Mini-Open Achilles Tendon Repair: Improving Outcomes While Decreasing Complications

An acute rupture of the Achilles tendon is a traumatic injury that can cause considerable morbidity and reduced function. Nonoperative intervention may put patients at higher risk of rerupture, whereas surgical intervention carries risk of infection, wound complications, and iatrogenic nerve injury. The mini-open Achilles tendon repair technique has been popularized in helping decrease complications. The goal of this study was to examine and compare the functional outcomes and rate of complications in patients treated with a mini-open repair technique versus a traditional open repair for acute Achilles tendon ruptures. A retrospective review was performed of all patients with a complete Achilles tendon rupture that were treated by a single foot and ankle fellowship-trained surgeon. Functional outcome scores were assessed using the American Orthopaedic Foot and Ankle scoring system (AOFAS) and the Achilles Tendon Rupture Score (ATRS). Eighty-one patients with a complete Achilles tendon rupture underwent mini-open repair and 22 patients underwent traditional open repair surgery between 2013 and 2020. The mean follow-up was 38.40 months (range, 12-71). Mean preoperative AOFAS and ATRS improved in the mini-open group from 45.60 and 47.18 respectively, to 90.29 and 87.97 after surgery (p < .05). Mean preoperative AOFAS and ATRS scores for the traditional open repair (n = 22) cohort were 44.02 and 42.27, respectively. Postoperatively, the AOFAS and ATRS scores improved to 85.27 and 86.64 (P value < .05), respectively. There was no statistically significant difference in postoperative ATRS scores. However, the mini-open repair group showed a statistically higher postoperative AOFAS score (90.30) than the traditional open-repair group (85.27) (P value < .05). The overall complication rate for our study was 2.9% (2 mini-open repair and 1 traditional open repair). The complication rate in the mini-open repair group and traditional open repair cohort were 2.4% and 4.5%, respectively (P value > .05). One patient in the mini-open repair cohort (1.2%) reruptured his Achilles tendon 4 months postoperatively. A second patient in the mini-open repair group (1.2%) developed a superficial skin infection and suture irritation. One patient (4.5%) in the traditional open repair group developed a superficial skin infection. There were no sural nerve injuries in our series. The mini-open approach to repair a ruptured Achilles tendon is a viable treatment option to decrease the incidence rate of postoperative complications and rerupture rates while also producing a superior cosmetic result.Level of Evidence: 3 (retrospective cohort study N ≥ 30).

Synthetic cartilage implant hemiarthroplasty versus cheilectomy for the treatment of hallux rigidus

Degenerative arthritis of the first metatarsophalangeal joint, hallux rigidus, is the most common type of arthritis of the foot, affecting nearly 2.5% of the population over the age of 50. Hallux rigidus can be treated surgically with either Cheilectomy or Synthetic cartilage implant (SCI) hemiarthroplasty. The purpose of this study is to compare outcomes from a single institution on the treatment of hallux rigidus using cheilectomy and SCI hemiarthroplasty. Between 2012 and 2020, 49 patients underwent either a SCI (Polyvinyl alcohol hydrogels) hemiarthroplasty or Cheilectomy for the treatment of hallux rigidus. Functional scores were assessed pre and postoperatively using the American Orthopedic Foot and Ankle scoring System (AOFAS) and the Foot and Ankle Outcome Score survey (FAOS). Plantar and Dorsal range of motion was also assessed pre and postoperatively. Outcomes, complications, and any reoperations were recorded for all patients. Mean pre-op AOFAS for Cheilectomy and SCI were 49.6 and 54.8, respectively, compared to 85.3 and 89.7, respectively, after surgery (p value < 0.05). Mean pre-op Dorsal range of motion (ROM) for Cheilectomy and SCI were 24.0 and 26.0 degrees, respectively, compared to 38.0 and 42.6 degrees, respectively, after surgery (p value < 0.05). SCI hemiarthroplasty patients had higher AOFAS and dorsal ROM at the latest follow up (p value < 0.05). Synthetic cartilage implant (SCI) hemiarthroplasty and cheilectomy both offer promising results and remain viable treatment options to decrease pain, improve function, and maintain motion for hallux rigidus. SCI hemiarthroplasty may offer superior range of motion and functional outcomes than cheilectomy for hallux rigidus. LEVEL OF CLINICAL EVIDENCE: 3.

