Bilateral hip replacement in three patients with lysosomal storage disease: Mucopolysaccharidosis type IV and Mucolipidosis type III

The management of joint replacement in lysosomal storage diseases has not been well reported. We present three patients with progressive degenerative changes of the hips who required bilateral total hip replacement in early childhood. The stature of the patients make it essential to have access to appropriately scaled prostheses. Consideration has to be given to associated disorders of the skeleton which must be carefully screened to ensure safety in providing appropriate anaesthesia as well as ensuring that there is no cardiac abnormality. In one patient, a periprosthetic fracture was sustained in one hip in the early post-operative course requiring internal fixation.

The patient made a full recovery and all six hips were clinically and radiologically satisfactory at mid-term review.

N-terminal pro-B-type natriuretic peptide levels and early outcome after cardiac surgery: a prospective cohort study

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a powerful predictor of cardiovascular outcome in many circumstances. There are, however, limited data regarding the utility of NT-proBNP or BNP levels in patients undergoing cardiac surgery. The current study assesses the ability of NT-proBNP to predict early outcome in this setting.

METHODS

One thousand and ten patients undergoing non-emergent cardiac surgery were recruited prospectively. Baseline clinical details were obtained and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet score were calculated. Preoperative NT-proBNP levels were measured using the Roche Elecsys assay. The primary endpoint was 30 day mortality.

RESULTS

Median NT-proBNP levels were 624 ng litre(-1) among patients who died within 30 days of surgery (n=29), compared with 279 ng litre(-1) in survivors [odds ratio (OR) 1.03 per 250 ng litre(-1), 95% confidence interval 1.01-1.05, P=0.001). NT-proBNP levels remained predictors of 30 day mortality in models including either the additive EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.01), the logistic EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.004), or the Parsonnet score (OR 1.02 per 250 ng litre(-1), P=0.04). Levels of NT-proBNP were also predictors of prolonged (>1 day) stay in the intensive care unit (OR 1.03 per 250 ng litre(-1), P<0.001) and of a hospital stay >1 week (OR 1.07 per 250 ng litre(-1), P<0.001). They remained predictive of these outcomes in regression models that included either the EuroSCORE or the Parsonnet score and in a model that included all study variables.

CONCLUSIONS

NT-proBNP levels predict early outcome after cardiac surgery. Their prognostic utility is modest-but is independent of traditional indicators and conventional risk prediction scores.

Socio-economic status and early outcome from coronary artery bypass grafting

OBJECTIVE

To determine the effects of socio-economic status (SES) on the outcome of coronary artery bypass grafting (CABG).

DESIGN

Prospective cohort study.

SETTING

Regional cardiac surgical unit.

PATIENTS

1994 consecutive patients undergoing non-emergency CABG.

MEASURES

SES was determined from the patient's postcode using Carstairs tables. The primary end-point was all-cause mortality at 30 days.

RESULTS

There were 50 deaths (2.5%) within 30 days of surgery. A higher Carstairs score demonstrated a trend towards increased 30-day mortality (odds ratio (OR) 1.09 per unit, 95% CI 1.00 to 1.20, p = 0.06). In a backward conditional model, including other predictors of early mortality, Carstairs scores were independently predictive (OR 1.12 per unit, 95% CI 1.01 to 1.24, p = 0.02). In a model including only Carstairs scores and the EuroSCORE, both were independent predictors of this outcome (OR for Carstairs score 1.11 per unit, 95% CI 1.00 to 1.22, p = 0.04). The 30-day mortality increases in each quartile of Carstairs scores, with patients in quartile 4 (most deprived) at significantly higher risk compared with quartile 1 (uncorrected OR 2.53 per unit, 95% CI 1.04 to 6.15; OR corrected for EuroSCORE, 2.56 per unit, 95% CI 1.03 to 6.34, p = 0.04 for both). Similarly, patients in the least affluent quartile were twice as likely to suffer a serious complication as those in the most affluent quartile (OR 2.14 per unit, 95% CI 1.32 to 3.46, p = 0.002). This increased risk was also independent of the EuroSCORE.

CONCLUSIONS

Lower SES is associated with a poorer early outcome following CABG and is independent of other recognised risk factors.

