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Importance: Transient hypocalcemia is a well-recognized occurrence after total thyroidectomy. It has been hypothesized that underlying vitamin D deficiency may increase the risk of this complication, although to date there are few data in the literature supporting this hypothesis., Objective: To investigate whether perioperative vitamin D levels have any effect on postthyroidectomy hypocalcemia., Design, Setting, and Participants: We performed a retrospective review of a prospectively maintained database of thyroidectomies from November 1, 2009, through September 30, 2012, at an academic teaching hospital. The study included 121 patients with available vitamin D levels undergoing total or completion thyroidectomy. Patients with preexisting hypercalcemia or hyperparathyroidism were excluded., Interventions: All patients underwent total removal of all thyroid tissue by a capsular dissection technique. Routine calcium or vitamin D supplementation was not administered. Biochemical hypocalcemia was defined as any single postoperative corrected calcium level less than 8.0 mg/dL (to convert to millimoles per liter, multiply by 0.25) and symptomatic hypocalcemia as any symptoms of hypocalcemia., Main Outcomes and Measures: Outcome measures were incidence of postoperative hypocalcemia and association with vitamin D levels. A multivariate analysis was performed to study the effect of other variables, including performance of central neck dissection, incidental parathyroidectomy, and hyperthyroidism, on the incidence of postoperative hypocalcemia., Results: The incidence of transient biochemical hypocalcemia was 24% (n = 29/121). There was no correlation between vitamin D levels and risk of postoperative hypocalcemia. On univariate analysis, performance of concomitant central compartment neck dissection revealed an increased risk of hypocalcemia (P = .06), but this finding was not significant on multivariate analysis., Conclusions and Relevance: Vitamin D levels do not appear to have a significant effect on the risk of postthyroidectomy hypocalcemia.

Objective: The tubercle of Zuckerkandl (TZ) is a lateral projection from the thyroid lobe in the vicinity of the extralaryngeal termination of the recurrent laryngeal nerve (RLN), which is a very useful landmark for identification of the RLN during thyroidectomy. The purpose of the present study was to test our hypothesis that the TZ is more consistently found and is larger on the right than on the left side, and to investigate the frequency of anatomic variations of the TZ., Study Design: Prospective cohort study of 156 consecutive patients undergoing primary total thyroidectomy at an academic teaching hospital. Thyroidectomy was performed using a capsular dissection technique, with identification of the RLN only at its entry point into the larynx, using the TZ as a landmark. In vivo recording of size of right and left TZ was performed. The size of the right and left TZ was compared., Results: Identification of the TZ was 72.6% right side and 53.9% left side (p = 0.003). The mean size of the TZ, when present, was 11.2 mm on the right and 7.5 mm on the left (p = 0.0002). In matched-pair analysis, the right TZ was significantly larger than the left TZ (p < 1 × 10(-7)). The TZ overlay the RLN in nearly all cases; however, there were 2 cases (0.8%) of a TZ extending medial to the RLN. In 12 cases (4.7%), the TZ appeared as a bilobed structure., Conclusion: The right TZ is consistently larger and more often identified than the left.

For two watersheds in the northern Midwest United States, we show that landscape depressions have a significant impact on watershed hydrology and sediment yields and that the Soil and Water Assessment Tool (SWAT) has appropriate features to simulate these depressions. In our SWAT models of the Willow River in Wisconsin and the Sunrise River in Minnesota, we used Pond and Wetland features to capture runoff from about 40% of the area in each watershed. These depressions trapped considerable sediment, yet further reductions in sediment yield were required for calibration and achieved by reducing the Universal Soil Loss Equation (USLE) cropping-practice (P) factor to 0.40 to 0.45. We suggest terminology to describe annual sediment yields at different conceptual spatial scales and show how SWAT output can be partitioned to extract data at each of these scales. These scales range from plot-scale yields calculated with the USLE to watershed-scale yields measured at the outlet. Intermediate scales include field, upland, pre-riverine, and riverine scales, in descending order along the conceptual flow path from plot to outlet. Sediment delivery ratios, when defined as watershed-scale yields as a percentage of plot-scale yields, ranged from 1% for the Willow watershed (717 km) to 7% for the Sunrise watershed (991 km). Sediment delivery ratios calculated from published relations based on watershed area alone were about 5 to 6%, closer to pre-riverine-scale yields in our watersheds., (Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.)

