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Background: Extreme heat events are the number one cause of weather-related fatalities in the United States. The current system of alert for extreme heat events does not take into account intra-urban spatial variation in risk. The purpose of this study is to evaluate a potential method to improve spatial delineation of risk from extreme heat events in urban environments by integrating sociodemographic risk factors with estimates of land surface temperature derived from thermal remote sensing data., Results: Comparison of logistic regression models indicates that supplementing known sociodemographic risk factors with remote sensing estimates of land surface temperature improves the delineation of intra-urban variations in risk from extreme heat events., Conclusion: Thermal remote sensing data can be utilized to improve understanding of intra-urban variations in risk from extreme heat. The refinement of current risk assessment systems could increase the likelihood of survival during extreme heat events and assist emergency personnel in the delivery of vital resources during such disasters.

This study investigates the feasibility and effectiveness of providing telepsychiatry services to Chinese immigrants in a nursing home. The psychiatrist interviewed patients face-to-face for the initial consultation, and encouraged them to participate in this study to receive telepsychiatry-based follow-up visits. The feasibility and outcomes of telepsychiatry visits and satisfaction of the subjects, their families, and the nursing home staff were assessed. Nine monolingual Chinese immigrants, 8 women and 1 man, ranging from 54 to 88 years of age, were enrolled. The main reasons for psychiatric consultation were mood and behavioral problems. Eight of the 9 (88.9%) subjects participated in videoconference follow-up visits, and 1 subject (11.1%) declined. Among the 8 subjects, 6 were referred for psychiatric intervention, 1 for differential diagnosis, and 1 for suicide assessment. At the end of the study, all 6 subjects referred for intervention had greatly improved; the subjects, their families, and the nursing staff were highly satisfied with the telepsychiatry service. It is feasible to provide psychiatry consultations to ethnic immigrants in a nursing home despite the fact that many of them are unfamiliar with the technology and suffer from dementia and psychotic symptoms. Telepsychiatry provides an efficient way for ethnic elders in nursing homes to connect with mental health professionals with the appropriate language and cultural background, regardless of location. Telepsychiatry may decrease the disparities in treatment of mental illnesses among ethnic immigrants in nursing homes.

In this article, we describe the clinical applicability of loving-kindness meditation (LKM) to individuals suffering from schizophrenia-spectrum disorders with persistent negative symptoms. LKM may have potential for reducing negative symptoms such as anhedonia, avolition, and asociality while enhancing factors consistent with psychological recovery such as hope and purpose in life. Case studies will illustrate how to conduct this group treatment with clients with negative symptoms, the potential benefits to the client, and difficulties that may arise. Although LKM requires further empirical support, it promises to be an important intervention since there are few treatments for clients afflicted with negative symptoms., ((c) 2009 Wiley Periodicals, Inc.)

Background: Vancomycin is the only US Food and Drug Administration-approved drug for treatment of Clostridium difficile infection (CDI). Metronidazole has been widely used for this purpose but may be inferior to vancomycin, especially for hospitalized patients with severe disease. We report a prospective, double-blind, randomized controlled trial comparing nitazoxanide with vancomycin for treatment of CDI., Methods: Fifty patients with CDI were randomized to receive vancomycin or nitazoxanide for 10 days. An initial response was considered to be the absence of all CDI symptoms between days 11 and 13, and a final response was considered to be lack of symptom recurrence by day 31., Results: One patient fulfilled an exclusion criterion and was removed from the study. Twenty-seven patients received vancomycin, and 23 received nitazoxanide; 23 and 18 patients, respectively, completed the full course of treatment. Initial responses occurred in 20 (74%) of 27 patients treated with vancomycin and in 17 (77%) of 22 patients treated with nitazoxanide (95% confidence interval, -24% to +28%). In those who completed therapy, response rates were 87% (20 of 23 patients) in the vancomycin group and 94% (17 of 18 patients) in the nitazoxanide group (95% confidence interval, -18% to +30%). Times to complete resolution of symptoms were similar in the 2 groups (P = .55). Two patients in the vancomycin group and 1 patient in the nitazoxanide group experienced relapse within 31 days after beginning treatment. Sustained response rates were 78% (18 of 23 patients) for the vancomycin group, and 89% (16 of 18 patients) for the nitazoxanide group (95% confidence interval, -18% to +35%)., Conclusions: The small sample precludes conclusions about noninferiority of nitazoxanide to vancomycin. Nevertheless, this is the first recent randomized controlled trial to compare any antimicrobial agent other than metronidazole with vancomycin. Results suggest that nitazoxanide may be as effective as vancomycin in treating CDI., Trial Registration: ClinicalTrials.gov identifier: NCT00384527.

