A flexible proton beam imaging energy spectrometer (PROBIES) for high repetition rate or single-shot high energy density (HED) experiments (invited)

The PROBIES diagnostic is a new, highly flexible, imaging and energy spectrometer designed for laser-accelerated protons. The diagnostic can detect low-mode spatial variations in the proton beam profile while resolving multiple energies on a single detector or more. When a radiochromic film stack is employed for "single-shot mode," the energy resolution of the stack can be greatly increased while reducing the need for large numbers of films; for example, a recently deployed version allowed for 180 unique energy measurements spanning ∼3 to 75 MeV with <0.4 MeV resolution using just 20 films vs 180 for a comparable traditional film and filter stack. When utilized with a scintillator, the diagnostic can be run in high-rep-rate (>Hz rate) mode to recover nine proton energy bins. We also demonstrate a deep learning-based method to analyze data from synthetic PROBIES images with greater than 95% accuracy on sub-millisecond timescales and retrained with experimental data to analyze real-world images on sub-millisecond time-scales with comparable accuracy.

1173 Airway and Breathing Problems in Pierre Robin Sequence: A Systematic Review Protocol

Aim

The primary aim is to systematically review the specific airway and/or breathing problems which have been reported in Pierre Robin Sequence (PRS). Secondary aims are to understand the prevalence and severity of these airway and breathing problems, and options for screening, assessment, and monitoring.

Method

A search strategy will be designed to search the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials(CENTRAL) including a grey literature search, to identify publications on airway and/or breathing problems in Pierre Robin Sequence patients. Airway or breathing problems to be included are defined upper airway conditions (e.g., sleep apnoea) or clinically or objectively defined airway/breathing problems (e.g., increased respiratory rate, polysomnography). Screening will exclude non-English articles, abstracts, letters, editorials, expert opinions and breathing problems not anatomically related to craniofacial underdevelopment.

Results

This systematic review has been successfully registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42020210572)

Conclusions

PRS is a rare craniofacial condition which presents at birth, consisting of micrognathia, glossoptosis and airway problems, and is usually, but not always, associated with a cleft palate. There is no consensus on the type of airway problems that affect patients with PRS. The findings of this systematic review will help to develop a consensus on the airway and breathing problems in PRS and options for assessment and monitoring of the airway and breathing problem. This data may also contribute to development of a standardized guideline for management of airway and breathing problems in PRS.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Position of the greater trochanter and functional femoral antetorsion: Which factors matter in the management of femoral antetorsion disorders?

Aims

The primary aim of this study was to define and quantify three new measurements to indicate the position of the greater trochanter. Secondary aims were to define 'functional antetorsion' as it relates to abductor function in populations both with and without torsional abnormality.

Patients and Methods

Three new measurements, functional antetorsion, posterior tilt, and posterior translation of the greater trochanter, were assessed from 61 CT scans of cadaveric femurs, and their reliability determined. These measurements and their relationships were also evaluated in three groups of patients: a control group (n = 22), a 'high-antetorsion' group (n = 22) and a 'low-antetorsion' group (n = 10).

Results

In the cadaver group, the mean anatomical antetorsion was 14.7° (sd 8.5; 0 to 36.5) and the functional antetorsion 21.5° (sd 8.1; 3.6 to 44.3): the posterior tilt was 73.3° (sd 10.8; 46.9 to 88.7) and the posterior translation 0.59 (sd 0.2; 0.2 to 0.9). These measurements had excellent intra and interobserver agreement with a range from 0.93 to 0.99. When the anatomical antetorsion decreased, the greater trochanter was more tilted and translated posteriorly in relation to the axis of the femoral neck, and the difference between functional and anatomical antetorsion increased. The results the three patient groups were similar to those of the cadaver group.

Conclusion

The position of the greater trochanter and functional antetorsion varied with anatomical antetorsion. In the surgical management of femoral retrotorsion, subtrochanteric osteotomy can result in an excessively posterior position of the greater trochanter and an increase in functional antetorsion. Cite this article: Bone Joint J 2018;100-B:712-19.

