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OBJECTIVE: To discuss the management of a patient with unilateral lower extremity pain as a consequence of a popliteal aneurysm. CLINICAL FEATURES: An 85-year-old male had difficulty in ambulating due to low back and lower extremity pain. Standard tests demonstrated and reproduced pain at the lower back while inspection, palpation, and auscultation revealed a pulsatile mass in the popliteal fossa of the right knee. INTERVENTION AND OUTCOME: Specific joint manipulation for relief of low back pain was performed. Comanagement of the patient with a vascular surgeon and subsequent surgical intervention resulted in relief of lower extremity pain. CONCLUSION: Resolution of pain and guarded gait was accomplished by a multidisciplinary approach combining conservative care and invasive techniques. [ABSTRACT FROM AUTHOR]

Botulinum neurotoxin subtype A4 (BoNT/A4) is ~1000-fold less potent than BoNT/A1. This study addresses the basis for low BoNT/A4 potency. Utilizing BoNT/A1-A4 and BoNT/A4-A1 Light Chain-Heavy Chain (LC-HC) chimeras, HC-A4 was responsible for low BoNT/A4 potency. Earlier studies showed BoNT/A1-receptor binding domain (Hcc) bound a β-strand peptide (556-564) and glycan-N 559 within Luminal Domain 4 (LD4) of SV2C, the BoNT/A protein receptor. Relative to BoNT/A1, the Hcc of BoNT/A4 possesses two amino acid variants (D 1141 and N 1142 ) within the β-peptide binding interface and one amino acid variant (R 1292 ) located near the SV2C glycan-N 559 . Introduction of BoNT/A4 β-strand peptide variant (D 1141 and N 1142 ) into BoNT/A1 reduced toxin potency 30-fold, and additional introduction of the BoNT/A4 glycan-N 559 variant (D 1141 , N 1142 , and R 1292 ) further reduced toxin potency to approach BoNT/A4. While introduction of BoNT/A1 glycan-N 559 variant (G 1292 ) into BoNT/A4 did not alter toxin potency, additional introduction of BoNT/A1 β-strand peptide variants (G 1141 , S 1142 , and G 1292 ) resulted in potency approaching BoNT/A1 potency. Thus, outcomes from these functional and modeling studies indicate that in rodent models, disruption of Hcc -SV2C β-peptide and -glycan-N 559 interactions mediate low BoNT/A4 potency, while in human motor neurons, disruption of Hcc-SV2C β-peptide alone mediates low BoNT/A4 potency, which link to a species-specific variation at SV2C 563 .

Research on racial-ethnic portrayals in television crime news is limited and questions remain about the sources of representations and how these vary for perpetrators versus victims. We draw from power structure, market share, normal crimes, racial threat, and racial privileging perspectives to further this research. The reported race or ethnicity of violent crime perpetrators and victims are modeled as functions of: (1) situational characteristics of crime stories; and (2) contextual characteristics of television market areas. The primary data are from a stratified random sample of television newscasts in 2002-2003 (Long et al. 2005). An important innovation of our work is the use of a national, more generalizeable, sample of local news stories than prior researchers who tended to focus on single market areas. Results indicate that both the context of the story itself and the social structural context within which news stories are reported are relevant to ethnic and racial portrayals in crime news. We find limited support for power structure, market share, normal crimes and racial threat explanations of patterns of reporting. Racial privileging arguments receive more extensive support.

Serum antibodies reactive with the keratin layer of rat esophagus (AKA) were found in 46 of 80 (57.5%) rheumatoid arthritis (RA) patients. In contrast, AKA were present in only 7 of 82 (9.5%) patients with other types of rheumatic disorders and in 2 of 47 (4.2%) healthy subjects. AKA were not specific for RA, however, because in the former group, AKA were present in 4 of 20 (20%) systemic sclerosis patients and in 3 of 12 (25%) ankylosing spondylitis patients. AKA belong predominantly to the IgG class and are complement fixing. Although found in some RA joint fluids, AKA were not selectively concentrated in the joint fluid. Absorption of RA serum with type I human collagen or with human epidermal keratin did not remove AKA activity. The frequency of AKA in RA patients both negative and positive for DR4 was equal. There was no relationship between the frequency of AKA and the occurrence of other serum autoantibodies such as antibodies to intermediate filaments, smooth muscle, and nuclear antigens. Serum antibody reactive with human stratum corneum found in patients with psoriatic arthritis was shown to be different from AKA. Rabbit antiserum to human keratin did not inhibit the reaction of AKA against the keratin layer of rat esophagus. Autoimmunity to structural proteins including collagen, vimentin intermediate filaments, smooth muscle antigens, and keratin is a characteristic feature of RA.