To examine the efficacy and overall tolerability of the simultaneous initiation of treatment (coinitiation) with triiodothyronine (T3) and a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder (MDD). Sources of date were Medline/Pubmed, EMBASE, the Cochrane database, and program syllabi from major psychiatric meetings held since 1995. The study selection comprised double-blind, randomized clinical trials comparing T3-SSRI coinitiation therapy versus SSRI monotherapy for MDD. Data were extracted with the use of a precoded form. Data from four clinical trials involving a total of 444 patients with MDD were identified and combined using a random effects model. There was no statistically significant difference in terms of remission rates or response rates at week 1, week 2, or at endpoint between the two treatment groups (SSRI+T3 coinitiation therapy vs. SSRI monotherapy). Pooled response and remission rates at endpoint for the SSRI+T3 versus SSRI monotherapy groups were 64.6 versus 58.5% and 46.8 versus 44.8%, respectively. In addition, there was no statistically significant difference in overall rates of premature discontinuation of treatment, or in the rate of premature discontinuation of treatment owing to inefficacy or intolerance between the two treatment groups. Notwithstanding important methodological differences between the studies included in the meta-analysis in terms of patient characteristics and treatment protocols, these results do not support the notion that simultaneous initiation of treatment of MDD with an SSRI and T3 is more effective than SSRI monotherapy. However, given the etiologically diverse and clinically heterogeneous nature of MDD, it is at least plausible that T3-SSRIs coinitiation therapy may be effective for a particular subgroup of patients including patients with atypical depression or patients with a functional polymorphism of the D-1 deiodinase gene. Clearly, further work is needed to help determine whether there are specific MDD populations that can, indeed, benefit from T3-SSRI coinitiation therapy.

A 35-year-old postpartum lactating woman presented with dyspnea and was found to be in non-diabetic ketoacidosis (pH 7.24, HCO3 10 mmol/L, urine ketones>80 mg/dL). Rapid clinical and laboratory resolution occurred after intravenous dextrose and enteral feeding along with discontinuation of lactation. This represents a rarely reported case of lactation "bovine" ketoacidosis in humans. We review the historical precedence for the diagnosis and detail the underlying physiology.

Ultrasonic techniques based on measurements of apparent backscatter may provide a useful means for diagnosing bone diseases such as osteoporosis. The term "apparent" means that the backscattered signals are not compensated for the frequency-dependent effects of attenuation and diffraction. We performed in vitro apparent backscatter measurements on 23 specimens of human cancellous bone prepared from the left and right femoral heads of seven donors. A mechanical scanning system was used to obtain backscattered signals from each specimen at several sites. Scans were performed using five different ultrasonic transducers with center frequencies of 1, 2.25, 5, 7.5, and 10 MHz. The -6 dB bandwidths of these transducers covered a frequency range of 0.6-15.0 MHz. The backscattered signals were analyzed to determine three ultrasonic parameters: apparent integrated backscatter (AIB), frequency slope of apparent backscatter (FSAB), and time slope of apparent backscatter (TSAB). Linear regression analysis was used to examine the correlation of these ultrasonic parameters with five measured physical characteristics of the specimens: mass density, X-ray bone mineral density, Young's modulus, yield strength, and ultimate strength. A total of 75 such correlations were examined (3 ultrasonic parameters x 5 specimen characteristics x 5 transducers). Good correlations were observed for AIB using the 5 MHz (r = 0.70 - 0.89) and 7.5 MHz (r = 0.75-0.93) transducers; for FSAB using the 2.25 MHz (r = 0.70 - 0.88), 5 MHz (r = 0.79 - 0.94), and 7.5 MHz (r = 0.80 - 0.92) transducers; and for TSAB using the 5 MHz (r = 0.68 - 0.89), 7.5 MHz (r = 0.75 - 0.89), and 10 MHz (r = 0.75 - 0.92) transducers.