Analysis of intensive care admissions among paediatric obstructive sleep apnoea referrals

Introduction The aim of this study was to identify the proportion of children referred to a paediatric tertiary referral centre who required admission to the paediatric intensive care unit (PICU) following surgery for obstructive sleep apnoea (OSA) and to establish risk factors for these admissions. Methods Retrospective review of case notes and the operative database was performed for all children undergoing adenotonsillectomy for sleep disordered breathing and OSA symptoms in Great Ormond Street Hospital over a 10-year period. Results Overall, 1,328 children underwent adenotonsillectomy for sleep disordered breathing and OSA. The mean age was 3.1 years (standard deviation [SD]: 1.7 years). A total of 37 (2.8%) were admitted to the PICU postoperatively (mean length of PICU stay: 1.2 days, standard deviation [SD]: 0.6 days) and 282 (21.2%) required nasopharyngeal airway (nasal prong) insertion intraoperatively. The mean length of stay on the ward following surgery was 1.4 days (SD: 0.8 days). Patients with severe OSA (apnoea-hypopnoea index [AHI] >10) and ASA (American Society of Anesthesiologists) grade ≥3 were more likely to require postoperative PICU admission (22/37 vs 381/1,291 [p<0.001] and 29/37 vs 660/1,291 [p=0.001] respectively). Severe OSA was also more common in children who required nasal prong insertion intraoperatively (186/282 vs 217/1,046, p<0.001). Conclusions Very few children referred to a paediatric tertiary referral centre actually require PICU admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe OSA (AHI >10) and an ASA grade of ≥3, nasopharyngeal airway insertion and potential admission to the PICU should be considered.

Late Sterile Abscess Formation in Carotid Endarterectomy Following Use of BioGlue: A Word of Caution

Introduction

BioGlue (CryoLife Inc., Kennesaw, GA) is a commonly used surgical adhesive, designed to achieve haemostasis following large vessel cardiovascular operations.

Report

An 88-year-old female presents with an enlarging right sided neck mass 9 months after carotid endarterectomy with bovine pericardial patch repair which utilised BioGlue seal the patch suture line.

Conclusion

BioGlue should be used properly and with caution. In cases of late wound complication following BioGlue use, simple drainage, debridement, and removal of BioGlue remnants may be a satisfactory approach.

Nasal dermoids in children: a proposal for a new classification based on 103 cases at Great Ormond Street Hospital

OBJECTIVES

Nasal dermoids are rare developmental anomalies seen in children. This study reports the largest case series of 103 patients seen in a quaternary specialist unit over a 10-year period. We report the surgical and radiological findings and propose a new classification system, which clearly describes the extent of the lesions, thus allowing better surgical planning.

METHODS

A retrospective review of case notes was conducted. Data collection included demographics, initial presentation, site of lesion, pre-operative CT and MRI imaging, surgical procedure, intraoperative findings (including depth of lesion), complications and recurrence. Surgical findings were correlated with radiological findings.

RESULTS

A total of 103 patients were included in the study. The mean age at presentation was 29 months. 89% of children presented with a naso-glabellar or columellar lesion and 11% had a medial canthal lesion. All the patients underwent preoperative imaging and were treated with surgical excision. 58 children had superficial lesions, 45 had subcutaneous tracts extending to varying depths. Of these, 38 had intraosseous extension into the frontonasal bones, eight extended intracranially but remained extradural and two had intradural extension. There was good correlation between radiological and surgical findings. The superficial lesions were locally excised. The lesions with intraosseous tracts were removed via open rhinoplasty and the frontonasal bones drilled for access. Intracranial extension was approached either via a bicoronal flap and frontal craniotomy or the less invasive anterior small window craniotomy.

CONCLUSIONS

This report describes the largest published cases series of nasal dermoids. The cases demonstrate the presenting features and the variable extent of the lesions. The new proposed classification; superficial, intraosseous, intracranial extradural and intracranial intradural, allows precise surgical planning. In the presence of intracranial extension, the low morbidity technique of using a brow incision and small window anterior craniotomy avoids the more invasive and commonly used bicoronal flap and frontal craniotomy.