In our study, we took a first step toward broadening our understanding of the sources of both housing and wealth inequality by studying differences in housing equity among blacks, Hispanics, Asians, and non-Hispanic whites in the United States. Using data from the American Housing Survey, we found substantial and significant gaps in housing equity for blacks and Hispanics (but not for Asians) compared with whites, even after we controlled for a wide range of locational, life-cycle, socioeconomic, family, immigrant, and mortgage characteristics. Furthermore, the payoffs to many factors are notably weaker for minority than for white households. This finding is especially consistent across groups for the effects of age, socioeconomic status, and housing-market value. Blacks and Hispanics also uniformly receive less benefit from mortgage and housing characteristics than do whites. These findings lend credence to the burgeoning stratification perspective on wealth and housing inequality that acknowledges the importance of broader social and institutional processes of racial-ethnic stratification that advantage some groups, whites in this case, over others.

Objective: To discuss the management of a patient with lateral epicondylitis refractory to previous medical and conservative interventions., Clinical Features: A 45-year-old woman had difficulty in supinating her left elbow because of pain from activities at work. Standard tests demonstrated and reproduced pain at the lateral epicondyle with resisted extension of the wrist and fingers., Intervention and Outcome: Specific joint manipulation for relief of lateral epicondylitis was performed. Immobilization of the elbow joint after manipulation was accomplished by means of a sugar tong plaster splint. Follow-up joint manipulation with a progressive rehabilitation program was effective in providing relief of symptoms., Conclusion: Resolution of pain and limited elbow motion was demonstrated after Mills' manipulation.

Objective: To discuss the management of a patient with wrist weakness and a diminution in active range of motion resulting from Colles' fracture., Clinical Features: A 58-year-old woman complained of persistent loss of grip strength and mobility in her right wrist. These complaints were from Colles' fracture occurring 19 months before initiation of care. Dynamometer and goniometric testing revealed significant loss of grip strength and range of motion compared with the uninvolved, nondominant wrist., Intervention and Outcome: Specific joint manipulation for improvement in mobility and grip strength of the wrist was performed. The patient's right wrist was evaluated for grip strength and active range of motion over a 3-week period, providing a baseline of function before treatment. After 4 visits of baseline measurements, a series of 4 treatments and 4 reevaluations was performed. The patient exhibited a significant increase in grip strength and active range of motion., Conclusion: Appropriate intervention of chiropractic manipulation and examination procedures culminated in a successful resolution of this case. When such cases are recognized, appropriate management may occur conservatively with judicious application of joint manipulation and reevaluation procedures.

We extend research on whites' neighborhood contact with blacks, population composition, and prospects for desegregation by developing a new measure of the floor of racial residential segregation under conditions of low black-white contact. The measure incorporates the way in which multiethnic contexts further constrain levels of black-white segregation. The results show that black-white desegregation is likely when the black population is small, but is unlikely otherwise. Yet, when multiple ethnic groups are sufficiently large, a moderate level of black-white segregation is necessary for whites to maintain low neighborhood contact with blacks, even when the proportion of African Americans is small.

Objective: To discuss the management of a patient suffering from an anterior sternoclavicular joint dislocation secondary to blunt trauma from a motor vehicle accident., Clinical Features: A 75-yr-old woman suffered from difficulty in swallowing and chest pain after release from a foreign medical facility. Anteroposterior chest X-rays demonstrated an anterior and superior displacement of the right sternoclavicular joint., Intervention and Outcome: Specific joint manipulation for reduction of the dislocation was performed. Immobilization of the joint after reduction was accomplished by a reverse figure-8 bandage. Follow-up radiographic evaluation demonstrated reduction of the dislocation. Resolution of difficulty in swallowing and pain was dramatic and instantaneous after reduction., Conclusion: Appropriate intervention of chiropractic examination procedures and imaging techniques culminated in successful resolution of this case. When such cases are recognized, appropriate management may occur conservatively with judicious application of joint manipulation and adjunctive procedures.

