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Prenatal smoking cessation has been described as an empathic action “for the baby,” but this has not been empirically demonstrated. We capitalized on a genetically-characterized extant dataset with outstanding measurement of prenatal smoking patterns and maternal face processing data (as an indicator of empathy) to test this hypothesis, and explore how empathy and smoking patterns may be moderated by a genetic substrate of empathy, the oxytocin receptor gene (OXTR). Participants were 143Caucasian women from the East Boston family study with repeated prospective reports of smoking level, adjusted based on repeated cotinine bioassays. Salivary DNA and face processing (Diagnostic Analysis of Nonverbal Accuracy-2) were assessed 14 years later at an adolescent follow-up of offspring. Two-thirds of participants reported smoking prior to pregnancy recognition. Of these, 21% quit during pregnancy; 56% reduced smoking, and 22% smoked persistently at the same level. A significant interaction between face processing and OXTR variants previously associated with increased sensitivity to social context, rs53576GG and rs2254298A, was found (β = −.181; p = .015); greater ability to identify distress in others was associated with lower levels of smoking during pregnancy for rs53576(GG)/rs2254298(A) individuals (p = .013), but not for other genotypes (p = .892). Testing this “empathy hypothesis of prenatal smoking cessation” in larger studies designed to examine this question can elucidate whether interventions to enhance empathy can improve prenatal smoking cessation rates.

Population-based evidence on second cancer risk following autologous haematopoietic SCT (HCT) is lacking. We quantified second cancer risk for a national, population-based cohort of adult Australians receiving autologous HCT for cancer and notified to the Australasian Bone Marrow Transplant Recipient Registry 1992-2007 (n=7765). Cancer diagnoses and deaths were ascertained by linkage with the Australian Cancer Database and National Death Index. Standardized incidence ratios (SIRs) were calculated and Cox regression models were used to estimate within-cohort risk factors treating death as a competing risk. During a median 2.5 years follow-up, second cancer risk was modestly increased compared with the general population (SIR 1.4, 95% confidence interval 1.2-1.6); significantly elevated risk was also observed for AML/myelodysplastic syndrome (SIR=20.6), melanoma (SIR=2.6) and non-Hodgkin lymphoma (SIR=3.3). Recipients at elevated risk of any second cancer included males, and those transplanted at a younger age, in an earlier HCT era, or for lymphoma or testicular cancer. Male sex, older age (>45 years) and history of relapse after HCT predicted melanoma risk. Transplantation for Hodgkin lymphoma and older age were associated with lung cancer risk. Second malignancies are an important late effect and these results inform and emphasize the need for cancer surveillance in autologous HCT survivors.

Osteochondral defects of the lateral trochlear ridge of the distal femur were identified in 15 joints of 10 horses. Lesions were bilateral in five horses and unilateral in five horses. Thirteen of these 15 defects were treated by curettage through a craniolateral femoropatellar arthrotomy. Subcutaneous seroma formation and partial skin dehiscence occurred in nine stifles. Lameness attributable to the stifle joint was no longer apparent at 6 and 12 months after surgery. The normal subchondral bony contour of the lateral trochlear ridge was altered in all joints after surgery. The subchondral bone was uniformly increased in density in all joints, and six lateral trochlear ridges had small focal radiolucent regions within the subchondral bone, which suggested that complete removal of the original lesion had not been achieved. Healing of the surgical site between 2 weeks and 14 months was evaluated in four joints. Granulation tissue from mesenchymal elements in subchondral marrow spaces gradually filled the defects with fibrocartilage.

The relative sensitivity of radiography, computed tomography, and magnetic resonance imaging for detecting palmar process fractures of the distal phalanx in foals was determined and the imaging findings were compared with histomorphologic evaluations of the palmar processes. Compared to radiography, computed tomography and magnetic resonance imaging did not improve the sensitivity for detection of palmar process fractures. Statistical agreement for palmar process fracture diagnosis was excellent among the three imaging modalities. Histomorphologic evaluations were more sensitive for diagnosis of palmar process fracture than any of the imaging modalities. Three-dimensional image reconstructions and volume measurements of distal phalanges and palmar process fracture fragments from computed tomography studies provided more complete anatomical information than radiography. Magnetic resonance imaging confirmed that the deep digital flexor tendon insertion on the distal phalanx is immediately axial to the site where palmar process fractures occur, and differentiated cartilage, bone, and soft tissue structures of the hoof.

OBJECTIVE To estimate the likelihood of poor surgical results being explained by chance rather than under-performance. METHODS The 30-day mortality rates after radical cystectomy for bladder cancer were analysed theoretically. Surgical competence was defined as a mortality rate of 4%, excellence as 2% and under-performance as 8%, 12%, 20% or 40%. Four scenarios were explored for surgeons of different competence: first, the sample size required to show that a given level of under-performance is very unlikely to be due to chance; second, the likelihood of two or more consecutive deaths in a series of cases; third, the likelihood of clustering of deaths, defined as two deaths in five or in 10 cases; and last, the likelihood of outstanding surgical results (i.e. no deaths) being achieved in small cohorts by surgeons of differing competence. RESULTS For surgeons with a mortality rate of 8%, 12%, 20% or 40%, the sample sizes needed to prove under-performance are 211, 65, 21 and seven, respectively. For consecutive deaths, 0.4% of excellent, 1.4% of competent and 21% of surgeons with a mortality rate of 12% will experience two or more consecutive deaths in the next 10 cases. For clustered deaths, 1% of excellent, 5% of competent and 23% of seriously under-performing surgeons (mortality rates ≥ 12%) will experience two deaths in their next 10 cases. Lastly, for the likelihood of outstanding results, only 3.6% of surgeons with an 8% mortality rate and < 1% of surgeons with a mortality rate ≥ 12% will experience no deaths over 40 consecutive cases. CONCLUSIONS Very large cohorts are needed to confirm even significant under-performance. Consecutive deaths are very unlikely events for competent surgeons. Clustered deaths (two deaths in 10 cases) are very unlikely events for excellent surgeons but plausible for competent ones. Analysis of consecutive/clustered deaths is limited by low statistical sensitivity; only up to a quarter of seriously under-performing surgeons are identified. No deaths in 40 consecutive cases implies competence.