Leadership in an academic discipline

Leading an academic discipline poses moral and ethical challenges, requiring a special set of capabilities. Leadership in a clinical academic discipline involves leading the transformation of education, research, leadership and patient care. Daily struggles within strategic, political and cultural milieu are the norm and effective leaders are able to navigate through these struggles and see opportunities for growth.

The survivorship tsunami: Sustainability of current models of follow-up care

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Background: Annual statistics describe the number of anticipated new cancer cases and deaths as well as the prevalence of those living with cancer. In practice, the number of new cases is used as a proxy for cancer program size, planning program growth and determining workforce needs. While the number of new cases and prevalence has been growing linearly, it may be a poor measure for anticipating health care workforce and clinical resource needs. We explored modeling growth curves of follow-up visits based on anticipated number of new cases alone or with follow-up visits to compare these two approaches. Methods: We used the following assumptions in creating the growth curves: 1) only 50% of new cancer cases would be counted to adjust for those with metastatic disease or different follow-up schedules; 2) the first year of diagnosis would be considered treatment; 3) a common solid tumor follow-up regimen would be used that included 4 visits in year 2, 3 visits in year 3, 2 visits in year 2 and 1 visit in year 5 and thereafter; and 4) new cases would grow at a rate of 10%/year. We then modeled discharging the 50% included in the model at 5 or 10 years. We did not factor in existing patients being seen in a program. Results: If a program had 5,000 new cases in the first year, with a 10% annual growth, there would be 11,790 new cases at 10 years. If you just looked at the 50% receiving follow-up care for 10 years after diagnosis, there would be 35,928 follow-up visits at 5 years and 70,662 visits at 10 years. If you just looked at the 50% receiving follow-up care for only 5 years after diagnosis, there would be 33,428 follow-up visits at 5 years and 53,870 visits at 10 years. Further analysis based on different program sizes and assumptions will be presented. Conclusions: Planning workforce and clinical resources based on number of new cancer cases alone will be inadequate to predict those needs. Risk based modeling and triage will be needed in a new model of follow-up or survivorship care that remains to be developed, tested and deployed to avoid a crisis in cancer survivorship care.

The Big Impact of Small Groups on College Drinking

College drinking is a problem with severe academic, health, and safety consequences. The underlying social processes that lead to increased drinking activity are not well understood. Social Norms Theory is an approach to analysis and intervention based on the notion that students' misperceptions about the drinking culture on campus lead to increases in alcohol use. In this paper we develop an agent-based simulation model, implemented in MATLAB, to examine college drinking. Students' drinking behaviors are governed by their identity (and how others perceive it) as well as peer influences, as they interact in small groups over the course of a drinking event. Our simulation results provide some insight into the potential effectiveness of interventions such as social norms marketing campaigns.

Effects of a 12-month moderate weight loss intervention on insulin sensitivity and inflammation status in nondiabetic overweight and obese subjects

Weight loss intervention is the principal non-pharmacological method for prevention and treatment of type 2 diabetes. However, little is known whether it influences insulin sensitivity directly or via its anti-inflammatory effect. The aim of this study was to assess the independent role of changes in inflammation status and weight loss on insulin sensitivity in this population.Overweight and obese nondiabetic participants without co-morbidities underwent a one-year weight loss intervention focused on caloric restriction and behavioral support. Markers of inflammation, body composition, anthropometric para-meters, and insulin sensitivity were recorded at baseline, 6, and 12 months. Insulin sensitivity was assessed with frequently sampled intravenous glucose tolerance test and Minimal Model. Twenty-eight participants (F: 15, M: 13, age 39±5 years, BMI 33.2±4.6 kg/m(2)) completed the study, achieving 9.4±6.9% weight loss, which was predominantly fat mass (7.7±5.6 kg, p<0.0001). Dietary intervention resulted in significant decrease in leptin, leptin-to-adiponectin ratio, hs-CRP, and IL-6 (all p<0.02), and improvement in HOMA-IR and Insulin Sensitivity Index (SI) (both p<0.001). In response to weight loss IL-1β, IL-2, leptin, and resistin were significantly associated with insulin, sensitivity, whereas sICAM-1 had only marginal additive effect. Moderate weight loss in otherwise healthy overweight and obese individuals resulted in an improvement in insulin sensitivity and in the overall inflammation state; the latter played only a minimal independent role in modulating insulin sensitivity.