End-tidal breath carbon monoxide (CO) is abnormally low in women with preeclampsia (PE), while women smoking during pregnancy have shown an increase in CO levels and a 33% lower incidence of PE. This effect may be, in part, due to lowered sFLT1 plasma levels in smokers, and perhaps low-level CO inhalation can attenuate the development of PE in high-risk women. Our previous work showed maternal chronic CO exposure (<300 ppm) throughout gestation had no maternal or fetal deleterious effects in mice. Our current study evaluated the uteroplacental vascular effects in CD-1 maternal mice that inhaled CO (250 ppm) both chronically, gestation day (GD) 0.5 to 18.5, and acutely, 2.5 h on each of GD 10.5 and 14.5. We demonstrated, using microultrasound measurements of blood velocity and microcomputed tomography imaging of the uteroplacental vasculature, that chronic maternal exposure to CO doubled uterine artery blood flow and augmented uteroplacental vascular diameters and branching. This finding may be of benefit to women with PE, as they exhibit uteroplacental vascular compromise. The ratio of VEGF protein to its FLT1 receptor was increased in the placenta, suggesting a shift to a more angiogenic state; however, maternal circulating levels of VEGF, sFLT1, and their ratio were not significantly changed. Doppler blood velocities in the maternal uterine artery and fetal umbilical artery and vein were unaltered. This study provides in vivo evidence that chronic inhalation of 250 ppm CO throughout gestation augments uterine blood flow and uteroplacental vascular growth, changes that may protect against the subsequent development of preeclampsia.

Objectives/hypothesis: Routine identification of all four parathyroid glands has been advocated as a means of reducing rates of postoperative hypocalcemia and inadvertent parathyroidectomy. The object of the present study was to investigate whether identification of more parathyroid glands during thyroidectomy performed by capsular dissection technique had any impact on incidence of postoperative hypocalcemia and unintentional parathyroid resection., Study Design: Prospective cohort study of consecutive patients undergoing total thyroidectomy by capsular dissection technique over a 3-year period. Exclusion criteria included performance of concomitant central neck dissection, hyperparathyroidism, revision surgery, and invasive cancer., Methods: The number of parathyroid glands identified intraoperatively was recorded. No effort was made to find glands that were not obviously apparent during the course of dissection. Patients were not placed on routine calcium supplementation., Results: The final study population consisted of 126 patients. The mean number of parathyroid glands identified was 2.3. The incidence of biochemical (any postoperative calcium <2 mmol/L) and clinical hypocalcemia was 22.2% and 10.3%, respectively. Patients in group A (0-2 parathyroids identified) had a significantly lower incidence of clinical hypocalcemia than patients in group B (3-4 parathyroids identified) (3.2% vs. 17.1%, P = .02). The differences in biochemical hypocalcemia were not significant (16.1% vs. 28.1%, P = .13). The incidence of inadvertent parathyroidectomy was 9.5%. There was no difference between the groups in incidence of inadvertent parathyroidectomy (9.7% vs. 9.4%, P = 1.0)., Conclusions: Routine identification of all four parathyroid glands is not necessary in thyroidectomy performed using capsular dissection technique., (Copyright © 2012 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To characterize persistent postpartum maternal endothelial dysfunction following pre-eclampsia (PE) through the assessment of endothelial progenitor cells as markers of endothelial reparative capacity., Study Design: Maternal circulating endothelial progenitor cells were measured at 2months and 6months postpartum in women who had recently experienced PE pregnancies (n=17). Normotensive controls (n=13) with uncomplicated pregnancies served for comparison at the same time points. Progenitor cells were measured by flow cytometry and by colony forming units. Maternal cardiovascular risk was measured at 6months postpartum., Main Outcome Measures: Levels of maternal circulating endothelial progenitor cells and cardiovascular risk in the early postpartum period of uncomplicated and PE pregnancies., Results: CD34+VEGFR-2+ and CD133+VEGFR-2+ cells were elevated in PE subjects at 2months postpartum compared to healthy control subjects, although reduced by 6months postpartum. PE was associated with reduced colony forming units at 2 and 6months postpartum. Cardiovascular risk scores were increased in PE compared to normotensive controls., Conclusions: We have demonstrated that there is a physiological alteration in the number and function of circulating progenitor cells following PE pregnancies. Furthermore, this population of women exhibited elevated cardiovascular risk profiles compared to those with uncomplicated pregnancies. Pregnancy and the development of PE identify an early window for cardiovascular risk screening in women. Cellular markers of vascular health offer an approach to the investigation of postpartum endothelial dysfunction., (Copyright © 2013 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Four weeks after elective embolisation of a symptomatic benign uterine fibroid, a lady presented to her general practitioner with facial twitching and severe lassitude. Acute hypocalcaemia was diagnosed. Further investigations demonstrated hypomagnesaemia. Parathyroid hormone (PTH) was within normal limits. Symptoms and the acute metabolic disturbance resolved with treatment by oral magnesium and calcium supplementation. While lassitude is a common symptom of postfibroid embolisation and may last for up to 6 weeks, the presentation with facial twitching alerted the clinician to a potential electrolyte or metabolic imbalance. This is a first reported case of hypomagnesaemia associated with PTH resistance leading to hypocalcaemia precipitated by alcohol particle embolisation for benign fibroid disease.