Preconception care (PCC) and strict periconceptional glycemic control are both used to minimize the risk of congenital birth defects in offspring of women with type 1 or type 2 diabetes mellitus (DM). These malformations are ascribed in large measure to poor periconceptional control. This study evaluated PCC by a meta-analysis of published studies of PCC in women with DM, published from 1970 to 2000. Two reviewers independently abstracted the data, and the rate and relative risk (RR) of major and minor malformations were pooled from eligible studies using a random effects model. Early first-trimester values of glycosylated hemoglobin were recorded. Eight retrospective and eight prospective cohort studies were included; they were carried out in Europe, the United Kingdom, the United States, and Israel. Most participants had type 1 DM, but three studies included women with type 2 DM. Women given PCC tended to be about 2 years older on average than the others. Methods of PCC were quite variable, although most centers provided some maternal education about the pregnancy risks associated with poor glycemic control. In seven studies reporting early gestational glycosylated hemoglobin values, mean levels were consistently lower in PCC patients. Among 2104 offspring, the pooled rate for major and minor anomalies was 2.4% in the PCC group and 7.7% in non-PCC recipients, for a pooled RR of 0.32. Among 2651 offspring, major malformations were less prevalent in the PCC group (2.1 vs. 6.5%; pooled RR = 0.36). Comparable results were obtained when only prospective studies were analyzed and in studies where the infant examiners were unaware of the mothers' PCC status. The lowest risk of major anomalies was in a study that administered folic acid periconceptionally to its PCC recipients; the RR was 0.11. This meta-analysis, which included both retrospective and prospective studies, demonstrates an association of PCC with a significantly lower risk of congenital anomalies in the offspring of women with established DM. The lowered risk was accompanied by significantly lower glycosylated hemoglobin values in the first trimester in recipients of PCC.

Objective— To determine the effects of intraarticular administration of Samarium-153 (153Sm) bound to hydroxyapatite microspheres (153SmM) on an osteochondral chip–Ninduced synovitis. Study Design— Sixty days after implantation of autogenous osteochondral fragments in the middle carpal and metacarpophalangeal joints, 153SmM was administered into 1 joint of each type. The contralateral joints were used as untreated controls. Animals or Sample Population— Fifteen horses without preexisting joint disease were randomly divided into 2 groups (7 in the carpal group, 8 in the metacarpophalangeal group). Methods— Horses had osteochondral fragments that were harvested from the lateral ridge of the trochlea of the talus and implanted bilaterally into a middle carpal joint and a metacarpophalangeal joint; the opposite joint type served as a control. Sixty days later, 10 to 15 mCi of 153SmM (20 to 50 μm diam) was injected into the fragment-implanted joints. Three horses were treated with nonradioactive hydroxyapatite fragments. Horses were examined clinically until they were killed 14 or 30 days later. Control and treated joints were examined grossly and microscopically to determine the effects of 153SmM on synovial membrane and cartilage. Results— Intraarticular 153SmM caused a transient flare with lameness, effusion, and edema for 48 to 72 hours. Implanted osteochondral chips induced a synovitis characterized by variable degrees of joint damage and synovial infiltrate. Use of 153SmM resulted in synovectomy of variable depth and extent. Conclusions— Intraarticular 153SmM may be a useful method for synovectomy of inflamed synovial membrane. Clinical Relevance— With further testing, radioactive pharmaceuticals might become useful clinical treatments for persistent synovitis not responsive to conventional techniques.

The hair follicle is characterized by cyclic transformations from active growth and hair fiber production through regression into a resting phase. The growth phase, known as anagen, is associated with rapid rates of cell turnover, and variations in the rate of DNA synthesis in mouse skin throughout the hair cycle are accompanied by changes in the activity of ornithine decarboxylase (ODC), a key enzyme in the synthesis of polyamines, which are actively involved in regulation of normal cell division, differentiation, and growth. Previously, a transgenic mouse was created that overexpressed ODC in the skin using a K6 promoter. The first hair cycle in neonatal transgenic mice appeared to be normal, but by the third week of postnatal life transgenic pups begin to progressively lose hair. The lower portion of the hair follicle was progressively replaced with enlarging cystic structures located in the deep dermis, and the transgenic mice exhibited excessive growth of skin mass resulting in pronounced wrinkling and folding. Interestingly, these findings bore striking resemblance to the rhino mouse phenotype and to human patients with papular atrichia, a rare congenital ectodermal disorder characterized by progressive and irreversible hair loss in early childhood. The similarities in phenotype between transgenic mice and human atrichia with papular lesions suggest that ODC transgenics may represent a useful model for studying this disorder. It appears that ODC plays a functionally important, yet still obscure role in a complex metabolic pathway that is critical in hair follicle function not only in mice, but in humans as well.

Sera from 516 participants enrolled in a population-based cross-sectional study in northwest Tanzania were tested for antibodies to hepatitis C virus (HCV). The mean age of study subjects was 29 years (range = 16-49 years); 43% were men, 6% reported a history of blood transfusion, and 4% were infected with human immunodeficiency virus-1 (HIV-1). Although 53 of 516 sera (10.3%, 95% confidence interval [CI] = 7.8-13.2%) were repeatedly reactive by a third-generation enzyme immunoassay (EIA-3), only 6 of the 53 were positive when tested with a third-generation recombinant immunoblot assay (confirmed HCV seroprevalence = 1.2%, 95% CI = 0.4-2.5%). The positive predictive value of the HCV EIA-3 in this population was 18.8% (95% CI = 7.0-36.4%). False positivity was not correlated with EIA-3 optical density values, age, sex, infection with HIV-1, or a history of blood transfusion, but it was marginally associated with increased serum IgG levels. We conclude that the prevalence of HCV is low in this region and that the HCV EIA-3 has a higher false-positivity rate in this population than has been reported among U.S. blood donors.