Simultaneous bilateral avulsion fractures of the tibial tuberosity in adolescence: A case report and review of over 50 years of literature

Simultaneous bilateral avulsion fractures of the tibial tuberosity is a rare injury. Since it was first described in 1955, there have been eight similar cases. We have reviewed each of these reports and describe an additional case of a 13-year-old boy, who sustained simultaneous bilateral avulsion fractures of the tibial tuberosity from jumping while playing soccer. Like the previous reports, our patient had a satisfactory result from open reduction and internal fixation of both fractures. Despite being bilateral, these injuries have a low complication rate and good outcome comparable with that of unilateral avulsion fractures of the tibial tuberosity.

Bilateral, asymmetrical congenital dislocation of the radial heads in trisomy 8 syndrome

Congenital radial head dislocation (CRHD) can occur as an isolated abnormality, as part of an upper-limb anomaly or as a feature of at least fourteen syndromes. The dislocation may be unilateral or bilateral, and rarely can be bilaterally asymmetrical. CRHD is often asymptomatic, and may go undiagnosed and remain undetected until after a radiography has been obtained for an incidental injury. It is therefore important to be able to differentiate congenital from traumatic dislocation of the radial head. We report a mentally retarded female, known to have trisomy 8, who presented with stiffness of her elbow joints and no history of preceding trauma. Radiographs confirmed bilateral asymmetrical radial head dislocation. This combination of anterior and posterior CRHD co-existing in the same patient has not been described previously with trisomy 8 syndrome.

Miniature angled sub-selective guiding catheter aids in placing guidewire through difficult anatomy

A method for fabricating and using a "mini" guiding catheter is presented. Use of the mini guiding catheter provides the back up support necessary to enable a guidewire to traverse difficult anatomy. Use of this device to cross a lesion in an acutely angulated circumflex artery is presented.

Clenbuterol, a beta-adrenoceptor agonist, increases relative muscle strength in orthopaedic patients

1. The sympathomimetic agent clenbuterol has a muscle-specific anabolic effect in normal and wasted muscles from animals. This trial was designed to examine the effect of the drug on the recovery of muscle strength and area after open medial meniscectomy. 2. A double-blind, completely randomized, placebo-controlled study was carried out on 20 healthy male patients. Muscle strength and cross-sectional area were determined before and after surgery. Patients were treated with drug or placebo for 4 weeks postoperatively and there was a 2 week washout period. 3. The results suggest that, in the operated leg, clenbuterol treatment is associated with a more rapid rehabilitation of strength in knee extensor muscles; in the unoperated leg, knee extensor strength increased above the initial values after 6 weeks (P = 0.01). However, in terms of absolute strength the differences were not significant between the two groups. 4. It is concluded that the data lend support to the proposition that clenbuterol has therapeutic potential in the treatment of muscle-wasting conditions.

Acute calcification and carpal tunnel syndrome

Carpal tunnel syndrome is a common diagnosis, and often there is no identifiable cause. We describe the case of a patient who developed acute symptoms secondary to calcification in the carpal tunnel. The patient was treated by decompression, and made a slow, but uneventful recovery.

Transient synovitis of the hip joint

A review of 286 children who presented with transient synovitis of the hip over a 6-year period shows that the condition remains a benign disease of the paediatric hip which settles quickly with simple symptomatic treatment. We have not found any obvious causal agent for the condition despite intensive laboratory investigation. There was only one subsequent case of Perthes' disease in association with transient synovitis, causing doubt on any relationship between the two conditions. The need for extensive investigation and long-term follow-up seems to be unnecessary in transient synovitis of the hip.

Structural and biochemical evidence that scrapie-associated fibrils assemble in vivo

Scrapie-associated fibrils (SAF) are a ubiquitous pathological feature of brains affected by scrapie and the other scrapie-like agents. They are composed of PrP, a heterogeneous glycoprotein which is also present in normal brain but not as SAF. The PrP protein associated with SAF is partially resistant to proteinase K, whereas the soluble form is not. It has been proposed that SAF do not exist as such in vivo, but rather self-assemble from subunit structures liberated from membranes by detergent extraction during purification. We have purified SAF by a method that does not employ proteinase K. We show that the PrP protein from infected but not uninfected brain is partially resistant to protease digestion before and after detergent extraction. Likewise, SAF can be sheared by sonication before or after detergent extraction. In addition, SAF from mice infected with different strains of scrapie have different sedimentation properties. Since SAF-dependent properties exist before detergent extraction, then so must SAF. They are therefore not a detergent-induced artefact but most probably assemble in vivo.