In previous hepatitis C virus (HCV) treatment studies, Black patients not only had a lower sustained viral response (SVR) rate to interferon and ribavirin (RBV) than non-Black patients but also a higher frequency of HCV genotype 1 (GT-1) infection. The aim of this community-based study was to determine whether Black patients have a lower SVR rate independent of genotype. We prospectively enrolled 785 patients (24.8% Black, 71.5% White, 3.7% others) who received interferon alpha-2b 3 MU three times weekly + RBV 1000-1200 mg/day for 24 weeks (GT-2/3) or 48 weeks (GT-1). Black patients were more commonly infected with GT-1 (86.8%vs 64.8%, P < 0.001) and less frequently had an SVR compared with non-Black patients (8.4%vs 21.6%, P < 0.001). Within GT-1, Black patients had a lower SVR rate than non-Black patients (6.1%vs 14.1%, P = 0.004) but not within GT-2/3 (50.0%vs 36.5%, P = 0.47). Black patients had lower baseline haemoglobin levels (14.8 vs 15.3 g/dL, P < 0.001) and neutrophil counts (2900 vs 4100/mm(3), P < 0.001) and required more frequent dose reductions of RBV (29.8%vs 18.5%, P < 0.001) and interferon (4.7%vs 1.6%, P = 0.012). However, dose reductions were not associated with lower SVR rates while early treatment discontinuations were (2.9%vs 25.7%, P < 0.001). Independent predictors of SVR were GT-1 [odds ratio (OR) 0.33; 95% confidence interval (CI) 0.20-0.55; P < 0.001], Black race (OR 0.45; 95% CI 0.22-0.93; P = 0.030), and advanced fibrosis, stages 3 + 4 (OR 0.53; 95% CI 0.31-0.92; P = 0.023). In conclusion, Black patients infected with HCV GT-1 (but not GT-2/3) have a lower SVR rate than non-Black patients. This is not explained by their lower baseline haemoglobin levels and neutrophil counts that lead to higher rates of ribavirin and interferon dose reductions.

(S,S)-2-(alpha-(2-Methoxyphenoxy)benzyl)morpholine (MeNER), an O-methyl analog of the selective and potent norepinephrine transporter (NET) inhibitor, (S,S)-reboxetine, and its less active enantiomer, (R,R)-MeNER, have each been radiolabeled by O-methylation of their corresponding phenolic precursors in good yields from [(11)C]methyl iodide or [(11)C]methyl triflate. Radiochemical purities were >99% and specific radioactivity at time of injection was about 74 GBq/micromol. Autoradiographic examination of (S,S)-[(11)C]MeNER binding to human brain slices post mortem indicated specific binding in a brain region including the locus coeruleus. PET examination of both [(11)C]MeNER enantiomers in a cynomolgus monkey demonstrated a higher specific binding of the (S,S)-enantiomer with ratios of 1.4-1.6 in the lower brainstem, mesencephalon and thalamus to striatum. Pretreatment with the NET ligand, desipramine, decreased the specific binding of (S,S)-[(11)C]MeNER. Labeled metabolites of [(11)C]MeNER were all more polar. (S,S)-[(11)C]MeNER is a good lead compound in the search for a selective radioligand for quantitation of NET in the human brain in vivo.

Objective: The purpose of this study was to evaluate the effect of induction on the route of delivery in nulliparous women laboring at term in a community hospital system., Study Design: From April 1997 to October 1999, there were 7282 deliveries in nulliparous patients who met inclusion criteria. Cesarean delivery rates were calculated for patients in spontaneous labor and for patients who underwent induction., Results: Among 4635 women (63.7%) in spontaneous labor, the cesarean delivery rate was 11.5% versus 23.7% among the 2647 (36.3%) patients who underwent induction. An important variable that affected the delivery route was the Bishop score at the initiation of the induction. The cesarean delivery rate was 31.5% among patients whose Bishop score was <5 at induction versus 18.1% for patients with a score > or =5(P <.001)., Conclusion: The induction of labor in nulliparous patients, especially those women with an unfavorable cervix as measured by Bishop score, is associated with a significantly increased risk of cesarean delivery.