Protein kinase C (PKC) is a major regulator of a broad range of cellular functions. Activation of PKC has been reported to stimulate Na+ transport across frog skin epithelium by increasing the apical Na+ permeability. This positive natriferic response has not been observed with other epithelial preparations, and could reflect the specific experimental conditions of different laboratories, or species or organ specificity of the response to PKC. In the present study, measurements were conducted with skins and urinary bladders from the same animals of two different species. The PKC activator TPA uniformly increased the transepithelial Na+ transport (measured as amiloride-sensitive short-circuit current, ISC, across skins from Rana temporaria and Bufo marinus, and inhibited ISC across bladders from the same animals. Inhibitors of PKC (staurosporine, H-7 and chelerythrine) partially blocked the TPA-induced stimulation of ISC across frog skin. The specificity of the PKC response by amphibian skin could have reflected an induction of moulting, similar to that observed with aldosterone. However, light micrographs of paired areas of frog skin revealed no evidence of the putative moulting. Separation of stratum corneum from the underlying stratum granulosum could be detected following application of aldosterone. We conclude that the effect of PKC on epithelial Na+ channels is organ, and not species specific. The stimulation of Na+ permeability in amphibian skin does not arise from sloughing of the stratum corneum. These observations are consistent with the hypothesis that the natriferic action arises from the calcium-independent isozyme of PKC previously detected in frog skin.

With the FACSCount TM flow cytometer, counts of CD4, CD8 and CD3 lymphocytes and CD4/CD8 ratios were performed in a rural hospital in Tanzania. A total of 168 subjects (21 HIV-1 seropositive and 147 HIV-1 seronegative) were tested as part of a population-based serosurvey and AIDS education programme; 134 other subjects were hospitalized patients who had signs and symptoms suggestive of AIDS (69 HIV-1 seropositive and 65 HIV-seronegative). Mean values for the 147 HIV-1 seronegative subjects from the local population were 980 CD4 cells (95% CI 930, 1031), 598 CD8 cells (560, 635) and CD4/CD8 ratio 1.78 (1.68, 1.89). Seropositive subjects from the local population had significantly lower CD4 cell counts, higher CD8 counts and a lower CD4/CD8 ratio. CD4 cells were significantly lower and CD8 cells significantly higher in HIV-1 seropositive hospital patients compared to HIV-1 seronegative patients. However, 23 (35%) seronegative hospital patients had CD4 counts lower than 600. These results establish baseline values for the lymphocyte subsets in this population and indicate that this technique can be used in remote areas to monitor progress of HIV-infected individuals.

To evaluate the frequency, pattern, and severity of liver function test abnormalities in patients with Lyme disease associated with erythema migrans (EM), 115 individuals with no other identifiable cause for liver function test abnormalities who presented with EM between July 1990 and September 1993 were prospectively evaluated. For individuals with abnormal liver function tests, common causes of hepatitis, including hepatitis A, B, and C, were excluded. A local control group was used for comparison. Forty-six (40%) patients had at least one liver test abnormality, and 31 (27%) had more than 1 abnormality compared with 19 (19%) and 4 (4%) of controls, respectively (P < .01 for each comparison). gamma-Glutamyl transpeptidase (28%) and alanine transaminase (ALT) (27%) were the most frequently elevated liver function tests among Lyme disease patients. Anorexia, nausea, or vomiting was reported by 30% of patients, but did not occur more frequently in patients with elevated liver function tests compared with those with normal values. Patients with early disseminated Lyme disease were more likely to have elevated liver function studies (66%) compared with patients with localized disease (34%) (P = .002). After antibiotic treatment, elevated liver function tests improved or resolved in most patients. Liver function test abnormalities are common in patients with EM but were mild, most often not associated with symptoms, and improved or resolved by 3 weeks after the onset of antibiotic therapy in most patients.

We report the clinical outcome of arthroscopic labral reconstruction using a transglenoid suture technique in a young, active-duty military population. Forty-eight patients (49 shoulders) with varying degrees of gleno humeral instability underwent arthroscopic labral re construction using a transglenoid suture technique. All patients had traumatic injuries to their shoulders and all patients had magnetic resonance imaging scans dem onstrating anterior labral tears. Postoperatively, the patients' shoulders were immobilized for up to 6 weeks. At a mean followup of 30 months (range, 12 to 49), 17 of the 41 patients (41%) with preoperative dislocation or subluxation had recurrent instability. Nine of these patients subsequently underwent open reconstruction procedures for recurrent instability. On the basis of the Rowe rating system, 53% had excel lent or good results and 47% had fair or poor results. The overall perioperative complication rate was 14%. Suprascapular nerve palsy occurred in three cases (6%). Using the Fisher exact test, we determined that immobilization for 6 weeks postoperatively correlated with a lower recurrence rate in the patients with a history of glenohumeral dislocation (P = 0.007). The results of arthroscopic labral reconstruction using transglenoid sutures in the military patient are inferior to the reported 3% to 5% recurrence rate with open Bankart procedures, and the transglenoid pin tech nique jeopardizes the suprascapular nerve.

Objectives: The aim of the paper is to present data on the first year of all appeals lodged with a Mental Health Review Tribunal against compulsory treatment orders of psychiatric inpatients. Method: Two tribunals have been in operation in New Zealand since the introduction of a new Mental Health (Compulsory Assessment and Treatment) Act in 1992. The case records of all patients who had appeals heard by either the Northern or Southern regional tribunal from 16/12/92 to 7/12/93 inclusive were examined. Results: 145 appeals were heard by the tribunals: 14.5% of appeal hearings resulted in the discharge of a patient from their compulsory treatment status. Discharge rates for the Southern Tribunal were found to be significantly higher at 22%, compared with 10% for the Northern Tribunal (p Conclusions: Ambiguities within the Act need to be addressed in order that criteria used to judge a patient's fitness for discharge may be standardised. In addition, the Act stipulates a maximum delay of 14 days in reviewing a patient's case; however in practice a mean of 22 days elapses, indicating that this stipulation requires review.

Intra-articular morphine has been shown to provide prolonged analgesia after arthroscopic knee surgery; the addition of local anaesthetic agents has been reported to improve this analgesic effect. Pethidine possesses local anaesthetic properties, and therefore this study was designed to evaluate its analgesic efficacy after arthroscopic meniscectomy. Sixty patients were allocated randomly to receive intra-articular injections of pethidine 50 mg, morphine 5 mg or saline after elective arthroscopic meniscectomy. Postoperative pain was assessed using an interval visual analogue scale and measuring analgesic requirements. Both treatment groups had significantly lower pain scores compared with the control group. Patients in the pethidine group had lower pain scores than those in the morphine group at 0.5, 1 and 2 h, but significantly higher scores at 12 and 24 h. These observations suggest that the local anaesthetic effect of pethidine may be responsible for the improved early analgesia, but its duration of action appears to be less than that of morphine.