The effects of denervation and formoterol administration on facial growth

OBJECTIVE

To identify and demonstrate possible alterations of skeletal structures which might follow either unilateral surgical denervation of the masseter muscle, unilateral intramuscular injection of formoterol directly into the masseter muscle, or intramuscular formoterol injection after surgical denervation.

MATERIALS AND METHODS

Male Sprague Dawley rats (N = 16; four weeks of age) were prepared as four groups: 1. surgical sham + saline injection into the masseter muscle (sham); 2. surgical denervation of the masseter muscle only (den.); 3. surgical denervation of the masseter muscle plus intramuscular formoterol injection into the affected muscle (den.+form.); 4. intramuscular formoterol injection into the masseter muscle only (form.). The specimens were submitted for CT examination, the skulls and hemimandibles were photographed and measurements of craniofacial bones were made.

RESULTS

In this relatively small sample, comparisons between non-experimental and experimental sides revealed differences, both within the groups and for the same measurements between groups, with the den. and den.+form. groups showing the most change. Relative increases in the gonial angle shown in these groups occurred bilaterally, with the change on the experimental side always greater in magnitude than the change on the contralateral side.

CONCLUSIONS

Surgical denervation of the masseter muscle leads to an alteration in the size and shape of the skeletal structures close to the zygoma and the mandible. The intramuscular injection of formoterol into denervated masseter muscle seems to limit this skeletal alteration after surgical denervation.

Denervation and beta2-adrenoceptor-agonist administration on craniofacial bone density

OBJECTIVE

Beta2-agonist medications are thought to have adverse effects on bone density. Surgical denervation and intramuscular beta2-agonist injections appear to have opposing effects on skeletal muscles. The present study has been designed to assess the effects of denervation of the masseter, intramuscular injection of a beta2-agonist and the combination of both procedures, on bone density in the craniofacial skeleton in rats.

MATERIALS AND METHODS

Sprague-Dawley rats were prepared as four groups: 1. surgical sham + saline injection into the masseter (sham); 2. surgical denervation of the masseter (den.); 3. surgical denervation of the masseter + intramuscular formoterol injection into the affected muscle (den.+form.); 4. intramuscular formoterol injection into the masseter (form.). All specimens were submitted for CT examination and volumetric calculations of the mineralised bone tissue were performed.

RESULTS

The sham and form. groups had a greater volume of mineralised bone in the zygoma on the experimental side compared with the control side. The maxilla on the experimental side had a higher volume of mineralised bone in the den.+form. and form. groups compared with the sham and den. groups. The control side of the maxilla had a higher volume of mineralised bone in the den.+form. and form. groups compared with the den. group only.

CONCLUSION

Intramuscular administration of formoterol appears to induce a bilateral increase in bone mineral density in the maxilla and the zygoma, likely explained as a secondary effect of the well-described increase in muscle mass and strength associated with beta2-agonist administration.

A sacrococcygeal extraspinal ependymoma in a 67-year-old man: a case report and review of the literature

Extraspinal ependymomas are extremely uncommon tumours of glial origin. They occur predominantly in children and adolescents. We report a case of a subcutaneous extraspinal ependymoma in a 67-year-old man. This was excised, and the defect reconstructed with a V-Y advancement flap.