An electron microscopic study of inclusion bodies in synaptic terminals of scrapie-infected animals

Inclusion bodies consisting of vesicles of about 25 nm diameter and occurring in the synaptic terminals of scrapie-infected animals have been described by a number of people. In the present study these inclusion bodies were looked for in the neocortex, hippocampus and corpus callosum in a variety of strains of mice (C3H, LM, RIII, IM, VL) infected with different strains of scrapie agent (22C, 79A, ME7, 87V) after intracerebral inoculation. In plaque-bearing models of scrapie, terminals containing synaptic inclusion bodies were frequently found surrounding the amyloid plaque cores in the neocortex but not in the corpus callosum. In non-plaque-bearing models, terminals containing synaptic inclusion bodies were found in the neuropil of the neocortex and hippocampus. For all models, these bodies were either presynaptic or postsynaptic but were not, as a rule, found on both sides of the same synapse. Fibrillary material was frequently seen in the postsynaptic terminals containing the inclusion bodies in both the plaque- and non-plaque-bearing models. On one occasion fibrillary material was seen, together with the inclusion bodies, in a neuron cell body. Inclusion bodies were also seen in the neocortex of hamsters infected with the 263K strain of scrapie agent and a Cheviot sheep infected with the ME7 strain of agent. The inclusion bodies and the fibrillary material were thought to be derived from the breakdown of neurotubules.

Prevention of haematogenous infection in prosthetic joints

A survey was conducted to identify the attitude of consultant orthopaedic surgeons and rheumatologists in Scotland, North East England and Ireland, to the prevention of blood-borne infection in prosthetic joints. Of the 61% who completed the questionnaire, 65% gave advice about intercurrent infection, a similar number gave advice about the use of prophylactic antibiotics before certain surgical procedures, with less than half of the patients receiving any written instructions about inter-current infection, and less than a quarter of the patients receiving any written instructions about antibiotic prophylaxis. 36% of the respondents were confused as to what to advise or ignored the problem. The reality of late infection is discussed and a policy to minimise the risk of late infection in prosthetic joints is presented for consideration.

Solubility of neurofibrillary tangles and ultrastructure of paired helical filaments in sodium dodecylsulphate

Temporal cortex from 14 cases of Alzheimer-type dementia and 6 cases of Down's syndrome, all selected for severe Alzheimer pathology, was homogenised in distilled water, NaOH, or sodium dodecylsulphate (SDS) containing 0.1% beta-mercaptoethanol. The homogenates were stained with Congo red, and the neurofibrillary tangles and plaque cores were counted under crossed-polarisation microscopy. The number of tangles and plaque cores in the water-treated extracts was not related to age, sex, post-mortem interval or duration of dementia. The number of tangles after extraction in SDS or NaOH, as a percentage of tangles in water-treated extracts, was 57 +/- 25 (mean +/- SD) for 1% SDS, 43 +/- 17 for 5% SDS and 37 +/- 22 for 0.2 M NaOH. Plaque cores were essentially insoluble in all three agents. The percentage of tangles insoluble in 1% SDS did not correlate with age or post-mortem interval but decreased with increasing duration of dementia. Enhanced tangle solubility with increasing duration of dementia suggests that the nature of tangles changes with time; one possibility is that this reflects transformation of intracellular to extracellular tangles. Paired helical filament (PHF) length and the number of repeats per PHF were measured in electron micrographs of PHF prepared with and without treatment by 1% SDS. There was no significant multimodality of PHF length to suggest that PHF broke at regular intervals. The mean repeat length (PHF length/number of repeats) was greater for PHF isolated in the presence of 1% SDS than in its absence, showing that SDS affects ultrastructure by untwisting PHF.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebellar lamellar bodies in two strains of murine scrapie

Lamellar inclusion bodies have been described by other authors in the granular layer of the cerebellum of people suffering from the unconventional slow-virus disease of kuru and were thought to be associated with the disease. In this study, these bodies were also found in mice infected with scrapie, which belongs to the same group of diseases, as well as their age-matched controls.