The radiographic and pathologic findings of two Peruvian Paso foals with osteopetrosis are described. Both foals, one male and one female, presented with respiratory difficulty, brachygnathia and failure to rise after birth. Both foals were mildly anemic, hypogammaglobulinemic and had elevations in serum alkaline phosphatase. Increased medullary bone opacity was noted on radiographs of the extremities, spine and skull in both foals. A lack of normal cortical:medullary bone distinction was evident radiographically. The medullary primary spongiosa appeared to run in parallel columns away from the physes of all long bones and the vertebrae. This created a distinctive hour glass appearance to the osteopetrotic bones. One foal developed a bacterial pneumonia. Both foals were euthanized due to failure to thrive. Histopathology and electron microscopy documented these foals to have normal osteoclastic numbers but lack normal ruffled borders, lack of a clear zone and normal lysosomal numbers indicative of cellular dysfunction. These clinical, radiographic and pathologic findings are similar to the juvenile, lethal autosomal recessive form of osteopetrosis described in humans. Osteopetrosis has not been previously described in a female foal.

Summary Complete thoracic radiographic examinations were performed on 7 horses ranging in age from 24 to 60 months, followed by in-situ lung fixation. Radiographs were examined by 3 radiologists for the presence, degree and distribution of generalised pulmonary patterns within a region of interest in the caudodorsal lung. Pulmonary tissue was obtained from 12 sites within a designated volume of interest in the caudodorsal lung, corresponding to the area of interest evaluated radiographically, and examined for the presence, character and severity of microscopic lesions. Radiographic findings within the volume of interest consisted of mild to moderate bronchial, bronchointerstitial, or interstitial pulmonary patterns. Interstitial and bronchointerstitial radiographic findings were related to severity of peribronchiolar mononuclear cell infiltrates, the degree of bronchiolar mucosal plication, and alveolar capillary and peribronchial blood vessel erythrocyte content. The severity of the interstitial radiographic pattern was inversely associated with the perceived diagnostic quality of the radiographic examinations. There was no evidence of spatial variation in the severity of the microscopic changes examined in this limited pulmonary region. Inter-rater reliability between radiologists was good in the assessment of diagnostic quality of the radiographic examinations but poor in assessing severity of the primary generalised pulmonary patterns within the radiographic region of interest.

Maternal cocaine abuse has been associated with neonatal neurological and neurobehavioral problems of unknown pathogenesis. We administered a single intravenous dose of cocaine (2 mg/kg) to 12 unanesthetized pregnant sheep; their fetuses had been catheterized in utero 2 days before the study. We measured fetal cerebral blood flow (CBF), cerebral metabolic rate of O2 (CMRO2), mean arterial blood pressure (MAP), and blood gases before and 2, 5, 15, and 30 min after maternal cocaine injection. Fetal CBF increased by 37 +/- 33% (mean +/- SD) at 5 min and returned to baseline by 15 min. Regional brain blood flow changes paralleled CBF changes with the greatest increases occurring in cerebellum (54 +/- 43%) and brain stem (54 +/- 52%). Cerebral vascular resistance was decreased for cerebellum (22%) and brain stem (19%) but was unchanged for cerebral hemispheres and caudate. Increased CBF at 5 min was associated with a 20 +/- 9% increase in fetal MAP and a 38 +/- 13% decrease in fetal arterial O2 content. Fetal CMRO2 was unchanged. There was a decrease in fetal intestinal blood flow at 2 min, an increase in myocardial, adrenal, and renal blood flow at 5 min, and no change in placental blood flow. Maternal cocaine injection causes fetal hypoxemia, hypertension, and increased CBF. Possible mechanisms for cerebral vasodilation (in some areas) include hypoxemia, impaired autoregulatory response to increased blood pressure, and/or direct or indirect vascular effects of cocaine or its metabolites.

Longitudinal epiphyseal bracket (LEB) is a rare ossification anomaly in which an epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This abnormal epiphysis tethers longitudinal growth, resulting in a shortened and oval-shaped bone. Four patients with five LEBs were treated by central physiolysis and followed for a mean of 6 years. The patients had significant hallux varus deformity. Three patients had duplicated great toes, and two had tibia hemimelia significant enough to require epiphysiodesis as they neared adolescence. Resection of the LEB allowed the proximal and distal epiphysis to resume untethered growth. Silastic or methyl methacrylate was placed over the resected physis to prevent bony rebridging. The associated hallux varus deformity was corrected by capsulorrhaphy and K-wire fixation. In all patients, the metatarsal resumed longitudinal growth and correction of the hallux varus was maintained.

Twenty-four-hour ambulatory blood pressure measurements (ABPM) are likely to eliminate the stress of visits and observer bias in office blood pressure (BP) recordings, allow consideration of the circadian variability in BP, and correlate well with target organ damage. To define the prevalence of "white coat" hypertension in a rural community to a nonacademic setting, and to assess age and sex related differences, we studied 131 patients who had more than two prior office diastolic BP measurements greater than 90 mm Hg and less than 115 mm Hg. Blood pressure was measured every 10 to 60 min for 24 h using the SpaceLabs 90207 device. Office BP readings were higher than ABPM in the group as a whole, in individual age groups, and in both sexes. The differences were more pronounced at night. Average differences between office and ambulatory BP ranged between 14.4 +/- 1.7/2.9 +/- 2.0 (ABPM at 10:00), and 33.8 +/- 2.3/22.8 +/- 1.5 mm Hg (systolic/diastolic +/- SE) (ABPM at 01:00). The nighttime drop in systolic BP was not apparent in subjects more than 65 years old. Women had a proportionately higher mean office BP than men (115.0 +/- 0.9 office v 110.2 +/- 1.3 mm Hg ABPM in women and 112.3 +/- 0.9 v 104.3 +/- 1.1 mm Hg in men) (P = .013), and the elderly did not display the relationship between ambulatory and office mean BP seen in younger subjects (r = 0.15, P = .30 v r = 0.36, P = .0004, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Two hundred eighty-one patients underwent magnetic resonance (MR) imaging of the shoulder over a 2-year period. Eighty-eight patients underwent arthroscopic surgery, and their surgical results were correlated with the findings at MR imaging. MR imaging enabled accurate prediction of anterior labral tears, with a sensitivity of 95%, a specificity of 86%, and an accuracy of 92%. MR imaging was less effective in the prediction of tears of the superior labrum, with a sensitivity of 75%, a specificity of 99%, and an accuracy of 95%. These two categories accounted for the majority of the surgically correctable disease. MR imaging was found to be unreliable in the prediction of posterior (sensitivity, 7.7%) or inferior (sensitivity, 40%) labral tears, isolated cases of which occurred in only two (2%) of those undergoing surgery. MR imaging proved to be a highly accurate, noninvasive technique for the clinical evaluation of shoulder instability.