Background: Pediatric ulcerative colitis (UC) care is variable with a lack of appropriate guidelines to guide practice until recently., Methods: UC inpatients <17 years old admitted to 23 U.K. pediatric hospitals had clinical details collected between September 2010 and 2011. Comparative data for 248 patients were available from a previous audit in 2008., Results: One hundred and seventy-six patients (98 males) of median age 13 years (interquartile range, 10-13) were analyzed; 23 were elective surgical admissions, 47 new diagnoses, and 106 needed acute medical care for established UC. Median length of stay was 6 days (interquartile range, 3-10) with no deaths. Eighty-eight of 126 patients (70%) with active disease had standard stool cultures performed (3 [2%] were positive), and 57 (45%) had Clostridium difficile toxin tested (none positive). Twenty-five of 66 (38%) emergency admissions had an abdominal x-ray on admission, and 13 of 66 patients (20%) had a Pediatric Ulcerative Colitis Activity Index score. There were 3 cases of toxic megacolon and 2 thromboses. Eighty-one of 116 patients (71%) responded to steroids. Nineteen patients who did not respond adequately to steroids received rescue therapy (7 infliximab, 11 ciclosporin, and 1 both) with overall response rate of 90%; 7 patients needed surgery acutely, 5 without previous rescue therapy. Compared with the 2008 data, stool culture rates improved significantly (86 of 121 [71%] versus 76 of 147 [52%], P = 0.001) as did heparinization rates (15 of 150 [10%] versus 5 of 215 [2%], P = 0.002) and rescue therapy usage (17 of 33 [52%] versus 10 of 38 [26%], P = 0.03)., Conclusions: There were signs of improving UC care with significantly increased rates of stool culture and rescue therapy. The majority of sites, however, did not use Pediatric Ulcerative Colitis Activity Index scores.

Objectives/hypothesis: Fine-needle aspiration (FNA) cytology is well established in the diagnosis of thyroid nodules. However, false-negative rates for malignancy of 3% to 10% are reported. The purpose of the present study was to investigate the impact of nodule size and follicular variant of papillary carcinoma (FVPTC) on false-negative FNA rates in thyroid nodules and on malignancy rates in nodules with indeterminate cytology., Study Design: Retrospective study., Methods: A total of 765 consecutive ultrasound-guided FNAs were reviewed. Histological correlation was available in 262 cases., Results: The overall sensitivity of FNA for malignancy was 84%, and the false-negative rate 9.1%. Nodules ≥ 3 cm were significantly more likely to ultimately be diagnosed as cancer by histology than nodules <3 cm (14% vs. 6.8%, P = .006); however, they were also significantly more likely to undergo surgery than smaller nodules (P < .0001). Among the surgical series, the false-negative rate was 10.9% in nodules ≥ 3 cm and 6.1% in nodules <3 cm (P = .71). Most false negatives were due to FVPTC. FVPTC was significantly more likely to be missed by preoperative cytology than conventional or other variants of papillary carcinoma (P < .001). Among cases with indeterminate cytology, nodule size and Thy-3f versus Thy-3a subclassification did not have any significant impact on likelihood of malignancy., Conclusions: The sensitivity of FNA for detection of FVPTC is reduced compared to conventional papillary carcinoma. The impact of nodule size is not significant., Level of Evidence: 4., (Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Definitive diagnosis of pediatric ulcerative colitis (UC) may be particularly challenging since isolated colitis with overlapping features is common in pediatric Crohn's disease (CD), while atypical phenotypes of UC are not uncommon. The Paris classification allows more accurate phenotyping of atypical inflammatory bowel disease (IBD) patients. Our aim was to identify the prevalence of atypical disease patterns in new-onset pediatric UC using the Paris classification., Methods: Information was collected from the EUROKIDS Registry, an inception cohort of untreated pediatric IBD patients undergoing evaluation at diagnosis. Patients with IBD-unclassified were excluded. Patients with isolated Crohn's colitis served as a control group., Results: Data from 898 pediatric patients (643 UC, 255 CD colitis) were included. Extensive or pancolitis was present in 77% of UC patients and macroscopic rectal sparing in 5%. Rectal sparing was inversely associated with age (mean age with rectal sparing 9.9 years vs. 11.8 without; P = 0.02). Upper gastrointestinal (UGI) involvement occurred in 4% of patients. Erosions in the stomach were present in 3.1% of children, but frank ulcerations in 0.4%; 0.8% of children had erosions or ulcerations limited to the esophagus or duodenum. The corresponding UGI involvement in Crohn's colitis was 22%. A cecal patch occurred in 2% of patients., Conclusions: Extensive disease and rectal sparing are age-dependent phenotypes in pediatric UC. Rectal sparing, cecal patch, backwash ileitis, and gastric erosions are not uncommon at diagnosis, while gastric ulcerations and erosions in the duodenum or esophagus are. Recognition of atypical phenotypes in pediatric-onset UC is crucial to prevent misclassification of IBD.