Desmopressin: therapeutic limitations in children and adults with inherited coagulation disorders

Desmopressin (DDAVP), a synthetic analogue of vasopressin has been successfully used in the treatment of type I von Willebrand's disease (VWD), mild factor VIII (FVIII) deficiency and intrinsic platelet function defects (PFDs) for almost three decades. However, there is limited published data documenting its efficacy and the reliability of circulating plasma FVIII:C as a surrogate marker of response to therapy in VWD. We report the haemostatic response to DDAVP in 133 consecutive patients (91 type I VWD, 20 mild FVIII deficiency and 22 PFDs). Minimal therapeutic response to DDAVP (0.3 microg/kg) was defined by normalization 30 min post- infusion of bleeding time for PFDs, factor VIII:C (FVIII:C) for mild haemophilia A, and von Willebrand factor antigen (VWF:Ag), von Willebrand factor functional activity (VWF:Ac) and FVIII:C for VWD. Nine out of 91 (10%) VWD patients failed to achieve minimal therapeutic response to DDAVP; plasma FVIII:C levels were an unreliable surrogate marker of DDAVP response as 6 out of 9 (67%) of these patients had normal post-infusion FVIII:C levels. Five out of the 20 (25%) patients with mild FVIII deficiency and 5 out of 22 (23%) patients with PFDs failed to achieve a minimal therapeutic response to DDAVP. DDAVP is an effective therapy in the majority of patients with type I VWD, PFDs and mild FVIII deficiency. The significant failure rate associated with this therapy supports the recent recommendations that response should be assessed in all patients at the time of diagnosis. FVIII:C is an unreliable guide of response to DDAVP in patients with VWD and therefore VWF:Ag and VWF:Ac should also be assessed. Failure to demonstrate the response of VWF:Ag, VWF:Ac and FVIII:C to DDAVP in patients with VWD is likely to increase the risk of haemorrhagic complications in patients with bleeding episodes or who are undergoing surgery.

The use of regenerable, affinity ligand-based surfaces for immunosensor applications

The regeneration of antibody-binding surfaces is of major importance for re-usable sensor formats such as required for direct 'real-time' biosensing technologies and is often difficult to achieve. Antibodies commonly bind the antigen with high avidity and may themselves be sensitive to regeneration conditions. The interaction of polyclonal anti-chlorpyriphos antibody with an immobilised chlorpyriphos-ovalbumin (chlor-oval) conjugate and the interaction of soluble recombinant CD4 with covalently immobilised anti-CD4 IgG are presented in order to highlight these difficulties. Affinity-capture is suggested as an alternative format as it facilitates surface regeneration, directed immobilisation and the attainment of interaction progress curves that conform to the ideal pseudo-first-order kinetic interaction model. Protein A, protein G and polyclonal anti-mouse Fe-coated surfaces were used to observe the interaction of captured anti-GST monoclonal antibody with glutathione-s-transferase (GST). It was shown that a protein A affinity-capture surface produced ideal interaction progress curves while both protein G and polyclonal anti-mouse Fe resulted in systemic deviations.

Estrogen treatment enhances hereditary renal tumor development in Eker rats

Hormonal influences are known to affect the development of renal cell carcinoma in man and laboratory animal models. We tested the hypothesis that estrogen treatment or ovariectomy of rats modulates renal tumor development using tuberous sclerosis 2 (Tsc2) heterozygous mutant (Eker) rats in which a germline mutation predisposes the animals to renal cell tumor development. Two-month-old female wild-type and Eker rats were ovariectomized or sham-operated and treated with placebo or 5 mg 17beta-estradiol in s.c. pellets for 6 or 10 months. Rats were examined at 8 or 12 months of age, at which time the numbers of renal tumors and preneoplastic foci were quantitated and the severity of nephropathy was assessed. In contrast to what may have been expected, prolonged estrogen treatment enhanced the development of hereditary renal cell tumors, with a 2-fold greater number of preneoplastic and neoplastic renal lesions compared with untreated Eker rats. Ovariectomized Eker rats had 33% fewer renal lesions than the unmanipulated control group. No tumors or preneoplastic lesions were present in wild-type rats at either time point. Estrogen treatment increased the severity of nephropathy in both wild-type and Eker rats, whereas ovariectomy was protective against nephropathic changes. Although estrogen is not a rat renal carcinogen, it enhanced the development of hereditary renal cell tumors when administered to Eker rats. Eker rats heterozygous for a mutation in the Tsc2 locus provide a good model in which to study how genetic and hormonal factors contribute to the development of renal cell tumors and to understand the influence genetic susceptibility has on the development of renal cell carcinoma.