Purpose: To examine the cost-effectiveness of empirical, parenteral antibiotic treatment of patients with chronic fatigue and myalgia and a positive serologic result for Lyme disease who lack classic manifestations., Data Sources: Peer-reviewed journals, opinion of experts in the field, and published epidemiologic reports., Study Selection: Consensus by authors on articles that indicated methods for patient selection; on criteria used for diagnosis; on immunologic methods used for classifying patients; on the dose and duration of therapy; and on criteria by which responses to therapy were ascertained., Data Extraction: In a cost-effectiveness model, the costs and benefits of empirical parenteral therapy for patients seropositive for Lyme disease were compared with a strategy in which only patients having classical symptoms of Lyme disease were treated., Data Synthesis: In areas endemic for Lyme disease, the incidence of false-positive serologic results in patients with nonspecific myalgia or fatigue exceeds by four to one the incidence of true-positive results in patients with nonclassical infections. Treatment of the former group of patients costs $86,221 for each true-positive patient treated. The empirical strategy causes 29 cases of drug toxicity for every case in the more conservative strategy. If patients were willing to pay $3485 to eliminate anxiety about not treating possible true Lyme disease, the empirical strategy would break even., Conclusion: For most patients with a positive Lyme antibody titer whose only symptoms are nonspecific myalgia or fatigue the risks and costs of empirical parenteral antibiotic therapy exceed the benefits. Only when the value of patient anxiety about leaving a positive test untreated exceeds the cost of such therapy is the empirical treatment cost-effective.

Guidelines for diagnosis of acute myocardial infarction recommend that, if acute myocardial infarction is suspected, creatine kinase (CK)-MB levels should be measured on admission and again at 12 and 24 hours. In light of these recommendations, we conducted a quality assurance study to determine whether utilization of CK-MB tests in our institution, a large, university-affiliated teaching hospital, was consistent with current guidelines. Also, several years ago, we had established a policy of cancelling lactate dehydrogenase isoenzyme orders if the request originated from an unauthorized location, unless it was approved by a laboratory staff. Since this policy led to a greater than 90% reduction in the requests for lactate dehydrogenase isoenzyme testing, an additional objective was to reevaluate this policy. Of 774 patients evaluated with CK-MB tests, 294 (38%) received only a single test. Of these single tests, 277 had normal results (CK-MB < 5%). For the remaining 17 patients, the single CK-MB test findings were abnormal (CK-MB > 5%) without follow-up testing. Only two CK-MB tests were ordered for 187 patients (24%). Three or more CK-MB tests were obtained in 293 cases (38%). When two or more CK-MB tests were ordered, the time interval between the first and second tests was inappropriately short in 70% and long in 24%. The recommended timing for the third CK-MB was followed in only 4% of cases. Review of 32 cancellations of lactate dehydrogenase isoenzyme tests disclosed that lactate dehydrogenase isoenzyme tests were requested when unnecessary in 26 cases. Despite published guidelines for use of CK-MB for acute myocardial infarction, physicians at our institution continue to use these tests inappropriately by ordering only single CK-MB tests or by ordering repetitions of CK-MB tests at excessively short or long intervals.

The Los Angeles County-University of Southern California (LAC-USC) Medical Center, a level I trauma center, has experienced a rapidly increasing incidence of gunshot wounds (GSWs). We sought to enumerate the annual monetary costs and medical consequences of thoracoabdominal gunshot wounds in the epicenter of urban violence. A consecutive series of patients admitted from September 1, 1989 to August 31, 1990 was studied. Their records were coded by trauma nurse reviewers and held in the Trauma Emergency Medical Information System (TEMIS) and Automated Medical Record Abstracting and Reporting System (AMRARS). Diagnoses, procedures, and complications were verified by chart review. An estimate of disability 3 months after discharge was made from the record and reported on a functional activity scale. The total number of patients with GSWs admitted to all of the level I Los Angeles County trauma centers was 2771 during the study period. The total number of patients with major gunshot injuries admitted to LAC-USC Medical Center was 1007. Thoracoabdominal wounds without any head wound component occurred in 686 gunshot patients. Three quarters of the injured patients with truncal gunshot injuries were Hispanic. Total length of stay at the LAC-USC Medical Center for those with truncal wounds was 4666 hospital bed days including 432 ICU bed days, representing a minimum estimated total medical cost of $5,441,334. Annual medical cost of all admissions including rehabilitation, however, could be as great as $12 million for the Medical Center and $53 million for the County of Los Angeles. Thirty percent of patients had MediCal insurance. Payment could not be recovered from another 57% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Structural bone grafts in acetabular reconstruction of total hip arthroplasty have come into more common usage with the increasing number of revision arthroplasties. The authors present the outcome of 40 bone grafts with follow-up periods of 2-8 years. Primary and revision arthroplasties with both cemented and noncemented fixation are included. Factors that had a statistically significant relationship to failure of the bone graft included fit and fixation of bone graft to host, fit and fixation of prosthesis to host, union of bone graft to host, and the presence or absence of the confluence of the anterior and posterior columns of the acetabulum. Other findings of interest were a higher failure rate of multiple grafts as compared to a single graft and freeze-dried femoral heads. Migration of the socket of more than 3 mm is statistically related to failure of the socket.