Multi-faceted case management: reducing compensation costs of musculoskeletal work injuries in Australia

OBJECTIVES

This study aimed to determine whether a multi-faceted model of management of work related musculoskeletal disorders reduced compensation claim costs and days of compensation for injured workers.

METHODS

An intervention including early reporting, employee centred case management and removal of barriers to return to work was instituted in 16 selected companies with a combined remuneration over $337 million. Outcomes were evaluated by an administrative dataset from the Victorian WorkCover Authority database. A 'quasi experimental' pre-post design was employed with 492 matched companies without the intervention used as a control group and an average of 21 months of post-intervention follow-up. Primary outcomes were average number of days of compensation and average cost of claims. Secondary outcomes were total medical costs and weekly benefits paid.

RESULTS

Information on 3,312 claims was analysed. In companies where the intervention was introduced the average cost of claims was reduced from $6,019 to $3,913 (estimated difference $2,329, 95 % CI $1,318-$3,340) and the number of days of compensation decreased from 33.5 to 14.1 (HR 0.77, 95 % CI 0.67-0.88). Medical costs and weekly benefits costs were also lower after the intervention (p < 0.05). Reduction in claims costs were noted across industry types, injury location and most employer sizes.

CONCLUSIONS

The model of claims management investigated was effective in reducing the number of days of compensation, total claim costs, total medical costs and the amount paid in weekly benefits. Further research should investigate whether the intervention improves non-financial outcomes in the return to work process.

A robust MRI-compatible system to facilitate highly accurate stereotactic administration of therapeutic agents to targets within the brain of a large animal model

Achieving accurate intracranial electrode or catheter placement is critical in clinical practice in order to maximise the efficacy of deep brain stimulation and drug delivery respectively as well as to minimise side-effects. We have developed a highly accurate and robust method for MRI-guided, stereotactic delivery of catheters and electrodes to deep target structures in the brain of pigs. This study outlines the development of this equipment and animal model. Specifically this system enables reliable head immobilisation, acquisition of high-resolution MR images, precise co-registration of MRI and stereotactic spaces and overall rigidity to facilitate accurate burr hole-generation and catheter implantation.

To demonstrate the utility of this system, in this study a total of twelve catheters were implanted into the putamen of six Large White Landrace pigs. All implants were accurately placed into the putamen. Target accuracy had a mean Euclidean distance of 0.623 mm (standard deviation of 0.33 mm). This method has allowed us to accurately insert fine cannulae, suitable for the administration of therapeutic agents by convection-enhanced delivery (CED), into the brain of pigs. This study provides summary evidence of a robust system for catheter implantation into the brain of a large animal model. We are currently using this stereotactic system, implantation procedure and animal model to develop catheter-based drug delivery systems that will be translated into human clinical trials, as well as to model the distribution of therapeutic agents administered by CED over large volumes of brain.

Sm-p80-based DNA vaccine formulation induces potent protective immunity against Schistosoma mansoni

No effective vaccine exists for the human parasitic disease, schistosomiasis. We have targeted a functionally important antigen, Sm-p80 as a vaccine candidate because of its consistent immunogenicity, protective potential and important role in the immune evasion process. In this study we report that a Sm-p80-based DNA vaccine formulation confers 59% reduction in worm burden in mice. Animals immunized with Sm-p80-pcDNA3 exhibited a decrease in egg production by 84%. Sm-p80 DNA elicited strong immune responses that include IgG2A and IgG2B antibody isotypes in vaccinated animals. Splenocytes proliferated in response to Sm-p80 produced appreciably more Th1 response enhancing cytokines (IL-2, IFN-gamma) than Th2 response enhancing cytokines (IL-4, IL-10). These data reinforce the potential of Sm-p80 as an excellent vaccine candidate for schistosomiasis.

Are initial demyelinating event recovery and time to second event under differential control?