Trans-antral temporalis transfer for the repair of adult cleft palates

Temporalis muscle transfer is a versatile technique frequently used for reconstructive procedures in the maxillofacial region. However the thickness of the pedicle may interfere with masticatory function when used anteriorly in the oral cavity. To repair full-length mid-palatal defects in fully dentate patients the flap can be passed through the maxillary sinus and combined with local repair of the soft palate, thus avoiding any occlusal trauma from the posterior teeth. The operation is a single stage procedure with low morbidity and few complications, and is a useful technique for repairing the large untreated clefts frequently encountered in developing countries. The procedure is used by members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons Bangladesh Project who have operated in Dhaka teaching hospitals on a regular basis since 1991.

Sex differences in myocardial infarction and coronary deaths in the Scottish MONICA population of Glasgow 1985 to 1991. Presentation, diagnosis, treatment, and 28-day case fatality of 3991 events in men and 1551 events in women

BACKGROUND

Scottish MONICA used medical and medico-legal records and World Health Organization MONICA Project criteria to register coronary events in 25- to 64-year-old residents of the high-incidence area of north Glasgow from 1985 to 1991.

METHODS AND RESULTS

Age-standardized data from 3991 episodes of nonfatal definite myocardial infarction and coronary deaths in men (mean age, 55.5 years) were compared with 1551 in women (57.0 years). Many results, such as the overall 28-day fatality rates of 49.8% in men and 48.5% in women, showed insignificant differences. However, 74.3% of deaths in men occurred out of hospital versus 67.8% in women (P = .0004). After admission to hospital, fatality rates in women were 14% higher (P = .07) and after admission to coronary care, 22% higher (P = .04). Women were more often widowed. Fewer had a history of previous myocardial infarction, but the prevalence of angina pectoris, of smoking, and of chest pain in the attack was the same as in men; more had shock, syncope, and breathlessness. More consulted a doctor before admission to hospital, which delayed their coming under care. More men had ECG Q-wave progression, and more women had smaller ECG changes. This, and marginally reduced chances of direct admission to coronary care, of thrombolysis, of aspirin, and of beta-blockers, did not explain women's excess hospital fatality.

CONCLUSIONS

Acute coronary events appear to be recognized and treated fairly equally in men and women 25 to 64 years old in Glasgow, so differences are small but subtle. More men die suddenly out of hospital; the reason why more women die after arrival may be because the equivalent number of men have already died outside.

Out-of-hospital cardiac arrest due to coronary heart disease: a comparison of survival before and after the introduction of defribrillators in ambulances

OBJECTIVE

To assess the actual impact on coronary mortality of equipping ambulances with defibrillators.

DESIGN

Retrospective analysis of routine medical and legal records of all those who had a cardiac arrest attributed to coronary heart disease occurring outside hospital in a defined population before and after the introduction of Heartstart.

SETTING

City of Glasgow, North of the River Clyde, 1984 and 1990.

PATIENTS

296 and 267 men and women aged 25-64 inclusive in 1984 and 1990 respectively who had a cardiac arrest outside hospital which was attributed to coronary heart disease (International Classification of Diseases codes 410-414, ninth revision).

RESULTS

The impact on coronary mortality in 1990 of equipping ambulances with defibrillators concurred with the earlier prediction of less than 1% of all coronary deaths. The circumstances of cardiac arrest were largely unchanged; most occurred outside hospital in the victim's home and the principal witnesses were members of the victim's family. A call for help before cardiac arrest was made in very few cases and cardiopulmonary resuscitation was attempted by laypersons in less than a third of the deaths they witnessed. There was a significant increase in the number of cardiopulmonary resuscitation attempts made by ambulance crews (16% v 32%, P < 0.01). Ambulance crews, however, still attended less than half of all cases (44% and 47%).