Scrapie associated fibrils in the diagnosis of scrapie in sheep

Previous research has consistently demonstrated by electron microscopy the presence of scrapie associated fibrils in brain extracts prepared from mice and hamsters with clinical signs of experimental scrapie. In the present study similar fibrils were seen in all the brain extracts prepared from 11 Cheviot or Suffolk sheep with natural or experimental scrapie that had been diagnosed clinically and confirmed neuropathologically. They were not found in the brain extracts of nine sheep that did not have scrapie and which included four that had been injected with infected material but did not develop the disease. The presence of such fibrils can therefore be used as an additional diagnostic criterion for natural scrapie in sheep.

An electron and light microscopic study of the numbers of dystrophic neurites and vacuoles in the hippocampus of mice infected intracerebrally with scrapie

Numbers of dystrophic neurites, seen with the electron microscope, in CA1 of the hippocampus of either C3H mice infected with 22C or 79A strains of scrapie, or LM mice infected with strain ME7 were greater than in age-matched control mice. Vacuolation, seen by light microscopy in CA1 of the hippocampus of mice infected with either 22C or 79A, preceded the increase in dystrophic neurites by up to about 20 days. In mice infected with ME7, however, the vacuolation followed the increase in dystrophic neurites by some 20 to 40 days. In view of the differences in the times at which dystrophic neurites and vacuolation were seen, no causative relationship between the two lesions appeared to exist.

Ultrastructural abnormalities in the cerebral neocortex and hippocampus associated with Alzheimer's disease and aging

Lesions of the frontal and temporal neocortices and hippocampus typically found in Alzheimer's disease were looked for with the electron microscope in 119 autopsy cases whose ages ranged from 24-93 years. By light microscopy 11 of the cases over the age of 60 had large numbers of plaques and neurofibrillary tangles, whereas the remaining cases had few or none. From the age frequency distribution of the electron microscopic lesions in these two categories of cases amyloid fibrils and abnormal neurites, both components of plaques, were first seen at approximately the same time. This suggests that amyloid is unlikely to precede the neurites in their formation. The abnormal neurites were thought, due to the small numbers of synapses in their walls, to be largely derived from degenerating neuronal processes and not synaptic boutons.

Stress radiography in degenerative arthritis of the knee

The accurate assessment of compartmental involvement in degenerative arthritis of the knee is important when planning operative treatment. Standard radiographic techniques often fail to define the degree of involvement of the less affected tibiofemoral compartment. The use of stress radiography in the preoperative assessment of 30 knees with degenerative arthritis is described and the radiographic findings correlated with the changes found at arthrotomy.

Screw fixation of subcapital fractures of the femur--a better method of treatment?

A series of 71 patients with subcapital fractures of the femur treated by internal fixation with three AO cancellous screws is reviewed. Sixty-five patients survived and were followed up for 26-73 months from injury (mean 47 months). The incidence of non-union was 4.7 per cent. The incidence of avascular necrosis was 33.3 per cent in displaced fractures and 7.7 per cent in undisplaced fractures. Early weight bearing did not affect the incidence of non-union, avascular necrosis or regression of the screw. We recommend internal fixation of subcapital fractures of the femur by this method.

Distributions of amyloid plaques in four regions of the brains of mice infected with scrapie by intracerebral and intraperitoneal routes of injection

VM mice were inoculated by intracerebral and intraperitoneal routes with brain homogenates containing the 87V strain of scrapie. The distribution and numbers of plaques were found for the parietal cortex, cingulate cortex, corpus callosum and hippocampus/dentate in coronal sections cut at the level of the thalamus and stained with Masson's trichrome. For the intracerebrally injected animals, the greatest numbers were seen on the side of the brain that had been injected. In the four regions, they were most numerous in the corpus callosum and least numerous in the parietal cortex and hippocampus/dentate. Following an intraperitoneal injection, plaques were absent from the corpus callosum and, in the remaining three regions, they were less numerous than in intracerebrally injected animals, although their relative numbers were similar. The distribution of the plaques was suggestive of an initial passive spread of inoculum following intracerebral injection and a tendency for plaques to be associated with myelinated axon tracts.

Congenital subluxation of the hip. A long-term review

In 1957 Somerville and Scott described their "direct approach" to the management of established congenital dislocation of the hip; arthrography after a period of traction served to distinguish the dislocated from the subluxated hip. We review the long-term outcome of hips which, using their criteria, were subluxated; 72 hips have been reviewed at periods ranging from 15 to 37 years after treatment by traction, closed reduction and femoral osteotomy. The results have been classified clinically and radiologically according to Severin's criteria. There was progressive deterioration with age in both clinical function and radiographic appearance: 48.5% of hips showed evidence of dysplasia or subluxation at review. The results are similar to those found in a series treated by open reduction and limbectomy, differing only in the much lower incidence of degenerative changes after closed reduction.