The (R,R) and (S,S) enantiomers of 2-[(2-methoxyphenoxy)phenylmethyl]morpholine (MeNER) have been radiolabelled with carbon-11 in good yield and at high specific activity. These radiotracers are close analogues of reboxetine, a potent and selective ligand for the norepinephrine transporter (NET). They were examined as potential ligands for imaging NET in vivo by positron emission tomography (PET). The in vivo brain distribution of both [(11)C]-labeled enantiomers were evaluated in rats. Following tail-vein injection of the (R,R)-enantiomer regional brain uptake and washout of radioactivity was homogeneous at all time points examined (5-60 min). In contrast, administration of the (S,S)-enantiomer produced a heterogeneous distribution of radioactivity in brain with highest uptake in the hypothalamus, a NET rich region, and lowest uptake in the striatum, a brain region devoid of NET. Hypothalamus to striatum ratios of 2.5 to one were achieved at 60 min post injection of (S,S)-[(11)C]-MeNER. Pre-injection of the norepinephrine reuptake inhibitors, reboxetine or desipramine, reduced hypothalamus to striatum ratios to near unity while reuptake inhibitors of dopamine and serotonin had no significant effect on binding. In vitro autoradiography studies (rat brain slices) with (S,S)-[(11)C]-MeNER produced a regional distribution pattern that was consistent with the reported distribution of NET. (S,S)-[(11)C]-MeNER has the potential to be the first successful PET ligand to image NET.

The recognition and treatment of iatrogenic medial subluxation of the patella following lateral retinacular release may be difficult. The diagnosis even by magnetic resonance imaging may be difficult. The use of a medial patellar stabilising brace may be helpful in the diagnosis, alleviating symptoms in the short term and to gain the confidence of the patient. A technique of direct repair that was used successfully is described in a case report.

This study tested the hypothesis that the posterior fibers of the patellar tendon are subjected to higher tensile strains than the anterior fibers in response to quadriceps tension. The quadriceps tendon was loaded to 1 kN in 10 human cadaver knees and the tensile strain was measured in the anterior and posterior fibers of the patellar tendon. The central third patellar tendon was divided into anterior and posterior halves which were tensile tested to failure. The mean strain at 1 kN load was 1.7% (90 degrees flexion), 2.7% (60 degrees ), and 3.9% (10 degrees ) anteriorly, and 3.2% (90 degrees ) 4.6% (60 degrees ), and 4.9% (10 degrees ) posteriorly. Quadriceps loading caused significantly greater strains in the posterior fascicles between 60 degrees and 90 degrees knee flexion. The material properties in the anterior and posterior regions were similar, except that failure strain was significantly higher posteriorly. Thus the posterior fascicles are adapted to sustain significantly greater tensile strains before failing. This suggests that the higher overall levels of tensile strain in the posterior fibers are not sufficient to explain the clinical pattern of patellar tendonitis.

Following arthroscopic anterior cruciate ligament reconstruction, radio-opacities were noted on the post-operative radiographs in 40 of 50 consecutive cases. There was no correlation between the presence of these opacities and post-operative knee pain, joint effusion, arthrofibrosis or knee recovery. In 12 cases undergoing a subsequent radiograph between 3 and 18 months post-operatively, opacities were noted in only one case.

The morphology of the attachment of the patellar tendon, its bundle orientation, the differential fascicles length and the position of the apex of the patella were assessed in 22 cadaveric human knees. The patellar apex was 39+/-6% of the width of the tendon from its medial edge. The bulk of tendon was attached to the distal two-thirds of the anterior aspect of the patella. In six cases tendon fibres originated from the posterior surface of the apex of the patella, forming a ridge on the back of tendon. This may represent an anatomical variant accounting for the increased tendon thickness noted on MRI, both incidentally and during assessment for patellar tendonitis. Fascicles were parallel in the sagittal plane but converged in the frontal plane toward their tibial attachment. When bone-patellar tendon-bone (B-PT-B) grafts were harvested, as for anterior cruciate ligament reconstruction, the grafts narrowed distally. When harvesting B-PT-B, the oblique orientation of the fibres in the coronal plane must be borne in mind.