CONCLUSION

The impact of equipping ambulances with defibrillators will remain small unless strategies are introduced that focus on improving the public's response to coronary emergencies by calling for help promptly and initiating cardiopulmonary resuscitation before the arrival of the emergency services.

Importance of different nuclear morphologic patterns in grading prostatic adenocarcinoma. An expanded model for computer graphic filters

The aim of this work was to continue the development of an interactive workstation for the nuclear grading of prostatic lesions by including a large range of nuclear patterns. A previous model was based on four groups: hyperplasia, Mostofi grade 1, Mostofi grade 2 and Mostofi grade 3. Each group included the most common nuclear patterns of the lesions. One set used to test the model included cases showing patterns different from the typical ones of the model. Poor results were obtained for low and medium grades. A review of all the cases in our database led to the conclusion that different nuclear patterns can belong to the same "nuclear grade." Thus, in this work the model was expanded to include six groups: hyperplasia, two subgroups for Mostofi grade 1, two subgroups for Mostofi grade 2 and Mostofi grade 3. A set of 900 nuclei, 150 in each group, was selected to test the model. An additional 300 nuclei, 50 in each group, were used for a test set. The overall success rate for classifying the nuclei in the test set using the new model was 93% as compared to a rate of 71% obtained for the similar test set, described above, using the previous model. Moreover, correlating karyometric features with nuclear morphology indicated a role for nucleoli in nuclear grading. The good results obtained with large and heterogeneous sets of cases indicate that the procedures used to develop this model may be adapted for the development of models for the nuclear grading of other tumors.

Use of computer graphic filters for the nuclear grading of hematoxylin and eosin-stained specimens from prostatic lesions

An inexpensive workstation is being developed to assist pathologists in diagnosing routine hematoxylin and eosin-stained slides. A linear discriminant model was applied to karyometric features of prostate lesions, and a grade according to Mostofi was determined from the discriminant values. Twenty cases, five of hyperplasia and five each of carcinoma Mostofi grades I, II and III, for a total of 600 nuclei, were selected to train the model. Computer graphic filters were constructed from the discriminant values. Each segmented nucleus has a colored frame (the graphic filter) displayed around it. The color, determined from discriminant values and correlated with the grades, ranges from green for hyperplasia, yellow for low grade, orange for medium grade and red for high grade. An additional 20 cases, 5 of hyperplasia and 5 each of the Mostofi grades, for a total of 538 nuclei, were selected to test the graphic filter. Ninety-six percent of the hyperplasia nuclei were framed in green, 84% of low grade nuclei were framed in yellow, 90% of medium grade nuclei were framed in orange, and 89% of high grade nuclei were framed in red. These results indicate the potential of the color graphic filter to show the pathologist immediate and accurate visual information about the grade of a nucleus. This method may help with the difficult diagnosis of borderline lesions and may help in making the diagnosis from scanty biopsy material.

Potential impact of emergency intervention on sudden deaths from coronary heart disease in Glasgow

OBJECTIVE

To determine the potential impact of emergency intervention strategies to prevent deaths from coronary heart disease outside hospital.

DESIGN

Analysis of routine medical and legal records of all persons dying of coronary heart disease in a defined population.

SETTING

Glasgow City, north of the river Clyde, 1984.

SUBJECTS

420 people under 65 years for whom the underlying cause of death on the death certificate was coronary heart disease (ICD 410-414, 9th Revision).

RESULTS

Of the 296 deaths outside hospital, 73% occurred at home. The deaths of 40% of those who died outside hospital were not witnessed and these people could not have received prompt cardiopulmonary resuscitation. Only 16% of the witnesses of a death attempted cardiopulmonary resuscitation before the arrival of a doctor or an ambulance crew. Over half (53%) of the cases in which cardiopulmonary resuscitation could have been attempted by a witness, but was not attempted, death occurred in the presence of the spouse or other close relative. Death occurred in the presence of a duty doctor or the ambulance crew in a maximum of 5% of deaths outside hospital. Ninety one per cent of people were dead before a call for help was made.

CONCLUSION

Unless a greater proportion of patients receive cardiopulmonary resuscitation before emergency staff arrive at the scene the provision of emergency care staff with defibrillators is unlikely to have a significant impact on deaths outside hospital caused by coronary heart disease.