Although levels of high density lipoprotein (HDL) cholesterol in males decrease during adolescence and after treatment with testosterone derivatives, several studies have reported that levels of HDL cholesterol are positively associated with endogenous levels of testosterone in men. This association was further examined using data collected during 1985 and 1986 from 3,562 white and 500 black men who ranged in age from 31 to 45 years. Black men had higher mean levels of both HDL cholesterol (8 mg/dl) and total testosterone (33 ng/dl) than white men, and positive associations were observed between testosterone and HDL cholesterol levels (r = 0.22, whites; r = 0.26, blacks). In addition, levels of testosterone were related positively to alcohol consumption and cigarette smoking and negatively to age, Quetelet index, and use of beta-blockers. We used stratification and regression analyses to determine if any of these characteristics could account for the positive association between levels of HDL cholesterol and total testosterone. Although controlling for most factors had little influence, adjusting for Quetelet index reduced the strength of the association between levels of testosterone and HDL cholesterol by approximately 30%. These findings suggest that the positive association between levels of testosterone and HDL cholesterol may not be causal. Multivariable analyses that control for obesity and other potentially confounding characteristics should be used in studies that assess the relation of testosterone levels to coronary heart disease.

This paper reports on a study and comparison of two techniques and notations suitable for the analysis and design of Web-based electronic commerce (ecommerce) applications. Some of the challenges facing developers of Webbased e-commerce applications are identified, examined and discussed. Individually these challenges are not unique but their combination and severity make the development of applications for the WWW a rather difficult softwareengineering problem. Techniques and notations devised to address some of these challenges are identified from the literature. The Technique for Analysing and Specifying Transactional Internet Sites of Beaudet et al. (1998) and the Object-Oriented Hypermedia Design Method (OOHDM) of Schwabe and Rossi (1998) were selected to analyse and design a typical e-commerce application. The results of this study are then used to evaluate the suitability of the two approaches for the development of Web-based applications. The paper concludes that the Beaudet et al. approach is more suited to rapid development projects and OOHDM to situations where comprehensiveness of specification is more important than speed. Both approaches need to be supplemented by additional techniques and supporting notations, particularly in the area of physical design.

Previous angiographic and radiological studies have suggested that the peroneal artery is the best preserved of the calf vessels in peripheral vascular disease and should be a site of preference for a femorodistal bypass graft. Calf vessel run-off assessed by pulse generated run-off (PGR) provides a more accurate prediction of graft success or failure than angiography and may therefore give a better functional picture of vessel patency than angiography. This study compares the presence and degree of preservation of the three calf vessels in patients with severe peripheral vascular disease using both intra-arterial digital subtraction angiography (IADSA) and PGR. Thirty-four limbs in patients with either ischaemic rest pain, ulceration or gangrene were studied and the results were scored according to the extent and severity of disease in the peroneal, posterior tibial and anterior tibial arteries. On IADSA, the peroneal artery was patent significantly more often (79%) than the posterior tibial artery (47%) or the anterior tibial artery (38%). Conversely, PGR examination showed no difference in patency between the three vessels (peroneal 91%, posterior tibial 88%, anterior tibial 79%). The peroneal artery was also significantly better preserved on IADSA (65%) compared to the posterior tibial artery (38%) and the anterior tibial artery (23%). PGR studies again showed no difference in the best preserved vessel between peroneal (47%), posterior tibial (50%) and anterior tibial (50%) arteries. Thus, the peroneal artery appears the better preserved vessel on angiography but this appearance may be misleading because the more functional PGR studies show no significant difference in the patency or degree of preservation of the three calf vessels.

Objective: To compare the results of cardiac output measurements obtained by lithium dilution and transpulmonary thermodilution in paediatric patients. Design: A prospective study.¶Setting: Paediatric intensive care unit in a university teaching hospital.¶Patients: Twenty patients (age 5 days–9 years; weight 2.6–28.2 kg) were studied.¶Interventions: Between two and four comparisons of lithium dilution cardiac output (LiDCO) and transpulmonary thermodilution (TPCO) were made in each patient.¶Measurements and results: Results from three patients were excluded: in one patient there was an unsuspected right-to-left shunt, in two patients there was a problem with blood sampling through the lithium sensor. There were 48 comparisons of LiDCO and TPCO in the remaining 17 patients over a range of 0.4–6 l/min. The mean of the differences (LiDCO–TPCO) was –0.1 ± 0.3 (SD) l/min. Linear regression analysis gave LiDCO = 0.11 + 0.90 × TPCO l/min (r 2 = 0.96). There were no adverse effects in any patient.¶Conclusions: These results suggest that the LiDCO method can be used to provide safe and accurate measurement of cardiac output in paediatric patients. The method is simple and quick to perform, requiring only arterial and venous catheters, which will already have been inserted for other reasons in these patients.