BACKGROUND

Relapsing-remitting multiple sclerosis (RRMS) begins with an initial demyelinating event (IDE) that can be monosymptomatic, polysymptomatic, or polyregional. Failure to recover from the IDE is a known predictor of later development of disability. Factors that predict IDE recovery (outside optic neuritis) and time to second event are relatively unknown. The authors speculate that IDE recovery and time to second event are under separate biologic or genetic control, and as such, their clinical predictors are different.

METHODS

Data on all UCSF MS clinic patients are entered prospectively into an ACCESS database. The authors identified all patients seen at the UCSF clinic within 1 year of their IDE. Expanded Disability Status Scale scores, functional system scores, and visual acuity were used to define IDE severity and recovery.

RESULTS

The cohort included 186 patients (127 women, 59 men) with an average onset age of 34 +/- 10 years with 150 whites (non-Hispanic), 15 African Americans, 11 Hispanics, eight Asians, and two unknown/unreported. Worse onset severity predicted worse IDE recovery (23.1% of the patients with severe onset vs 32.9% with moderate severity vs 56.4% with mild onset recovered completely, p < 0.001). Polyregional onset predicted poor recovery compared to monoregional onset (46.2% vs 14.4%, p < 0.001). Nonwhite patients were 2.48 times more likely than whites to experience a second episode within 1 year from onset (95% CI: 1.45 to 4.23, p < 0.001). Similarly, age younger than 30 years predicted higher risk of a second exacerbation (hazard ratio 1.92, 95% CI: 1.17 to 3.15, p = 0.010).

CONCLUSION

Initial demyelinating event recovery and time to second event may have distinct predictors. These findings suggest that recovery and time to second event might be under separate biologic control.

Comparison of treatment planning dose calculations with measurements and Monte Carlo calculations in a RANDO phantom

Solid tumours are often treated with external beams of photons generated by Bremsstrahlung radiation. These beams are shaped and filtered to optimise the dose to specific regions defined by the treatment plans, which may involve irradiations from multiple angles. It is important that doses to healthy tissue do not exceed tolerance doses and that the dose to the tumour is maximised. To accomplish these objectives, commercially available 3-D treatment planning software is used to calculate doses to healthy tissue and to the tumour. It is generally believed that these commercial software packages calculate doses through the patient to within a few per cent. In order to examine this claim, dose calculations obtained from ADAC software for external beam treatment to the pelvic region of a RANDO phantom are compared with 37 thermoluminescence dosemeters placed into several slices of a RANDO phantom. The phantom was irradiated to obtain a prescription dose of 180 cGy at the tumour location. Data from homogeneous regions agree within several per cent with results obtained from ADAC software, whereas this comparison is less favourable in regions of heterogeneity. Results from Monte Carlo calculations in a homogeneous phantom are comparable to results from ADAC treatment planning software.

2001 Volvo Award Winner in Clinical Studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice

STUDY DESIGN

Quasi-experimental, nonrandomized, nonequivalent, parallel group-controlled study involving before and after telephone surveys of the general population and postal surveys of general practitioners was conducted, with an adjacent state used as a control group.

OBJECTIVES

To evaluate the effectiveness of a population-based intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and workers' compensation-related costs.

SUMMARY OF BACKGROUND DATA

A multimedia campaign begun during 1997 in Victoria, Australia, positively advised patients with back pain to stay active and exercise, not to rest for prolonged periods, and to remain at work.

METHODS

The campaign's impact on population beliefs about back pain and fear-avoidance beliefs was measured in telephone surveys, and the effect of the campaign on the potential management of low back pain by general practitioners was assessed by eliciting their likely approach to two hypothetical scenarios in mailed surveys. Demographically identical population groups in Victoria and the control state, New South Wales, were surveyed at three times: before, during, and after intervention in Victoria.