Categorization is essential for survival, and it is a widely studied cognitive adaptation in humans and animals. An influential neuroscience perspective differentiates in humans an explicit, rule-based categorization system from an implicit system that slowly associates response outputs to different regions of perceptual space. This perspective is being extended to study categorization in other vertebrate species, using category tasks that have a one-dimensional, rule-based solution or a two-dimensional, information-integration solution. Humans, macaques, and capuchin monkeys strongly dimensionalize perceptual stimuli and learn rule-based tasks more quickly. In sharp contrast, pigeons learn these two tasks equally quickly. Pigeons represent a cognitive system in which the commitment to dimensional analysis and category rules was not strongly made. Their results may reveal the character of the ancestral vertebrate categorization system from which that of primates emerged. The primate results establish continuity with human cognition, suggesting that nonhuman primates share aspects of humans' capacity for explicit cognition. The emergence of dimensional analysis and rule learning could have been an important step in primates' cognitive evolution., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: The incidence of seroma after thyroidectomy has been reported between 1.3% and 7%. We hypothesised that a flapless thyroidectomy technique would reduce the incidence of seroma., Design: Observational case-control study with comparison between retrospective cohort of patients undergoing thyroidectomy with raising of conventional skin flaps and prospective cohort undergoing flapless surgery., Setting: Academic Teaching Hospital., Participants: Hundred and seventy-five consecutive patients undergoing thyroidectomy performed by a single surgeon. After the first 85 cases, a change in practice took place, from raising of conventional skin flaps to performing flapless surgery wherever feasible., Main Outcome Measures: Occurrence of postoperative seroma, defined as central neck swelling in postoperative period, confirmed by aspiration of serous fluid, and other complications., Results: Eight patients who underwent concomitant lateral (jugular) neck dissection were excluded. Among the remaining 167 patients, there were eight seromas (5%). Following the change in practice to flapless surgery, there was a significant reduction in the incidence of seroma (P = 0.025). There was no significant difference in other complications (haematoma; recurrent laryngeal nerve injury; and hypocalcaemia). Among the entire group, the association between seroma and flapless surgery tended towards significance (P = 0.07). Other variables studied, including use of drain and concomitant central compartment neck dissection, had no effect on seroma., Conclusion: Flapless technique for thyroid surgery may reduce the incidence of postoperative seroma., (© 2012 Blackwell Publishing Ltd.)

Objective: The Tubercle of Zuckerkandl (TZ), which is the remant of the lateral thyroid process, is an important anatomic structure that serves as a reliable landmark for the recurrent laryngeal nerve in thyroid surgery. Furthermore, removal of the TZ is critical for the adequate performance of a total thyroidectomy. However, there is little mention of the TZ in surgical textbooks or papers., Methods: Prospective observational study of 138 consecutive thyroid surgeries. The presence of the TZ, its size, and relationship to the recurrent laryngeal nerve, were recorded., Results: A total of 211 thyroid lobes were included in the study. The TZ was identified in 61.1% of all thyroid lobes. The median size was 8 mm (range = 3-40 mm). A TZ was more commonly identified on the right (69.6%) than on the left side (53.2%) (P = .02). The recurrent laryngeal nerve was found deep to the TZ in 98.4% of cases., Conclusions: A TZ is present in the majority of thyroid lobes. Awareness of the TZ is critical in performing an adequate total thyroidectomy, and is very useful as a landmark for the recurrent laryngeal nerve., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: Adalimumab is efficacious therapy for adults with Crohn's disease (CD)., Aim: To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience., Methods: British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA)., Results: Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate)., Conclusions: Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate., (© 2011 Blackwell Publishing Ltd.)

Recent theoretical and empirical developments in human category learning have differentiated an analytic, rule-based system of category learning from a nonanalytic system that integrates information across stimulus dimensions. In the present study, the researchers applied this theoretical distinction to pigeons' category learning. Pigeons learned to categorize stimuli varying in the tilt and width of their internal striping. The matched category problems had either a unidimensional (rule-based) or multidimensional (information-integration) solution. Whereas humans and nonhuman primates strongly dimensionalize these stimuli and learn rule-based tasks far more quickly than information-integration tasks, pigeons learned the two tasks equally quickly to the same accuracy level. Pigeons may represent a cognitive system in which the commitment to dimensional analysis and category rules was not strongly made. Their performance could suggest the character of the ancestral vertebrate categorization system from which that of primates emerged.

