability as determined by the acetabular index (p less than 0.05), shelf index (p less than 0.001), and acetabular dysplasia (p less than 0.001). In unilateral cases, two therapeutic subgroups were identified: Class I (patients with less than 17 cm of projected extremity shortening, and evidence of pelvofemoral stability), and Class II (patients with greater than 17 cm of predicted extremity shortening). Class I patients are potential candidates for height equalization by ipsilateral lengthening and/or contralateral shortening. Class II patients should have early ablative procedures and conversion to an above-knee or below-knee amputee. In bilateral PFFD, function at maturity was primarily dependent upon leg-length differential, foot position, and associated anomalies.

Pantalar arthrodesis: a long-term follow-up

Eighty-three pantalar arthrodeses in 69 patients performed at the Shriners Hospital for Crippled Children, Greenville, South Carolina, between 1941 and 1977 were evaluated. Follow-up was from 1 to 33 years. Diagnoses included poliomyelitis, myelodysplasia, arthrogryposis, clubfeet, and extremity or spinal cord trauma. Methods of fusion were one-stage pantalar arthrodesis, two-stage triple ankle fusion, one-stage completion of prior tarsal fusion, and one-stage denudation of the talus. Pantalar arthrodesis is successful in the paralytic sensitive foot with a stable knee and there is no greater incidence of nonunion in the one-stage (Hunt-Thompson) procedure than in the two-stage procedure. Complications and failure of fusion are common in the insensitive foot.

Axillary hibernoma: review of the literature with report of a case examined angiographically

A case of hibernoma of the axilla and a review of the literature are presented. This benign tumor showed angiographic findings of hypervascularity without neovascularity or A-V shunting which differentiate it from lesions such as lipoma, fibroma, or neurofibroma.

Myelodysplastics--fate of those followed for twenty years or more

Of a total of 143 myelodysplastic patients treated between 1928 and 1951, there were sixty-three patients with severe myelodysplasia whose records allowed long-term review. At the time of writing twenty-nine were alive and were twenty to forty-three years old. All were walking in the hospital while under an intensive physical therapy program. However only two of the nine with twelfth thoracic-second lumbar function were walking at final follow-up as adults, while nineteen of the twenty with function at the third lumbar level were doing so. The status of the hips did not correlate with the ability to walk. One-third of the survivors were self-supporting at the time of writing. About one-half had scoliosis and in one-third was greater than 20 degrees.