The 17-kDa antigen of Bartonella henselae has previously been shown to elicit a strong humoral immune response in patients with cat scratch disease (CSD) and to be useful in screening human serum samples for CSD. In this study, PCR amplification of genes homologous to the 17-kDa antigen gene of B. henselae was performed using genomic DNAs from several species of Bartonella, including the currently recognized human pathogens. Amplicons of similar size were demonstrated using the following chromosomal DNA templates: B. henselae (two strains), B. quintana (two strains), B. elizabethae, B. clarridgeiae, B. vinsonii subsp. vinsonii, and B. vinsonii subsp. berkhoffii. No evidence of a B. bacilliformis homolog of the 17-kDa antigen gene was obtained using multiple primer pairs. DNA sequencing revealed open reading frames capable of coding for proteins with sizes similar to that of the 17-kDa antigen of B. henselae in all of the amplicons; however, extensive sequence divergence across the genus was noted. Cloning of the amplified products into pUC19 resulted in recombinants that directed synthesis of homologs of the 17-kDa protein. Immunoblot analysis using human sera from CSD cases demonstrated very little cross-reactivity among different species for this protein. In contrast, immunoblots using rabbit serum raised to the recombinant B. henselae antigen showed extensive cross-reactivity with the proteins of other Bartonella species. The data suggest that the use of the 17-kDa antigen as a serologic reagent may allow the development of more specific diagnostic assays. Furthermore, the nucleotide sequences from the various versions of the 17-kDa antigen gene should be useful for rapid identification of Bartonella at the species level.

The skin is unique in its accessibility for the diagnosis of diseases acquired because of decreased immunity in human immunodeficiency virus (HIV) infection. A majority of HIV-infected patients will have dermatologic problems at some time during their illness. Many of the cutaneous conditions identified will provide the means by which systemic opportunistic infections, neoplasms, and complications of therapy can be identified. The skin provides an opportunity for the recognition of new or foreign conditions as well as exotic manifestations of diseases that complicate HIV infection. A high degree of suspicion and a willingness to examine the entire skin thoroughly and frequently can enable practitioners to reduce the morbidity and mortality associated with HIV infection.

The radiological and MRI appearances of 24 knees with patellar tendonitis resistant to conservative therapy were analysed to identify the characteristic MRI appearance and to determine if the patellar morphology was abnormal. A significant thickening of the tendon was found in all cases; this was a more reliable diagnostic feature than a high signal within the superior posterior and central aspect of the tendon at its proximal attachment. The site of the lesion shown by MRI is more compatible with impingement of the inferior pole of the patella against the patellar tendon than a stress overload of the tendon. There were no significant differences in the length of the patella, inferior pole or length of the articular surface when the patellar morphology was compared with that of a matched control group.

Objective: The objective of this study was to evaluate the value of magnetic resonance (MR) imaging in the diagnosis of the os trigonum syndrome., Design: Sagittal and coronal spin echo MR sequences of the ankle were acquired along with sagittal images in both dorsiflexion and plantar flexion., Patients: Three consecutive patients presenting with posterior triangle pain were assessed., Results and Conclusions: MR imaging delineated the anatomical site of the abnormality and demonstrated coexisting pathology in all patients. Flexion/extension MR images yielded additional information regarding the mobility of the os trigonum in one patient. MR imaging is the technique of choice for investigating the os trigonum syndrome.

Forty-five knees (thirty patients) with a specific diagnosis of synovial plica syndrome, and without any other known lesion, were randomized to be treated with either diagnostic arthroscopy alone or arthroscopy and division of all plicae. The diagnosis of synovial plica syndrome had been made on the basis of intermittent pain in the anterior aspect of the knee, painful clicking with activity, giving-way, and a palpable, tender plica. The patients were selected for arthroscopy only if the symptoms had continued unabated after a course of physical therapy. At the time of follow-up, improvement had occurred in only six (29 per cent) of the twenty-one knees in which the plicae had not been divided, in contrast with twenty (83 per cent) of the twenty-four knees in which they had been divided (p < 0.001). Ten (48 per cent) of the knees in which arthroscopic division had not been done were treated with another arthroscopic operation. Seven of these ten knees improved after the subsequent division of the plicae (p < 0.01). We concluded that synovial plicae of the knee may be a definite cause of anterior pain in children and adolescents.