Conquest of indigenous peoples in North America is understood primarily through ethnohistorical documents, archaeological evidence, and osteological analyses. However, in the Central Andes, the colonial enterprise and its effects are understood only from postcontact historical and ethnohistorical sources. Few archaeological and bioarchaeological studies have investigated Spanish Conquest and colonialism in the Andean region [for exceptions see Klaus and Tam: Am J Phys Anthropol 138 (2009) 356-368; Wernke, in press; and Quilter, in press]. Here we describe bioarchaeological evidence of violence from the cemeteries of Huaquerones and 57AS03 within the archaeological zone of Puruchuco-Huaquerones, Peru (circa A.D. 1470-1540). A total of 258 individuals greater than 15 years of age were analyzed for evidence of traumatic injuries. Individuals were examined macroscopically and evidence of traumatic injuries was analyzed according to the skeletal element involved, the location of the injury on the skeletal element, and any additional complications of the injury. This study examines and compares the evidence of perimortem injuries on skeletonized individuals from the two cemeteries and focuses specifically on the interpretation of weapon-related perimortem injuries. Evidence of perimortem trauma is present in both cemeteries (18.6%, 48/258); however, the frequency of injuries in 57AS03 is greater than that in Huaquerones (25.0% vs. 13.0%). Several injuries from 57AS03 are consistent with documented cases of injuries from firearms and 16th Century European weapons. We believe that the nature and high frequency of perimortem trauma at 57AS03 provide evidence of the violence that occurred with Spanish Conquest of the Inca Empire., (Copyright 2010 Wiley-Liss, Inc.)

In nonunion after distal humerus fracture, osteoporosis, devascularized fracture fragments, and periarticular fibrosis limit potential reconstructive options. We assessed pain relief, functional gains, and complications in 12 patients whose long-standing, painful nonunions after previous treatment with rigid internal fixation were reconstructed with a semiconstrained total elbow arthroplasty, frequently with a triceps-sparing approach and anterior ulnar nerve transposition. At mean follow-up of 63 months, 11 patients had good pain relief and a good or excellent functional result: mean flexion/extension, 134 degrees to 18 degrees; mean total arc of motion, 117 degrees ; mean pronation/supination, 74 degrees to 69 degrees. Despite the 75% rate of complications (8), semiconstrained total elbow arthroplasty provides a viable treatment for this difficult problem.

Aims: The aims of this study were to describe the prevalence and clinical features of diabetes in hereditary haemochromatosis (HH), with particular emphasis to how this has changed since the introduction of genetic testing in 1996., Subjects and Methods: Two hundred and thirty-seven patients were diagnosed with HH (based on elevated iron indices and liver biopsy or genetic testing) by a single physician, and all biochemical and clinical data recorded from diagnosis to the end of the study., Results: The prevalence of diabetes (21.9%) was lower than most previously published studies. There was a significantly greater prevalence of diabetes and cirrhosis in those diagnosed before the introduction of genetic testing, p<0.001. The type of genetic mutation for HH, degree of ferritin elevation at diagnosis, or the presence of cirrhosis was not predictive for the development of diabetes. Iron depletion did not result in an improvement in glycaemic control or reduction in insulin requirements in the majority of patients., Conclusions: This is one of the largest published series of diabetes in HH. Because the occurrence of diabetes in patients with HH reduces life expectancy, our finding of a lower prevalence of diabetes is expected to translate into a greater survival rate in these patients.

Recent evidence indicates that pigeons can readily learn visual discriminations based on both absolute and relational stimulus factors. To examine how these two types of control function in their non-dominant auditory modality, we tested four pigeons in a go/no-go sequential auditory discrimination in which both absolute and relational cues were redundantly available. In this task, sequences of different sounds created from one set of pitches were reinforced, while different sequences created from another set of pitches and any same sequences made from either set of pitches were not. Across three experiments, we independently varied the relative discriminability of the absolute and relational components. The pigeons were consistently and primarily controlled by the absolute fundamental pitch of our notes in all of the experiments, although this was influenced by the range and arrangement of the pitches used in each set. A majority of the pigeons also demonstrated relational control when this component was made more salient. The more robust control exhibited by absolute factors is consistent with the comparative hypothesis that birds in general may have a well-developed aptitude for processing absolute pitch in many auditory settings. The relational control is consistent with our recent evidence of same/different auditory learning by pigeons.

Background: Active Crohn's disease can be treated using liquid diet therapy (LDT), but non-adherence may limit success, necessitating corticosteroid therapy. Whole-protein polymeric formula (PF) seems to be much more palatable than amino acid-based elemental formula (EF) and thus may significantly improve adherence to LDT., Aim: To compare adherence to LDT using PF versus EF., Methods: Success in completing a 6-week course of LDT, need for nasogastric tube administration of formula and use of LDT for relapses were compared between children presenting with active disease and treated with EF (n = 53) and children given PF (n = 45)., Results: Remission rates were similar (EF 64%, 95% CI 51 to 77 vs PF 51%, 95% CI 37 to 66; p>0.15). 72% (95% CI 60 to 84) given EF completed the initial course of LDT compared with 58% (95% CI 44 to 72) given PF (p = 0.15). Of those failing to complete the initial course, 13% on EF and 16% on PF gave up by choice (non-adherence), the remainder stopping due to treatment failure. Nasogastric administration was more frequent with EF (55%, 95% CI 42 to 68) compared to PF (31%, 95% CI 17 to 45) (p = 0.02). Among those treated successfully at first presentation, LDT was used for 28% of relapses in the EF group (95% CI 12 to 44) and 39% in the PF group (95% CI 19 to 59) (p>0.2) over the next year., Conclusion: PF did not effect adherence to LDT but was associated with significantly reduced need for nasogastric tube administration of formula.