RESULTS

The studies were completed by 4730 individuals in the general population and 2556 general practitioners. There were large statistically significant improvements in back pain beliefs over time in Victoria (mean scores on the Back Beliefs Questionnaire, 26.5, 28.4, and 29.7), but not in New South Wales (26.3, 26.2, and 26.3, respectively). Among those who reported back pain during the previous year, fear-avoidance beliefs about physical activity improved significantly in Victoria (mean scores on the Fear-Avoidance Beliefs Questionnaire for physical activity, 14, 12.5, and 11.6), but not in New South Wales (13.3, 13.6, and 12.7, respectively). General practitioners in Victoria reported significant improvements over time in beliefs about back pain management, as compared with their interstate colleagues. There were statistically significant interactions between state and time for 7 of 10 responses on management of acute low back pain, and for 6 of 10 responses on management of subacute low back pain.

CONCLUSION

A population-based strategy of providing positive messages about back pain improves the beliefs of the general population and general practitioners about back pain and appears to influence medical management.

Population based intervention to change back pain beliefs and disability: three part evaluation

OBJECTIVE

To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation.

DESIGN

Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database.

SETTING

Two states in Australia.

PARTICIPANTS

4730 members of general population before and two and two and a half years after campaign started, in a ratio of 2:1:1; 2556 general practitioners before and two years after campaign onset.

MAIN OUTCOME MEASURES

Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims.

RESULTS

In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P<0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign.

CONCLUSIONS

A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.

Two sox9 genes on duplicated zebrafish chromosomes: expression of similar transcription activators in distinct sites

Sox9 is a transcription factor required for cartilage formation and testis determination in mammals. We have cloned from zebrafish two sox9 genes, termed sox9a and sox9b. Gene phylogenies showed that both genes are orthologous to tetrapod SOX9 genes. Genetic mapping showed that these two loci reside on chromosome segments that were apparently duplicated in a large-scale genomic duplication event in ray fin fish phylogeny. Both Sox9a and Sox9b proteins bind to the HMG consensus DNA sequences in vitro. We tested different domains for transactivation potential and identified a potential activation domain located in the middle of both Sox9a and Sox9b. During embryogenesis, sox9a and sox9b expression patterns are distinct but overlap in some regions of the brain, head skeleton, and fins. Expression of sox9a/b correlates well with that of col2a1 in chondrogenic elements. In the adults, sox9a is expressed in many tissues including brain, muscle, fin, and testis, whereas sox9b expression is restricted to previtellogenic oocytes of the ovary. This expression pattern predicts that sox9a and sox9b may have unique functions in some specific tissues during development. The role of gene duplication for the evolution of developmental gene function is discussed.

Functional laryngeal dyskinesia: an important cause of stridor

Functional laryngeal dyskinesia is a disorder that presents with stridor. Failure to recognize its features can result in inappropriate investigation and treatment for a condition that has a psychogenic origin. The key feature in diagnosis is paradoxical vocal fold adduction on inspiration, as seen on fibre-optic nasendoscopy. This phenomenon together with the associated stridor may disappear after distraction techniques or when the patient is asleep. We present five such cases which presented to hospitals in south west London over a 12 month period.

Six cases of fibromatosis of the head and neck in children

Six cases of aggressive fibromatosis occurring in the head and neck in children are described. Fibromatosis is a rare, benign but locally infiltrative condition. Primary excision is not always possible in the head and neck areas. It is not always appropriate to treat children using the same modalities as adults due to associated growth problems. The case histories illustrate the management difficulties that can be encountered when treating the paediatric population.

Dercum's disease (adiposis dolorosa)

Dercum's disease (adiposis dolorosa) is a rare condition characterized by progressively painful fatty deposits, usually, in menopausal women with obesity, asthenia and mental phenomena. We report a case of a 48-year-old woman with recurrent neck swelling and pain in the neck and parotid region, and a review of management of this uncommon problem.

Laryngeal paraganglioma in a five-year-old child--the youngest case ever recorded

A paraganglioma is a neuroendocrine neoplasm that originates from the paraganglion cells of the parasympathetic system. The average age of presentation is in the fifth decade. We report a case of laryngeal paraganglioma in a five-year-old child, the youngest case ever recorded. The features of paraganglioma which differentiate it from other tumours are also discussed.