Bilateral traumatic internal carotid artery dissections: case report

Bilateral internal carotid artery dissections after blunt cervicofacial trauma are rare, with 16 cases being previously published. Management is presumed to be an extension of the dominant therapy for unilateral dissection, that being anticoagulant therapy; however, bilateral stenoses engender questions of threat to total cerebral blood flow. We herein present a patient who suffered bilateral type B dissections and who then had progression of the process on anticoagulant therapy, resulting in an unusual carotid reconstruction.

Clinical and financial aspects of shared/part-time practice

Shared and part-time medical practices are popular with both the medical group and the clinicians who fill these positions at Group Health Cooperative. The medical group benefits from the flexibility provided by part-time practitioners. Part-time clinicians have the opportunity to devote time to their families or second careers. There are, however, additional costs and administrative problems associated with shared and part-time practices.

Islet cell tumor

A case of islet cell tumor occurring in a patient with the multiple endocrine neoplasia type I syndrome is reported. Immunostaining for insulin was strongly positive in the tumor cells. Numerous dense-core granules of endocrine caliber were identified ultrastructurally. Morphometric analysis of the secretory granules in 20 islet cell tumors gave a granule size of 182 +/- 52 nm (mean +/- standard deviation).

Correlation between visual clues, objective architectural features, and interobserver agreement in prostate cancer

Three pathologists evaluated a number of designated architectural features to assign grades to 41 cases of well- to moderately differentiated adenocarcinoma, and their opinions were compared. The consensus opinion was obtained and evaluated against objective measurements of glandular architecture that were obtained by morphometric techniques. The observers agreed on gland size, gland uniformity, and the number of glands per field in only 49%, 31%, and 39% of cases, respectively. There were significant differences in the Gleason grades assigned by observers. Paired matching of individual Gleason grades showed agreement among observers in 44% (18 of 41), 56% (23 of 41), and 75% (31 of 41) of cases, respectively. This level of interobserver disagreement occurred even though cases with predominant patterns were selected carefully and those with variable patterns were excluded. A direct relationship appears to exist between increasing Gleason grade and increasing glandular variability, and there is an inverse relationship between Gleason grade, gland lumen area, and the number of glandular nuclei, as assessed by a group of pathologists.

Is compliance mismatch the major cause of anastomotic arterial aneurysms? Analysis of 42 cases

In 1,348 anastomoses carried out prior to 1976 at St. Laurence's Hospital, Dublin, 36 anastomotic aneurysms developed for an incidence of 2.7%. Six further anastomotic aneurysms occurred following repair of anastomotic false aneurysms. Suture material failure, infection or lymphatic leakage were not associated with aneurysm formation. Twenty three aneurysms occurred in eight hundred and sixty Dacron to artery anastomoses while 6 occurred in 420 vein to artery anastomoses. Anastomotic false aneurysms were found only with the Dacron to artery anastomoses. Only 9 of 590 anastomoses performed for abdominal aortic aneurysm developed false aneurysms while 14 occurred in 270 for occlusive atherosclerosis. We have concluded that compliance mismatch producing anastomotic shear stress damages the arterial wall. This structural impairment permits tearing out of sutures from the vessel wall. The process is facilitated by prior loss of structural integrity of the vessel wall.

Comparison of the pharmacokinetics of ceftazidime and moxalactam and their microbiological correlates in volunteers

We compared ceftazidime with moxalactam, a commonly utilized, currently available drug. The microbiological activities of ceftazidime and moxalactam were studied. In addition, single-dose pharmacokinetics and serum bactericidal activity 1 and 6 h after a 2.0-g, 30-min infusion of each drug were determined in a crossover study in human volunteers. In vitro, both drugs had MICs for 90% of the isolates of less than 1.0 microgram/ml against the common members of the family Enterobacteriaceae and of 8.0 micrograms/ml against Staphylococcus aureus. Against Pseudomonas aeruginosa ceftazidime was more active than moxalactam, the respective MICs for 90% of the isolates being 8 and 128 micrograms/ml. Mean half-lives were 1.75 (+/- 0.21) h for ceftazidime and 2.5 (+/- 0.38) h for moxalactam. The serum bactericidal titers for both compounds against Escherichia coli and Klebsiella pneumoniae were high. Titers against S. aureus 6 h after infusion were negative. The mean (geometric) serum bactericidal titer of ceftazidime against 31 strains of P. aeruginosa (1:44) was higher than that of moxalactam (1:3.4).