We report a case of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS), occurring in association with mydriasis, in a female infant born to consanguineous Asian parents. This association has not previously been reported and is of interest because mydriasis has been found in a murine MMIHS model produced by knockout of the genes coding for the alpha3 subunit or the beta2 and beta4 subunits of the neuronal nicotinic acetylcholine receptor. This may provide an important clue to the genetic basis of MMIHS in humans.

Background: Little data exist on immunosuppressive drug absorption in children with short bowel syndrome and intestinal failure associated liver disease (SBS-IFALD)., Aim: To evaluate the absorption of immunosuppressive medications in children with SBS-IFALD undergoing isolated liver transplantation (iLTx)., Methods: A retrospective review was performed in children with SBS-IFALD undergoing LTx and comparison made with weight, age-matched children undergoing iLTX (extra-hepatic biliary atresia (EHBA) and normal intestinal length and function)., Results: Seven children with SBS-IFALD undergoing iLTx (median residual bowel length, 60 cm, range 40-80) were compared with 15 children undergoing LTx for EHBA. SBS-IFALD children had significantly lower trough tacrolimus levels at three months (5.8 vs. 7.9 ng/mL, p<0.05) and six months (5.0 vs. 8.0 ng/mL, p<0.05), but equivalent levels at 12 months after iLTx. The median calculated dose-normalized concentrations indicated that systemic availability of tacrolimus was comparable in two groups at 3, 6, 12 months (33.1 vs. 23.3; 42.4 vs. 36; 51 vs. 52.9) despite the differences in enteral function. The incidence of acute rejection was 1/7 (SBS-IFALD) and 10/15 (EHBA) group (p = 0.06)., Conclusion: Children with SBS-IFALD demonstrated adequate absorption of oral tacrolimus without significant acute rejection rate after iLTx suggesting that modification of immunosuppression is not necessary.

Background and Aims: Total enteral nutrition (TEN) with a liquid formula can suppress gut inflammation and induce remission in active Crohn's disease. The mechanism is obscure. Studies have suggested that long term nutritional supplementation with a liquid formula (partial enteral nutrition (PEN)) may also suppress inflammation and prevent relapse. The aim of this study was to compare PEN with conventional TEN in active Crohn's disease., Patients and Methods: Fifty children with a paediatric Crohn's disease activity index (PCDAI)>20 were randomly assigned to receive 50% (PEN) or 100% (TEN) of their energy requirement as elemental formula for six weeks. The PEN group was encouraged to eat an unrestricted diet while those receiving TEN were not allowed to eat. The primary outcome was achievement of remission (PCDAI<10). Secondary analyses of changes in erythrocyte sedimentation rate (ESR), C reactive protein, albumin, and platelets were performed to look for evidence of anti-inflammatory effects., Results: Remission rate with PEN was lower than with TEN (15% v 42%; p=0.035). Although PCDAI fell in both groups (p=0.001 for both), the reduction was greater with TEN (p=0.005). Moreover, the fall in PCDAI with PEN was due to symptomatic and nutritional benefits. With both treatments there were significant improvements in relation to abdominal pain, "sense of wellbeing", and nutritional status. However, only TEN led to a reduction in diarrhoea (p=0.02), an increase in haemoglobin and albumin, and a fall in platelets and ESR., Conclusions: TEN suppresses inflammation in active Crohn's disease but PEN does not. This suggests that long term nutritional supplementation, although beneficial to some patients, is unlikely to suppress inflammation and so prevent disease relapse.

Purpose: The outcome of silicone metacarpophalangeal (MCP) joint implant arthroplasty in the osteoarthritic patient population has not been well established. Typically patients with idiopathic osteoarthritis have no history of underlying systemic disease and may respond well to treatment with MCP joint implant arthroplasty. This study examined the efficacy of silicone MCP joint implant arthroplasty for patients with idiopathic osteoarthritis for whom nonsurgical treatment had failed., Methods: Of 14 patients (15 arthroplasties) who had silicone MCP joint implant arthroplasty for idiopathic osteoarthritis 12 (13 arthroplasties) returned for follow-up evaluation at an average of 40 months after surgery. There were 9 index finger and 4 middle finger arthroplasties. The average age at the time of surgery was 62 years. Patients completed a subjective questionnaire and were examined by a certified therapist. Range of motion and strength were recorded and the Jebsen-Taylor examination was administered to assess function. Range of motion values at final follow-up evaluation were compared with preoperative and early postoperative values. Radiographs were taken at final follow-up evaluation and compared with preoperative and early postoperative films to assess joint position, wear, and radioulnar alignment., Results: At final follow-up evaluation excellent (9 patients) and good (3 patients) overall improvement were reported. Nine patients (10 implants) reported greater than 75% functional improvement. A notable increase was seen in MCP joint flexion. Grip and lateral pinch strengths were below age-matched normative data. Of the 11 patients (12 implants) who came in for follow-up evaluation 7 performed all tasks of the Jebsen-Taylor examination within the allotted time. At final follow-up evaluation all silicone implants were located and showed no signs of subluxation. Radiographic radioulnar alignment was maintained. One implant was revised at 35 months secondary to fracture., Conclusions: Silicone implant arthroplasty is a motion-sparing procedure that provides good pain relief and maintenance of function at intermediate follow-up evaluation in patients with idiopathic osteoarthritis of the MCP joint.