A randomised, controlled study of the use of postoperative continuous passive motion (CPM) and immobilisation regimen after total condylar knee arthroplasty was performed. CPM resulted in a significant increase in both the early and late range of knee flexion. This increase occurred in both rheumatoid and osteoarthritic patients. The improvement of 10 degrees at 12 months allowed additional important function to be attained. CPM resulted in significantly earlier discharge from hospital. It did not increase the clinical incidence of wound healing problems, nor did it significantly increase the postoperative fixed flexion deformity or the extension lag. CPM can be recommended as a safe and effective modality to achieve more rapid and more successful postoperative rehabilitation after knee arthroplasty.

In the United States, the baby boom-era pattern of high Catholic and low Protestant fertility has ended. Among non-Hispanic whites in the 1980s, Catholic total fertility rates (TFRs) were about one-quarter of a child lower than Protestant rates (1.64 vs. 1.91). Most of the Protestant-Catholic difference is related to later and less frequent marriage among Catholics. Future research on the demography of religious groups should focus on explaining the delayed marriage pattern of Catholics, the high fertility of Mormons and frequently attending Protestants, and the very low fertility of those with no religious affiliation.

A prospective study on 56 knees was performed to analyze the incidence and cause of patellar complications following total knee arthroplasty with the Kinematic prosthesis inserted with the Universal Instrumentation system. Patellar complications occurred in 23 cases: 15 had anterior knee pain. There was 1 case of patellar fracture. Subluxation of the patella occurred in 13 cases, of which 6 were painful. Although the mechanical alignment was correctly reconstructed to neutral in all but 2 cases, the instrumentation tended to allow malpositioning of the components into excessive femoral valgus and compensatory excessive tibial varus that predisposed to patellar subluxation. With this prosthesis and instrumentation, patellar stability is hindered by a very short anterior femoral flange, a shallow patellar groove, and insertion of the components at 3 degrees to the mechanical axis. It should be ensured that the components are correctly positioned, that patellar stability is carefully checked before closing the capsule, and that lateral release is performed more often.

A prospective study analyzing the effects of intraoperative lateral patellar release for patellar instability in total condylar knee arthroplasty demonstrated that lateral release was successful in preventing postoperative patellar instability. Division of the superolateral geniculate vessels resulted in an increased incidence of wound discoloration (P < .01) and superficial wound infection (P < .05). Perioperative transcutaneous measurement of the skin oxygen tension demonstrated an objective reduction in lateral wound edge skin viability following lateral release (P < .02). A lower threshold for performing lateral patellar release is necessary. To preserve the viability of the lateral skin edge, lateral release should be performed using the intracapsular approach with preservation of the superolateral geniculate vessels.

A new technique for percutaneous release of the trigger finger is described. A 21-gauge hypodermic needle is used to release the A1 pulley. The technique is effective, convenient, safe, and well tolerated by patients. Thirty-three of 35 procedures (94%) led to complete relief of symptoms, and in the remaining two digits partial symptomatic relief was achieved. There were no significant complications. After a mean follow-up of 13 months, there had been no recurrences. This technique should be the treatment of choice for the established trigger finger with symptoms of more than 4 months' duration.

A study of the secondary structures of the 5'-leader RNA sequences of avian leukosis/sarcoma viruses was conducted using phylogenetic sequence alignment, theoretical structures calculated from base-pairing interactions involving the calculated minimal delta G values, and RNaseT1 sensitivity. The results suggest that all of the avian retroviral RNA leaders may be able to adopt similar conformations. Open reading frames in the leader RNAs may be positioned to facilitate viral activities such as translation and packaging of the genomic RNA into virus particles.

A significant proportion of deep infections following knee arthroplasty are consequent on a failure of primary wound healing. The management of such infections is difficult and the functional outcome is poor. It is essential to ensure that the initial biomechanical conditions are such that wound healing is encouraged. The ability of a wound to heal is dependent on factors such as the orientation of the skin incision, the wound tension and the viability of the wound edges as assessed by skin oxygen tension estimations. Consideration of these factors has led us to advocate the use of the medial parapatellar incision for knee arthroplasty. Early, excessive knee flexion following arthroplasty can lead to significant wound edge hypoxia but by modifying the rehabilitation programme and with the administration of 24% oxygen to the patient in the perioperative period, this effect can be minimized. Modification of the surgical techniques involved in knee arthroplasty can help preserve the vascular supply and hence the viability of the wound edge, and thus achieve a suitable biomechanical environment for primary wound healing.