Objective To determine the functional and radiographic outcome of low Weber C ankle fractures and to evaluate the contribution of the syndesmotic screw in their outcome. Design Prospective evaluation of a consecutive series. Setting Level I trauma center. Patients Forty-five patients divided into two groups matched for age, sex, and severity of injury. Twenty-six patients were treated with open reduction, internal fixation, and a supplemental syndesmotic screw, and nineteen patients were treated without a syndesmotic screw. Minimum time to follow-up was three years. Methods A subjective, objective, and radiographic ankle scoring system was used. Logistical regression analysis was performed to determine whether the presence or absence of a syndesmotic screw was a predictor of a poor outcome. The likelihood ratio test was used to evaluate the significance of each variable in both univariate and multivariate analyses. Results There was no statistically significant difference between either group, either using subjective outcome criteria (p = 0.86) or in ankle range of motion (p = 0.94). Logistical regression analysis indicated that fracture dislocation could be used as a predictor of a poor outcome for either group. Inadequate reduction and advancing age were also found to be significant predictors of a poorer outcome regardless of the use of a syndesmotic screw (p = 0.003, p = 0.004). Conclusions Judicious fixation of Weber C type injuries within five centimeters of the ankle joint, with or without a syndesmotic screw, gives similar results. Obligatory fixation of these fractures with syndesmotic screws appears to have no benefit and creates the need for an additional procedure.

Objective—To assess the suitability of lithium dilution as a method for measuring cardiac output in anesthetized horses, compared with thermodilution and transesophageal Doppler echocardiography. Animals—6 horses (3 Thoroughbreds, 3 crossbreeds). Procedure—Cardiac output was measured in 6 anesthetized horses as lithium dilution cardiac output (LiDCO), thermodilution cardiac output (TDCO), and transesophageal Doppler echocardiographic cardiac output (DopplerCO). For the LiDCO measurements, lithium chloride was administered IV, and cardiac output was derived from the arterial lithium dilution curve. Sodium nitroprusside, phenylephrine hydrochloride, and dobutamine hydrochloride were used to alter cardiac output. Experiments were divided into 4 periods. During each period, 3 LiDCO measurements, 3 DopplerCO measurements, and 3 sets of 3 TDCO measurements were obtained. Results—70 comparisons were made between LiDCO, DopplerCO, and triplicate TDCO measurements over a range of 10 to 43 L/min. The mean (± SD) of the differences of LiDCO – TDCO was –0.86 ± 2.80 L/min; LiDCO = –1.90 + 1.05 TDCO (r = 0.94). The mean of the differences of DopplerCO – TDCO was 1.82 ± 2.67 L/min; DopplerCO = 2.36 + 0.98 TDCO (r = 0.94). The mean of the differences of LiDCO – DopplerCO was –2.68 ± 3.01 L/min; LiDCO = –2.53 + 0.99 DopplerCO (r = 0.93). Conclusions and Clinical Relevance—These results indicate that lithium dilution is a suitable method for measuring cardiac output in horses. As well as being accurate, it avoids the need for pulmonary artery catheterization and is quick and safe to use. Monitoring cardiac output during anesthesia in horses may help reduce the high anesthetic mortality in this species. (Am J Vet Res 2000;61:731–737)

Objective— To determine the effects of Samarium-153 bound to hydroxyapatite microspheres (153SmM) when injected into the metacarpophalangeal and metatarsophalangeal joints of horses. Study Design— Horses were injected with 153SmM in metacarpophalangeal and metatarsophalangeal joints with the diagonal contralateral joints used as untreated controls. Animals or Sample Population Twelve adult horses without pre-existing disease involving the metacarpo/metatarsophalangeal joints. Methods— Horses were divided into three groups: high-dose Samarium-153 (12.5 to 17.0 millicurie [mCi]), intermediate dose (6.5 to 12.0 mCi), and low dose (3.5 to 6.0 mCi). Horses were examined daily for 7 days postinjection for clinical abnormalities, lameness, and surface and systemic radiation levels. One horse from each group was euthanatized at 14, 30, and 60 days postinjection and the effects of the 153SmM examined microscopically in the cartilage and synovial membrane. Results— Intraarticular153SmM caused inflammation characterized by lameness, effusion, and regional edema for 48 to 72 hours. Minimal levels of active 153SmM were identified in the blood or urine and were well below the maximal tolerance of 1 mCi. Microscopically the radiation caused no effects on the articular cartilage. The synovectomy created was good but not ideal in that some areas did have necrosis into the subintimal regions and a few islands of intact intimal cells persisted. Conclusions— The use of 153SmM is an effective means of targeting the synovial intimal cells with minimal extrasynovial leakage of radiation. Clinical Relevance— The metacarpophalangeal and metatarsophalangeal joints of the horse can be safely treated with 153SmM without damage to the cartilage or significant extracapsular leakage.

This study sought to determine if extensive trimming of the front hooves of foals results in a higher incidence of palmar process fractures compared to untrimmed foals, and to characterise the clinical course of foals with palmar process fractures with physical findings, hoof measurements and radiography. Twenty foals age 4-8 weeks of multiple breeds were examined every 2 weeks over a 12 week period. Ten foals had both front hooves extensively trimmed every 4 weeks, while 10 foals remained untrimmed. Palmar process fractures occurred in 4 trimmed and 3 untrimmed foals. Four foals with fractures had brief lameness (Grades I-II/V) and hoof tester sensitivity was found inconsistently with fractures. All foals with fractures were sound at the end of the study. Fractures healed based on radiographic evaluations in an average of 8.4 weeks. Two of 3 foals with fractures developed club-footed conformation. None of the measured hoof parameters significantly differed between foals with and without fractures. We conclude that extensive trimming of the heels did not appear to affect the occurrence of palmar process fractures in this group of foals.

Systemic capillary leak syndrome (SCLS) is characterized by intermittent attacks of leakage of intravascular fluids into the extravascular space. Hypovolemia, hemoconcentration, weakness, edema, and visceral congestion are resulting manifestations of SCLS. Most patients with SCLS have clear mentation during attacks, and encephalopathy is not a known manifestation of the syndrome. We report a patient with acute idiopathic capillary leak syndrome manifested in an acute encephalopathy. The possibility of SCLS should be considered in patients who have an encephalopathy and hemoconcentration.