Background: Transient global amnesia presents as paroxysmal, transient loss of memory function and has been shown to have a number of inciting factors., Aims: To report a case and its inciting factor in order to heighten awareness of the condition., Methods: A 56-year-old woman who presented with TGA after sexual intercourse is reported., Results: The episode of TGA resolved after 14 hours. Results of laboratory tests including MRI brain and MR angiogram and venogram were normal., Conclusion: An inciting event can often be identified for TGA and a targeted history should be used to help elicit such events.

A significant number of patients infected with Mycobacterium marinum have been treated at the Curtis National Hand Center in Baltimore, Maryland. The purpose of this study was to review the authors' experience with M. marinum infections of the upper extremity. Twenty-nine patients were identified and their charts were reviewed for all factors related to diagnosis and treatment. The most common presenting symptoms were swelling (n = 25) and pain (n = 14). Only 69 percent of patients could correlate their injury with aquatic activities. The mean time from injury to diagnosis was 5.2 months. Acid-fast bacilli stains were positive in only 22 percent of specimens. The mean number of procedures was 1.75, with the majority being tenosynovectomy. The mean duration of antibiotic therapy was 6 months. Clinical history, pathological evaluation, and a high clinical suspicion can lead to early diagnosis and introduction of antibiotics. The authors' patients were successfully treated with 6 months of antibiotic therapy and early surgical intervention.

Enteropathogenic Escherichia coli (EPEC) strains deliver effector proteins Tir, EspB, Map, EspF, EspH, and EspG into host cells to induce brush border remodeling and produce attaching and effacing (A/E) lesions on small intestinal enterocytes. In this study, the role of individual EPEC effectors in brush border remodeling and A/E lesion formation was investigated with an in vitro human small intestinal organ culture model of EPEC infection and specific effector mutants. tir, map, espB, and espH mutants produced "footprint" phenotypes due to close bacterial adhesion but subsequent loss of bacteria; an espB mutant and other type III secretion system mutants induced a "noneffacing footprint" associated with intact brush border microvilli, whereas a tir mutant was able to efface microvilli resulting in an "effacing footprint"; map and espH mutants produced A/E lesions, but loss of bacteria resulted in a "pedestal footprint." An espF mutant produced typical A/E lesions without associated microvillous elongation. An espG mutant was indistinguishable from the wild type. These observations indicate that Tir, Map, EspF, and EspH effectors play a role in brush border remodeling and production of mature A/E lesions.

Objective: To evaluate (99m)Tc-HMPAO leukocyte scintigraphy as an investigation for inflammatory bowel disease (IBD)., Study Design: Scintigraphy was performed in 95 children undergoing investigation for IBD in a tertiary Gastroenterology Department. Diagnosis was based on conventional investigations including small bowel barium contrast radiology (BCR), upper gastrointestinal endoscopy (UGIE), colonoscopy, and endoscopic biopsy (the "gold standards"). IBD was confirmed in 73 (57 Crohn's disease; 10 ulcerative colitis; 6 indeterminate colitis) and excluded in 22 (controls). Scintigraphy was (1) evaluated as a screening test, (2) compared with individual conventional tests, (3) assessed for each gut segment., Results: Screening test: sensitivity 0.75 (95% CI, 0.63-0.85), specificity 0.82 (95% CI, 0.59-0.94), PPV 0.93, NPV 0.5. Comparison with BCR: sensitivity 0.87 (95% CI, 0.72-0.96), specificity 0.57 (95% CI, 0.39-0.73), PPV 0.69, NPV 0.2. Comparison with UGIE: specificity 0.9 (95% CI, 0.79-0.96), NPV 0.13 (sensitivity and PPV unavailable). Comparison with colonoscopy: sensitivity 0.57 (95% CI, 0.41-0.73), specificity 0.71 (95% CI, 0.54-0.85), PPV 0.71, NPV 0.42. Comparison with biopsies paralleled that with endoscopy. False negatives were especially common (NPV< or =0.2) in the proximal gut., Conclusions: (99m)Tc-HMPAO leukocyte scintigraphy should not be relied on as a screening test for IBD because false negative results are common. This method is especially unreliable at detecting disease in the proximal gut.

A focused history and thorough physical examination, combined with a working knowledge of the normal vascular anatomy, can help identify most vascular abnormalities of the upper extremity. Technologic improvements now allow accurate diagnosis by noninvasive methods. Most abnormalities can be categorized into one of five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic. Behavioral modifications and pharmacologic agents may improve symptoms. Appropriately selected surgical candidates often experience pain relief and functional improvement.