Prospective study of zero drift in fiberoptic pressure monitors used in clinical practice

One hundred and one fiberoptic pressure transducers (59 subdural and 42 ventricular) were studied in 86 patients (some in whom more than one device had been inserted). Only four complications occurred: two transient cerebrospinal fluid leaks after removal and two clinically insignificant intracerebral hematomas. No intracranial infections could be attributed to the devices. Technical problems occurred 23 times, with 11 devices ceasing to function before removal, seven becoming displaced, and five microventricular catheters failing to enter the ventricles. Zero-drift readings were obtained for 83 devices at the time of removal (median 66 hours after insertion, range 2 hours-13 days). There was a clear negative bias in the readings (median -3), with a wide range of values (-12 to +14 mm Hg; interquartile range -6 to -1) that was apparent even in the first 3 days of use. There was no important relationship between zero drift and any recorded variable. It is concluded that zero drift of fiberoptic pressure transducers is a significant problem and that undue reliance should not be placed on intracranial pressure readings from these devices in isolation from other clinical and radiological information.

Clinical use of prediction regions for motion analysis

This study assesses the diagnostic capability of statistically defined prediction regions, developed by a 'bootstrap' method, for assessing the curves of angular rotation of joints in children as they walk. The prediction regions had been previously developed in the authors' laboratory from a study of 309 normal children. The goal of the present study was to determine whether these computer-generated prediction regions could be used as a screen in clinical gait analysis, to determine whether a movement falls outside the normal range of variability. Kinematic analysis of 38 consecutive children referred to the motion analysis laboratory for clinical gait assessment provided 912 curves of lower-extremity joint angle dynamics. An experienced observer first inspected the patients' curves with mean normal curves superimposed and designated the curves as normal or abnormal. The performance of the computer-generated prediction regions was judged by comparison with the experienced observer's designations. The prediction regions were found to have a high sensitivity (81%), indicating that they can be used as an initial screen to identify deficits in lower limb function.

Molecular surface comparison: application to drug design

An interactive system for the display and manipulation of molecular surface properties is presented. The property at the molecular surface is mapped onto the sphere by gnomonic projection. This representation allows direct comparison of the surface properties of pairs of molecules. The system allows the user to explore the similarities between a pair of molecules in an interactive manner, and provides extensive visual (color-coded field and field difference maps) and numerical (rms difference value) aids to complement the user's chemical intuition. Examples of the use of the system to study beta-lactam compounds and phosphodiesterase inhibitors are presented.

Impedance analysis versus colour Duplex in femorodistal vein graft surveillance

Fifty patients who have undergone femorodistal bypass surgery have been followed up using impedance analysis and colour Duplex, with biplanar intraarterial digital subtraction angiography being used as the arbiter to define "at risk" grafts. An impedance score of 0.49 (0.43-0.55) was found in the "at risk" grafts, all of which underwent an interventional procedure compared to 0.39 (0.36-0.42) (p = 0.003, Mann-Whitney U test) in those with no problem. In total, 166 examinations were performed. The sensitivity and specificity were all greater than 91% when compared to angiography. Impedance analysis is simple, non-invasive, easy to perform and it takes only 10 min to complete the examination. In view of the results obtained using impedance analysis in comparison with Duplex scanning, we suggest that non-invasive impedance is a suitable alternative to colour Duplex for graft surveillance (mean +95% confidence interval).

Perceptions of nurses' uniforms

Patients (N = 100), nurses (N = 30), and administrators (N = 15) in a regional medical center were surveyed about the professional image inherent in different styles of nurses' uniforms. The Nurse Image Scale (NIS) was used as the data-gathering tool with pictures of the same nurse in a variety of uniforms. Results showed that patients rated some uniforms significantly differently for professional image than did nurses and administrators. There was general agreement among all respondents on the nurse they would most like to have care for them (dress with stethoscope) and the nurse they would least like to have care for them (white pants with colored top).