The M-1 cell line is derived from the mouse cortical collecting duct and displays the low-conductance, highly Na(+)-selective channel activity of the alpha,beta, gamma-heterotrimeric epithelial Na+ channel (ENaC). The short-circuit current (Isc) across M-1 monolayers was 89 +/- 4 microA/cm2, and the transepithelial conductance was 2.1 +/- 0.2 mS/cm2. Isc was abolished by blocking the Na+ pump with ouabain. Both Isc and transepithelial conductance (gT) were inhibited by benzamil > amiloride >> dimethylamiloride. Under our experimental conditions, vasopressin, vasopressin, forskolin, and dibutyryl adenosine 3',5'-cyclic monophosphate (cAMP) had no detectable effects on Isc or gT. Increasing apical Na+ entry with nystatin increased Isc. The possible regulation of the M-1 Na+ channel by cAMP-activated protein kinase A (PKA) was further examined with excised inside-out patches. The open-time probability (Po) was not fixed, displaying substantial variance. Perfusion with ATP itself, with the catalytic subunit of PKA with ATP, or with alkaline phosphatase had no consistent effect on Po, the unitary current, or the kinetics of the M-1 Na+ channel. The data are consistent with the concept that PKA stimulates ENaCs by phosphorylating a site with access to but not within the apical membrane patch during cell-attached and excised-patch studies.

Background The speed, quality, and cost of mask induction of anesthesia and laryngeal mask airway insertion or tracheal intubation were studied in young non-premedicated volunteers given high inspired concentrations of sevoflurane (6 to 7%). Methods Twenty healthy persons who were 19 to 32 years old participated three times, received 6 l/min fresh gas flow, and were randomized to receive 6 to 7% sevoflurane in 66% nitrous oxide/28% oxygen by face mask until tracheal intubation (treatment 1) or until laryngeal mask airway insertion (treatment 3), or 6 to 7% sevoflurane without nitrous oxide to tracheal intubation (treatment 2). Participants exhaled to residual volume and took three vital capacity breaths of the gas mixture; thereafter ventilation was manually assisted. The time of exposure to the inhaled gas was varied for consecutive participants. It was either increased or decreased by 30-sec increments based on the failure or success of the preceding volunteer's response to laryngoscopy and intubation after a preselected exposure time. Failure was defined as poor jaw relaxation, coughing or bucking, or inadequate vocal cord relaxation. Results Loss of the lid-lash reflex in unpremedicated young volunteers was achieved in 1 min and did not differ among groups. Average time (and 95% confidence interval) for acceptable conditions for LMA insertion was achieved in 1.7 (0.7 to 2.7) min, and all participants had an immediate return of spontaneous ventilation. The time for acceptable tracheal intubating conditions after manual hyperventilation by mask was 4.7 (3.7 to 5.7) min and 6.4 (5.1 to 7.7) min in treatments 1 and 2, respectively. There were no cases of increased secretions or laryngospasm. The incidence of breath holding and expiratory stridor ("crowing") was 7.5% and 25%, respectively, during treatment 1 and 15% and 40%, respectively, during treatment 2. Conclusions The induction of anesthesia to loss of lid reflex in young non-premedicated adults approaches the speed of intravenous induction techniques. No untoward airway responses were noted during mask induction of anesthesia with a three-breath technique. In response to intubation, no adverse airway responses, including jaw tightness, laryngospasm, and excessive coughing or bucking, occurred in participants whose duration of mask administration of sevoflurane met the appropriate times (as determined in this study).

There is still a need for improvements in the way one measures blood flow. Cardiac output is a fundamental physiological parameter and one that changes rapidly in the patient i.e. it is suitable for attention as a point-of-care (POC) measurement. Its accurate measurement with thermodilution comes at a high cost both clinically and financially. An ideal system would be less invasive, quicker, more cost effective and ultimately continuous. It is the authors' feeling that an improved indicator dilution method provides the first step towards the development of a continuous cardiac output (CCO) system. This has been described. The second step is to critically evaluate the synergy of the lithium indicator dilution cardiac output (LiDCO) system with a number of potentially continuous technologies. Early research on such combination technology suggests that a CCO system may be developed from combining the LiDCO system with a continuous technology based on arterial pressure waveform analysis.

Primary leiomyosarcoma of the testis is an extremely rare condition with only a few reported cases in the literature. None has been reported in men of afrocaribean descent. This report describes the first case of a primary leiomyosarcoma in a mixed race man. Several different immunostains were used to confirm the morphological suggestion of a primary intratesticular smooth muscle tumour. Scrotal ultrasound and abdominal computed tomography imaging were used to exclude paratesticular and retroperitoneal pathology. Where reported, primary intratesticular leiomyosarcoma is described as an indolent tumour with the potential for distant metastases. Its occurrence in younger men is usually associated with anabolic steroid abuse. Although the number of reported cases is very few, radical orchidectomy followed by surveillance appears to be the treatment of choice.

Salter innominate osteotomy is a widely used operative procedure to redirect the acetabulum in cases of acetabular dysplasia. The effectiveness of this redirection is indicated by the change in the appearance of the obturator foramen after the procedure. This is usually accompanied by an increase in the center edge (CE) angle with an effective decrease in the forces transmitted across the hip joint. In a prospective study of 20 Salter innominate osteotomies performed on two different age groups, one mature and one immature, we studied the change in the deformity of the obturator foramen with time after this procedure. In the immature pelvis, the asymmetric appearance of the obturator foramen remodeled gradually during the 6 months after the procedure. However, in the mature patient, no such remodeling potential was demonstrable during the study period. This finding has clinical implications regarding the advice for performing Salter innominate osteotomies in mature and immature patients.

We reviewed Atlanta area hospital records to determine the following regarding neonatal circumcision: incidence in July 1985; incidence after publicized serious complications of circumcision in August 1985; medical record documentation; and the complication rate. After stratified sampling from hospital birth logs, we abstracted information from medical charts and calculated weighted estimates and P values. The circumcision incidence was 89.3% in July 1985, 87.5% in September 1985, and 84.3% in September 1986. Circumcision was recorded on the medical record face sheet for 84.3% of circumcised boys. The complication rate was 3.1%; no serious complications were recorded. We conclude the following: circumcision incidence was high during the study period; publicity regarding adverse outcomes may have decreased the subsequent incidence of the procedure; hospital discharge data, which rely on medical record face sheet information, underestimate the true incidence of neonatal circumcision; and neonatal circumcision is usually safe, but serious complications may occur.