There are multiple causes of elbow swelling, with RA being the most common. Crystalline disease such as gout is also frequently seen. Oral medication or intra-articular steroid injection can be extremely effective in controlling symptoms. Synovectomy in conjunction with radial head excision continues to have a role. Fascial arthroplasty can be beneficial in younger patients in isolated disease. In more advanced cases, total elbow arthroplasty is an attractive alternative.

Background: Upper gastrointestinal endoscopic biopsies often show histologic abnormalities in Crohn disease. Consequently, it has been proposed that routine endoscopy could help to distinguish Crohn disease from ulcerative colitis. Surprisingly, however, recent case reports and an uncontrolled study suggested that similar abnormalities may occur in ulcerative colitis. Therefore, a blinded, controlled study was performed., Methods: Esophageal, gastric antral, and duodenal biopsies from children with Crohn disease (n = 28) and ulcerative colitis (n = 14) were compared with those from controls undergoing endoscopy for suspected reflux esophagitis (n = 22). Two pathologists, unaware of patient identity and diagnosis, agreed on a consensus report. Severity of inflammation was scored semiquantitatively. Helicobacter pylori colonization was an exclusion criterion., Results: Inflammation was reported as follows: esophagitis: controls 91%; Crohn disease: 72%; ulcerative colitis: 50%; gastritis: controls: 27%; Crohn disease: 92% (P < 0.001); ulcerative colitis: 69%; duodenitis: controls: 9%; Crohn disease: 33%; ulcerative colitis: 23%. In Crohn disease, granulomas were noted in 40% of patients (P = 0.001). Duodenal cryptitis was noted in 26% of patients with Crohn disease but not ulcerative colitis. In one patient with ulcerative colitis, neutrophilic infiltration of gastric glands was seen. Abnormalities seen in Crohn disease and ulcerative colitis included gastroduodenal ulceration (Crohn disease, 7%; ulcerative colitis, 8%), villus atrophy (Crohn disease, 11%; ulcerative colitis, 15%), and increased intraepithelial lymphocytes (Crohn disease, 15%; ulcerative colitis, 31% [P < 0.05]). None of these abnormalities was noted in the controls., Conclusion: Although the presence of granulomas can support a diagnosis of Crohn disease, severe inflammation and other abnormalities occur in the proximal gastrointestinal tract in Crohn disease and ulcerative colitis.

Controversy persists regarding optimal management of perilunate injuries. Traditionally, closed treatment, with or without percutaneous pin fixation, was advocated for these highly unstable carpal disruptions, but the inconsistent and often disappointing outcome of closed reduction, coupled with the recognition that functional recovery closely parallels the accuracy of restoring carpal alignment, have led to increasing enthusiasm for open treatment. The favorable outcome reported in this article supports both the contention that the acute perilunate injury affords the opportune time for operative preservation of carpal stability and the efficacy of the combined dorsal and volar approaches as the optimal means of surgical repair. This clinical experience also corroborates experimental evidence that perilunate injuries are apt to cause a predictable spectrum of osseous and soft tissue lesions--lesions usually suitable for early, precise repair. For the skilled athlete, prompt recognition and precision treatment of all components of injury are the critical factors to attain a functional outcome commensurate with a successful return to competition.

This paper reviews areas of interest in gut mucosal growth factor physiology. Several epidermal growth factor (EGF)-like peptides (EGF, transforming growth factor [TGF]-alpha, heparin-binding EGF-like peptide, amphiregulin, and betacellulin) have been identified in the gut, EGF is produced by the salivary glands and is present in milk. It may act on the mucosa from the lumen as a surveillance peptide promoting mucosal repair. A stem-cell-derived "ulcer-associated cell lineage" develops adjacent to ulcers and produces EGF, which may play a role in ulcer healing. TGF-alpha is expressed by villus enterocytes and may have an important role in mucosal healing. The Trefoil peptides (pS2, spasmolytic polypeptide, intestinal trefoil factor) are protease resistant molecules secreted by mucin cells throughout the gut, with a role in mucosal healing. The TGF-beta family inhibit cell proliferation, and promote cell differentiation. TGF-beta has a gradient of expression along the crypt villus axis, with maximum production at the villus tip. It is suspected that it may prevent cell proliferation and support differentiation of villus enterocytes. Hepatocyte growth factor is a multifunctional growth factor expressed in many tissues, including the gastrointestinal tract. It has a role in organogenesis. Intestinal adaptation is highly dependent on enteral nutrition, and it is likely that growth factors are involved in adaptation. Little is known, however, about interactions between nutrients and growth factors. Milk contains a range of potentially important growth factors. Their biological significance is uncertain, and this is an area of active research.

Introduction: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation., Setting: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team., Methods: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05)., Results: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground., Conclusion: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.