Relationship between numbers of cortical argentophilic and congophilic senile plaques in the brains of elderly people with and without senile dementia of Alzheimer type

Four neocortical regions (frontal, parietal, temporal, occipital) of 44 cases were impregnated by a silver stain to show neuritic plaques and stained with Congo red to show amyloid plaques. In 11 cases with large numbers of argentophilic plaques these plaques decreased significantly with age while the reverse appeared to be true for the congophilic plaques. In the remaining 34 cases which had few argentophilic plaques the numbers of congophilic plaques increased significantly with age in the parietal and occipital regions. These results suggest that the neuritic component of senile plaques precedes the amyloid cores in their pathogenesis although a causative relationship is not implied.

The influence on the spine of leg-length discrepancy after femoral fracture

We investigated the spines of 15 patients who had significant leg-length inequality as a result of femoral shaft fractures sustained after skeletal maturity but below the age of 21 years. The patients were examined at least 10 years after fracture. The spines were studied clinically and radiographically before and after correction of leg-length inequality with a shoe-raise. Lateral spinal flexion was measured from radiographs. The lumbar scoliosis associated with the leg-length inequality was compensatory: after equalisation of leg-length the overall curve and the axial rotation were corrected completely. There was also an equal range of lateral flexion to either side after correction. Minor malalignments of the whole spine remained despite correction of the compensatory scoliosis, and within the lumbar spine correction of the scoliosis had not occurred equally at all levels. No patients complained of significant discomfort and neither structural abnormalities nor degenerative changes were seen on the radiographs.

Scaphoid--trapezium--trapezoid dislocation

A case of scaphoid-trapezium-trapezoid dislocation is reported. The radiological differences between this condition and scapholunate dissociation are discussed.

Form and distribution of senile plaques seen in silver impregnated sections in the brains of intellectually normal elderly people and people with Alzheimer-type dementia

Brains came to autopsy from elderly cases that had been psychometrically tested and were shown to be either intellectually normal (n = 48) or suffering from dementia of the Alzheimer-type (n = 56), as well as elderly cases that had not been tested (n = 32). Cortical senile plaques, impregnated by von Braunmuhl's silver method, were found to range in structure from amorphous (neuritic) through to discrete (amyloid). Large numbers of the amorphous plaques were most frequently found in the outer half of the cortex of the demented cases, aged 60-75, whereas small numbers of the discrete plaques were most frequently found in the inner half of the intellectually normal cases, aged 75 onwards. The distribution of the senile plaques per se was found for four different regions of the cortex as well as the correlation of their numbers with the ages of the cases. The pathogenesis of the plaques is discussed.

A quantitative method for comparing the distribution of cerebral trauma in closed-head injuries with and without tentorial herniation

Damage to the cerebral and cerebellar hemispheres and brain-stem was investigated in forty-seven cases of closed-head injury of which twenty-four had undergone tentorial herniation. The damage was assessed by eye in coronal sections as well as microscopically using celloidin and paraffin techniques. All cases had damage to the hemispheres and brain stem. The types and positions of the damage were plotted on charts and quantified by using a cm2 grid system. The quantity of the haemorrhage and ischaemia in the hemispheres was found by Student's t-test to be statistically greater (P less than 0.001) for cases which had herniated. Haemorrhage and ischaemia were most frequently seen on the ventral aspect of the hemispheres and particularly the frontal lobes. The distribution of the haemorrhage and ischaemia was the same for both the herniated and non-herniated brains. In a subsample of sixteen cases statistically significant differences were found using the X2 test for the positions of brain-stem damage per se in herniated and non-herniated brains. In a second subsample of thirty-two cases a statistical difference in the position of haemorrhage was also found. The greatest damage to the brain-stem was medial and rostral in herniated brains and paralateral and rostral but extending further caudally in non-herniated brains. The variation in quantity of the five types of damage with length of survival was compared for herniated and non-herniated brains.