387 Background: Oxaliplatin plays an important role in chemotherapy regimens for colorectal and other GI malignancies. Debilitating peripheral neuropathy (PN) often develops with use of this drug. One study (Grothey A et al, ASCO 2009, abst #4025) has shown that pre- and post-oxaliplatin infusions with calcium (Ca) and magnesium (Mg) may reduce this toxicity. To confirm this in an unselected indigent minority population, a retrospective review was performed comparing development of PN in oxaliplatin exposed patients treated with or without Ca/Mg. Methods: Records of patients who received oxaliplatin from 1/2008 to 12/2009 at MetroHealth Medical Center, a large safety net hospital in Cleveland, OH, were reviewed. 47 patients received Ca/Mg + oxaliplatin and 46 oxaliplatin alone. Data collected included age, race, gender, insurance status, performance status, tumor type, stage, concomitant diseases (DM and EtOH), number of cycles and cumulative dose of oxaliplatin. PN was determined using the Common Terminology Criteria of Adverse Events (CTCAE) version 3.0. Patients were followed 6 months after completion of oxaliplatin. Results: Demographic data was similar between the two groups. Colorectal cancer compromised 77% of the treatment group and 85% of control group. Patients who received Ca/Mg had significantly less PN in all three grades (1-3) compared with the control group (grade 1 89.4% vs. 71.7%, grade II 10.6% vs. 19.6%, grade 3 0% vs. 8.7%, respectively). The cumulative dose of oxaliplatin did not differ between the two groups (Ca/Mg median 1,143 range 260-2,169; control median 1,425 range 137-2,635). The combined total grades 2 and 3 in both the treatment and control (10.6% vs. 28.3%, p = 0.038) favored use of Ca/Mg. Conclusions: This small, retrospective study confirms that Ca/Mg infusions reduce the incidence of clinically significant (grade 2/3) PN in pts receiving oxaliplatin. No significant financial relationships to disclose.

We performed a randomised double-blind controlled study in patients undergoing elective knee arthroscopy to assess the effect of intra-articular morphine on postoperative pain relief. Patients in the study group (n = 10) received 5 mg of morphine in a 25 ml dilution intra-articularly while those in the control group (n = 10) received 25 ml of saline. Postoperative pain was assessed at intervals by a visual analogue scale and the requirement for supplementary analgesia was recorded. Those in the study group had significantly lower pain scores and required less systemic analgesics than those in the control group. Plasma profiles for morphine and its metabolites were assayed and showed that they were too low to produce effective analgesia. Evidence suggests that analgesia was mediated by local action within the joint.

Clinical records and thoracic radiographs of 19 horses with a confirmed pathologic diagnosis of silicosis were reviewed. These horses had histories of varying degrees of chronic weight loss, exercise intolerance, and respiratory distress. At the time of presentation, two horses were asymptomatic. Ten horses were geldings and nine were female. The mean age of the 19 horses was 10.7 +/- 5.5 years. Fourteen horses were identified as being from the Monterey-Carmel Peninsula of midcoastal California. An abnormal, structured interstitial pulmonary pattern was identified on thoracic radiographs in each horse. The interstitial pulmonary changes were classified as miliary (13 horses), reticulonodular (4), or linear interstitial (2), and were best visualized dorsally and caudodorsally. In addition to the abnormal interstitial pulmonary pattern, areas of pulmonary consolidation were evident caudodorsally in seven horses. Other thoracic radiographic features included: hilar lymphadenopathy (4 horses), pleural effusion/thickening (4), cranial mediastinal lymphadenopathy (2), hyperinflation (1), and a discrete pulmonary mass (1). Necropsy findings in eight horses and results of lung biopsies in an additional five horses showed a diffuse, multifocal, granulomatous pneumonia with areas of pulmonary fibrosis. Cellular infiltrates included predominantly macrophages with intracellular and/or extracellular crystalline material, occasional lymphocytes, and giant cells. Similar cellular changes were also identified, during necropsy, in the hilar and tracheobronchial lymph nodes in each of the eight horses, although gross enlargement of the lymph nodes was present in only six horses. The radiographic and pathologic findings of these 19 horses are consistent with chronic or the accelerated forms of silicosis that are recognized in humans.

Successful ligament prosthetic surgery involves the rational design of a ligament “system”. Such a “system” should have inputs from professionals in the fields of bioengineering, textile technology, and surgery. This paper reexamines the ABC scaffolding ligament design philosophy and surgical technique, from a multidisciplinary standpoint, in light of clinical results obtained from the follow-up of 198 patients over a 5 year period.

Purpose of Study To present a case of a gonadotroph adenoma with markedly elevated testosterone levels. A review of relevant literature is also included. Methods A 61-year-old African American male was referred for evaluation of persistent headaches. Symptoms initially started 5 months earlier with bifrontal, pounding headaches and right temporal hemianopia. He admitted to decreased sexual activity and overall energy level, as well as increased facial hair growth. He denied any galactorrhea or enlargement of hands or feet. Examination was significant for mildly enlarged testes but no testicular masses. MRI revealed a pituitary macroadenoma measuring 2.7 × 2.2 cm, with extension into the right cavernous sinus and elevation of the optic chiasm. Results Laboratory workup to assess for secretory capacity was initiated. Prolactin was 24 ng/mL (2.1-17.7 ng/mL), LH 15.7 mIU/mL (1.5-9.3 mIU/mL), FSH 102.9 mIU/mL (1.4-18.1 mIU/mL), and total testosterone 2,270 ng/dL (241-827 ng/dl). He subsequently underwent successful transsphenoidal resection of the adenoma. Immunoperoxidase staining of the tissue was strongly positive for LH and weakly positive for FSH. Eighteen days postoperatively, laboratory results showed LH 1.6 mIU/mL, FSH 18.1 mIU/mL, and total testosterone 58 ng/dL. Conclusions Gonadotroph adenomas may produce supranormal concentrations of intact LH, which can rarely cause a supranormal testosterone concentration. The endocrinologist should be aware of this entity to facilitate diagnosis in the future.

We read with interest the report of Ayuso-Peralta et al ,1 which describes a 58 year old woman who presented with several neurological symptoms. Brain imaging was consistent with leukoencephalopathy, and analysis of blood and cerebral spinal fluid was unrevealing. A few months later the patient experienced further neurological deterioration and an open brain biopsy showed central nervous system (CNS) lymphoma, together with diffuse demyelination. The authors observed that the presentation of cerebral lymphoma …