Bactericidal activity of ceftazidime in serum compared with that of ticarcillin combined with amikacin

We compared the bactericidal activity of serum attained 1 and 6 h after the termination of infusions of either ceftazidime (2 g) or ticarcillin plus amikacin (5 g and 7.5 mg/kg, respectively) in 6 volunteers against a panel of the most common pathogens found in the blood of febrile granulocytopenic cancer patients. Ceftazidime consistently produced significantly higher serum bactericidal titers at both 1 and 6 h against all species of gram-negative bacilli. Its performance against Pseudomonas aeruginosa was especially impressive. The geometric mean titer against this organism was 1:41 at 1 h, contrasted with 1:12 for ticarcillin plus amikacin (P = 0.025). However, for Staphylococcus aureus, the geometric mean serum bactericidal titer of ceftazidime was 1:3.6 at 1 h and undetectable at 6 h. Ceftazidime shows promise as single-agent therapy for serious gram-negative bacillary infections. Whether this promise is fulfilled and whether the observed antistaphylococcal activity is adequate for empiric therapy in infected granulocytopenic patients need further investigation.

A randomized, controlled trial of cefoperazone vs. cefamandole-tobramycin in the treatment of putative, severe infections with gram-negative bacilli

Cefoperazone was compared with the combination of cefamandole and tobramycin in a prospective, randomized study of putative, severe, gram-negative bacillary infections. We attempted to exclude patients with granulocytopenia or infections due to Pseudomonas species. A total of 118 isolates (94 gram-negative bacilli and 24 gram-positive cocci) caused infection in 99 of the 120 patients studied. Cefoperazone (16 micrograms/ml) was active against 93% of the organisms tested; cefamandole (16 micrograms/ml) and/or tobramycin (4 micrograms/ml) was active against 95%. Infection was cured or improved in 77% of cefoperazone-treated patients and 81% of cefamandole-tobramycin-treated patients. Bacteremia was cured or improved in 61% of cefoperazone-treated patients and in 63% of cefamandole-tobramycin-treated patients. Adverse reactions included five cases of probable antibiotic-associated nephrotoxicity in the cefamandole-tobramycin group; there were no such cases in the cefoperazone group. One patient given cefoperazone plus eight other drugs became granulocytopenic, but the condition resolved when all medications were stopped. This analysis suggests that cefoperazone alone may be as effective as cefamandole plus tobramycin in the treatment of severe infections with gram-negative bacilli and is less nephrotoxic. The role of cefoperazone in patients with granulocytopenia or infections due to Pseudomonas aeruginosa was not evaluated.

Current concepts in the surgical management of the atrophic mandible

1. For the severely atrophic mandible surgery cannot be considered as a magical panacea. 2. Retention of teeth or tooth roots is important as we are unable to predict the degree of mandibular bone resorption relating to the innate vascular pattern. 3. More emphasis should be given to mylohyoid reduction as described in this paper. 4. A gain in stability by surgery should not be at the expense of retention. 5. Mucosal grafts are more satisfactory than skin grafts. 6. Bone graft augmentation in the future must be considered with great caution. 7. When removing denture hyperplasia which involves the sulcus, every effort must be made to preserve viable mucosa in order to reconstitute a resilient border seal.

Mid-face osteotomy in the adolescent cleft palate patient

Retrognathia or retrusion of the maxilla and mid-face is present in about one-third of treated cleft palate patients. Surgical repositioning of either the dental segments, or the entire mid-face into a forward position, can greatly enhance appearance and at the same time provide for a more functional occlusion. Some surgical aspects of this work are presented together with an evaluation of soft tissue change.