Hemiarthroplasty of the elbow with an endoprosthesis has been reported very infrequently; only about 20 cases have been reported previously in the literature. This case merits reporting because of the youth of the patient (age 19), the uniqueness of the prosthetic component, and the long-term follow-up observation. The patient had posttraumatic bony ankylosis of the elbow with a painful supracondylar pseudoarthrosis and loss of bone from the proximal metaphysis. A custom humeral endoprosthesis was inserted, and anatomic reconstitution of the sigmoid notch of the ulna was provided. Reasonably good, painless, stable motion was achieved, which has not deteriorated in the subsequent 21 years of observation. The clinical significance of this case is that in a nonweight-bearing hinged joint, endoprosthesis arthroplasty can be an excellent option when given the proper indications and carried out with meticulous planning.

A prospective, controlled, randomized trial of continuous passive motion and immobilization after knee arthroplasty revealed that continuous passive motion significantly improved early and late flexion of the knee, reduced the duration of stay in the hospital, and did not increase the incidence of superficial infection or problems with wound-healing. Flexion of the knee beyond 40 degrees progressively diminished viability of the edges of the wound, particularly the lateral edge. On the basis of these results, a protocol for continuous passive motion was designed to minimize the detrimental effects on viability of the wound.

The Microbiological Assay Branch of the National Center for Antibiotics Analysis assays over 100,000 samples of antibiotic products annually, using more than 1000 Ib dehydrated media. The media must be consistently dependable to produce accurate, reliable test results. To assure that the supply of media will meet the established requirements, each lot before purchase is subjected to a series of trials designed to examine growth support, sensitivity, and behavioral and physical factors. Actual antibiotic assays are conducted with the test medium, and performance is rated against a control medium. Controls on the system reduce the variables to allow appraisal of the medium itself.

Monovalent acetone-inactivated typhoid vaccine and heat-killed TAB caused local reactions in 82-88% of volunteers vaccinated by jet injection, whereas they caused local reactions in only 24% of volunteers injected by means of a conventional syringe. Both vaccines induced a high seroconversion rate to typhoid H antigen, but neither proved significantly immunogenic to antigens O and Vi. There was no increase in the occurrence of local reactions when a second jet injection was given 5 weeks after the first.

The main argument of this paper is that the subjective experience of loneliness among older people must be analyzed in relation to the overall value system of society or the subcultural values of particular segments of society. Cultural or subcultural value systems are contrasted in terms of whether they give priority to individualistic values or to collective values such as family or community bonds. These differences in value systems result in important differences in people's social contacts and socioemotional bonding experiences as well as their level of satisfaction with a given level of social relationships. It is suggested that these differences must be looked at in relation to basic human needs for social bonding as well as needs for individuation. The concept of the loneliness threshold is introduced to identify the level of social contacts that individuals desire to avoid the experience of loneliness or emotional isolation.

Rupture of the deltoid ligament usually occurs in association with a fracture of the fibula. While reduction and internal fixation of the fibula is usually recommended, the deltoid ligament is left unrepaired. A 15-month follow-up of 30 patients with such injuries revealed that 41 per cent of the patients continued to experience pain while walking and 34 per cent were restricted by the pain in their activities. In 34 per cent of patients these symptoms originated from chronic overuse of the attenuated deltoid ligament rather than ankle instability which, though present in 17 per cent of cases, was rarely the cause of symptoms. Surgical treatment of these injuries resulted in morbidity and a poor symptomatic and functional result in 41 per cent of patients.

The vapor pressure of water at its triple point was measured with greatly increased accuracy. The triple point was realized with newly designed equipment that enhanced the stability of the pressure and permitted any air released from solution to be removed by pumping. A diaphragm pressure transducer separated the water vapor from the helium used to transmit the pressure to the manometer. The pressure was measured with the National Bureau of Standards precision mercury manometer. The vapor pressure at the triple point was found to be 611.657 pascals with random uncertainties at the 99 percent confidence level of +/- 0.010 pascal. The systematic errors are estimated to be relatively insignificant.

The theory of diffusion of vapor between the walls of a tube and a stream of gas is applied to a generator of known humidities. The rate of approach to equilibrium is evaluated for gas velocities in the laminar flow range. The effect of pressure drop is examined.