EM study of the numbers of cortical synapses in the brains of ageing people and people with Alzheimer-type dementia

Numbers of synapses were counted in columns of neuropil orientated at right angles to the pia in frontal and temporal regions from postmortem brains. In the frontal region of 28 patients aged 26-90 years there were 1.2 X 10(8) mm3 (SD 0.03 X 10(8], and in the temporal of 18 patients aged 16-90 years there were 1.4 X 10(8) mm3 (SD 0.04 X 10(8]. Regression analysis showed a statistically significant (P less than 0.01) decrease with age for the frontal region but not the temporal. Four patients had been clinically diagnosed as suffering from Alzheimer-type dementia and had neurofibrillary tangles and numerous senile plaques in the cortex. The numbers of synapses in these four patients did not differ from the remaining apparently intellectually normal people.

A method for determining tentorial herniation in closed-head injury from a quantitative estimation of cerebral trauma

Cerebral damage in 42 cases involving closed-head injury was studied post mortem. The cases were divided into those that showed tentorial herniation and those that did not on the basis of the clinical histories and examination of the intact brains at autopsy. Damage seen histologically in coronal sections through the cerebral hemispheres and brain-stem was recorded on diagrams. The area of damage was quantified by placing over the diagrams a cm2 grid. The numbers of squares with damage in, length of survival following the accident and the age of the cases were found by a ranking method to be statistically significantly different in herniated and non-herniated cases. These three parameters were used in an empirically derived expression to give an index that was statistically significantly different for herniated and non-herniated cases. The purpose of the index was to obtain an objective method of assessing the degree of tentorial herniation in brain-stem damage resulting from herniation.

Amyloid and senile plaques and cerebral blood vessels. A semi-quantitative investigation of a possible relationship

The possibility of a direct association between the amyloid in senile plaques and in cerebral blood vessels was tested by a quantitative analysis of amyloid in these sites in the autopsy brains of 15 patients suffering from senile dementia of Alzheimer type and 30 non-demented old subjects. The numbers and severity of involvement of vessels showing amyloid were expressed as a vascular 'amyloid score'. Over all the cases amyloid within vessels was found to increase with each decade but no direct correlation existed between age and amyloid scores. Plaques were found in the absence of vascular amyloid and in 2 cases, vascular amyloid occurred without plaque formation. Nevertheless, there was a statistically significant association between the presence of vascular amyloid and of plaques and a significant correlation between total amyloid scores and plaque counts in the temporal lobe of demented subjects. However, amyloid scores only explained about 30% of the variance in plaque counts and amyloid in vessels is unlikely to contribute to the development of all senile plaques. There was no significant correlation between the amount of vascular amyloid observed and the clinical severity of the dementia.

Electron microscopic study of intranuclear spheres of Bouteille type-III in astrocytes with special reference to liver carcinoma

Astrocytic intranuclear spheres of Bouteille type-III were studied with the electron microscope in the neocortex of 29 patients dying from various causes. The numbers of laminate whorls in these spheres in patients with carcinoma involving the liver were found statistically to be significantly more numerous than the whorls in the spheres of patients who did not have carcinoma of the liver. This second group included patients who were suffering from carcinoma of other organs or from cirrhosis of the liver. The frequency of cases with the spheres increased with age. The numbers of spheres found in people with liver carcinoma, carcinoma of other organs and cirrhosis were the same as the numbers found in people dying from other diseases. The possibility that the increase in numbers of whorls found in people with liver carcinoma was related to a raised metabolic activity of the astrocytes resulting from reduced catabolism of hormones or metabolites by the liver is briefly discussed.

Congenital dislocation of the hip. Review at maturity of 147 hips treated by excision of the limbus and derotation osteotomy

In 1957 Somerville and Scott presented their principles of management for the older child with congenital hip dislocation. They advocated preliminary traction followed, in those hips which remained dislocated, by excision of the limbus and subsequent derotation varus osteotomy of the femur. As alternative regimes are advocated it becomes increasingly important to subject each method to detailed long-term review. One hundred and forty-seven hips in 121 patients aged between 12 months and three years and treated by the standard Somerville and Scott regime have been reviewed. The age at review ranged from 16 to 31 years. The recall rate was 91 per cent. Each patient was seen regularly in a special clinic where detailed notes, radiographs and records were available. The results have been assessed clinically and radiographically by modifications of Severin's criteria to enable comparisons to be made with other published series. Attention has been focused on the good and the bad prognostic factors and on the long-term complications. The most worrying feature has been the premature onset of degenerative arthritis even in hips which seemed to have been satisfactorily reduced.