The non-reversed vein femoro-distal bypass graft: a modification of the standard in situ technique

The results of 85 in situ vein femoro-distal bypass grafts using a modified technique where the vein was completely mobilised but left "non-reversed" have been reviewed with particular regard to risk factors and complications. The distal anastomosis was to the infrageniculate popliteal artery in 55% and to the tibioperoneal trunk or a single calf vessel in the rest. Arteriographic run-off was by a single vessel in 42%. The primary failure rate at 1 month was 20% and the secondary failure rate 9%; the majority of early failures being due to missed technical errors despite the use of a pulse volume recorder. The cumulative secondary patency rate at 1 and 2 years was 77% and 72%; limb salvage 85% and 77%; and patient survival 89% and 83% respectively. The only significant risk factors were the level of the distal anastomosis and the run-off (P = 0.002 and 0.03 respectively). Complete mobilisation of the vein allows a tension free proximal anastomosis to the common femoral artery and avoids the risk of arteriovenous fistulae. A high vein utilisation rate of 93% was achieved by using a small 2.5 mm Hall valvulotome. Although there was a trend towards lower patency rates in veins with a minimum diameter less than 4 mm the results are still superior to PTFE. Compared to reversed vein the in situ technique has a better utilisation rate and the long-term patency rates are at least as good if not better. Improved methods of haemodynamic assessment during reconstruction to reduce technical errors may be the key to better early patency rates.

A technique for determining femoral head containment during gait

Kinematic gait analysis was carried out on 42 hips, including normal joints and joints affected with Legg-Calvé-Perthes disease. Data were analyzed by a computer algorithm that calculated three-dimensional femoral head contact with the acetabulum (containment). Patients were studied in and out of various abduction orthoses. The three-dimensional containment of the hip is reproducibly altered by various devices; specifically, the Atlanta brace increases posterior coverage and slightly increases lateral coverage, and Petrie casts improve lateral and anterior coverage at the expense of posterior containment. This analysis allows modeling of osteotomies and enhances clinical assessment of actual changes in containment with bracing.

Influence of chronic ethanol consumption on the metabolism and carcinogenicity of tobacco-related nitrosamines

The effect of chronic ethanol consumption by Syrian golden hamsters (SGH) on the carcinogenicity and target tissue metabolism of N-nitroso-pyrrolidine (NPYR) and N'-nitrosonornicotine (NNN) has been examined. Ethanol-consuming hamsters treated with NPYR developed more nasal cavity and tracheal tumours than controls. Ethanol consumption did not affect the carcino-genicity of NNN. When the metabolism of NPYR and NNN by isolated tracheal rings was examined, it was observed that tracheal rings isolated from ethanol-consuming SGH metabolized NPYR at a higher rate than similar preparations from control animals. In contrast, no differences in the rates of metabolism of NNN were observed.

The pathomechanics of gait in Duchenne muscular dystrophy

Forty-six separate gait studies were analysed for 21 ambulatory patients with Duchenne muscular dystrophy. Three groups were defined on the basis of significant gait variables: early, transitional and late. Disease progression can be predicted with 91 per cent accuracy by three gait variables: cadence, dorsiflexion in swing, and anterior pelvic tilt. The patients in the early group manifested a positive Gower's sign but gait changes were subtle, being principally slightly increased hip flexion in swing, decreased dorsiflexion in swing and reduction in cadence. The force line moved in front of the knee center early in single-limb support. In the transitional stage, anterior pelvic tilt was exaggerated, cadence was further reduced, and foot drop in swing phase was increased. Shoulder sway was noted as a compensation for gluteus medius weakness. The base of support widened. The force line remained behind the hip joint and in front of the knee joint throughout single-limb support. In the late stage, work output increased, cadence continued to drop, shoulder sway increased further, and there was a wider base of support. The force line remained very close to the center of the hip and in front of the knee at all times during single-limb support. The authors' conclusions are: (1) the earliest postural change in gait is increased lumbar lordosis secondary to gluteus maximus weakness, and at this time the quadriceps are relatively competent; (2) quadriceps insufficiency was the key factor in gait deterioration. It appeared in the transitional stage and was characterized by exaggerated anterior pelvic tilt, restricted hip extension in stance phase, equinus posturing, and maintenance of the force line in front of the knee throughout single-limb support. Long-leg bracing is indicated when these signs of quadriceps insufficiency are noted.