Coenzyme A-acetylating enzymes in Alzheimer's disease: possible cholinergic 'compartment' of pyruvate dehydrogenase

In the mammalian central cholinergic system the precise mechanism for the production of acetyl-CoA used in acetylcholine synthesis has not yet been identified. As a possible means of investigating this problem the relationship between the activities of several enzymes which can synthesize acetyl-CoA and the cholinergic defect of Alzheimer's disease has been examined. Small, but significant reductions in the activities of pyruvate dehydrogenase, ATP-citrate lyase and acetoacetyl-CoA thiolase were found in post mortem brain tissue from cases of Alzheimer's disease, and the decrease in pyruvate dehydrogenase appeared to be related to the extent of the cholinergic defect (as indicated by loss of choline acetyltransferase). Furthermore, the regional distribution of choline acetyltransferase was similar to that of pyruvate dehydrogenase but not to the distribution of the other enzymes investigated in normal human brain tissue. These observations tend to support a recent suggestion that there may be a particular form of pyruvate dehydrogenase associated with cholinergic neurones.

Cell counts in human cerebral cortex in normal adults throughout life using an image analysing computer

Cortical cells have been counted in 11 areas of brain from each of 64 normal subjects from 18 to 95 years of age, all cases studied being selected after careful consideration of their clinical records and detailed histological examination of the brain. Cells (features) in cresyl fast violet stained 20 micrometer paraffin sections were initially divided into 8 groups according to size in multiple columns of cortical tissue; statistical evaluation of the results showed that there were 3 populations of cortical cells, based on size discrimination, which behaved in significantly different ways. The smallest cells have been designated "glial celons were initially divided into 8 groups according to size in multiple columns of cortical tissue; statistical evaluation of the results showed that there were 3 populations of cortical cells, based on size discrimination, which behaved in significantly different ways. The smallest cells have been designated "glial cells" and the other two groups "small" and "large" neurons. The number of cells in all three groups decreased from youth to old age, the least loss being in the "glial cells" and the greatest (up to 60%) in "large neurons". The variation and statistical significance of cell loss in each cell group in the different areas examined is described, and the findings in this investigation discussed in relation to previous studies using manual methods.

Vacuolation in the human cerebral cortex and its relationship to the interval between death and autopsy and to synapse numbers: an electron microscopic study

Vacuolation in the human cerebral cortex resulting from swelling of cell processes after death was measured in electron micrographs in material obtained up to 69 hours post mortem from subjects with no known neurological abnormality. Vacuolation was found to increase significantly up to 30--35 hours after death and then to decrease. Accompanying this change was a significant reduction in the numbers of recognizable synapses which probably resulted from compression due to the vacuolation rather than from post-mortem disintegration.

Correlation of cholinergic abnormalities with senile plaques and mental test scores in senile dementia

Necropsy brain tissue from normal (control) patients and patients with depression and dementia was examined for activities of various cholinergic components, and these related to the degree of senile plaque formation and extent of intellectual impairment. Choline acetyltransferase and acetylcholinesterase activities decreased significantly as the mean plaque count rose, and in depressed and demented subjects the reduction in choline acetyltransferase activity correlated with the extent of intellectual impairment as measured by a memory information test; muscarinic cholinergic receptor binding activity remained unchanged with increasing senile plaque formation but butyrylcholinesterase activity increased. The results suggest a close relation between changes in the cholinergic system and Alzheimer's dementia, but the precise role of the system in this disease remains to be elucidated.

Light and electron microscopic observations on the relationship between Hirano bodies, neuron and glial perikarya in the human hippocampus

Hippocampi from two intellectually normal and four demented subjects were examined in autopsy material. Large Hirano bodies seen by light and electron microscopy were thought to be glial in origin and not to be produced by the perikarya of neurons as has been suggested in the literature. Myelination of two Hirano bodies found in the stratum lacunosum-granulosum where neuron perikarya are rare suggests that these bodies are produced by oligodendroglia. Hirano bodies were found to be associated with neurons showing granulovaculoar degeneration. With electron microscope they were frequently seen to be divided by clefts filled with amorphous material which possibly consisted of free ribosomes.