Rheumatoid pericarditis occurs in approximately one third of rheumatoid arthritis (RA) patients. However, clinically apparent rheumatoid pericarditis is infrequent. The authors found clinical pericarditis in 12 of 960 patients admitted for RA, 5 of whom had manifestations of cardiac compression. These 5 had longer duration of RA, worse functional class, and more extraarticular features than the patients without cardiac compression. Presenting features of cardiac compression included dyspnea, edema, chest pain, and pulsus paradoxus. Treatment of patients with cardiac compression due to rheumatoid pericarditis may include a trial of systemically administered corticosteroids, but this should not delay surgical intervention for impending tamponade. Pericardiocentesis should only be performed as an emergency, life-saving procedure. It may be followed by intrapericardiac injection of corticosteroids, but this does not prevent recurrence. Longer-lasting benefit is obtained by surgical decompression. Two-year mortality in patients with cardiac compression was 100%. The literature on the subject is reviewed.

We describe a patient with a 10-year history of rheumatoid arthritis who developed septic arthritis of the knee secondary to Candida albicans. Joint sterilization was obtained by debridement and 865 mg. of IV amphotericin B. We review 23 other cases of candidal arthritis in adults with specific reference to disease recognition and treatment.

Serum antibodies reactive with the keratin layer of rat esophagus (AKA) were found in 46 of 80 (57.5%) rheumatoid arthritis (RA) patients. In contrast, AKA were present in only 7 of 82 (9.5%) patients with other types of rheumatic disorders and in 2 of 47 (4.2%) healthy subjects. AKA were not specific for RA, however, because in the former group, AKA were present in 4 of 20 (20%) systemic sclerosis patients and in 3 of 12 (25%) ankylosing spondylitis patients. AKA belong predominantly to the IgG class and are complement fixing. Although found in some RA joint fluids, AKA were not selectively concentrated in the joint fluid. Absorption of RA serum with type I human collagen or with human epidermal keratin did not remove AKA activity. The frequency of AKA in RA patients both negative and positive for DR4 was equal. There was no relationship between the frequency of AKA and the occurrence of other serum autoantibodies such as antibodies to intermediate filaments, smooth muscle, and nuclear antigens. Serum antibody reactive with human stratum corneum found in patients with psoriatic arthritis was shown to be different from AKA. Rabbit antiserum to human keratin did not inhibit the reaction of AKA against the keratin layer of rat esophagus. Autoimmunity to structural proteins including collagen, vimentin intermediate filaments, smooth muscle antigens, and keratin is a characteristic feature of RA.

27 paired specimens of ascitic fluid and serum obtained from patients with alcoholic liver disease were tested for cryoproteins and immune complexes by the C1q binding assay. 20 sera (74%) and ten ascitic fluid (37%) had significant amounts of cryoproteins. The cryoproteins were of the 'mixed' type of cryoglobulins consisting of IgG, IgM, IgA, C3 and C1q. The C1q binding test was positive in 17 sera (63%) and in 16 ascitic fluid (59%). Intracytoplasmic inclusions of immunoglobulin and complement were found within the ascitic fluid leukocytes by direct immunofluorescence. The presence of immune complexes in the ascitic fluid may be important in the reduction of the complement level of cirrhotic ascitic fluid.

Rheumatoid cervical myelopathy was studied in 14 patients, clinically, radiographically and by computerized tomography with multiplanar reconstruction (CT/MPR). CT/MPR demonstrated significant unsuspected areas of compromise in 9 of the 14 patients, and altered the surgical procedure in 7 of these 9 patients. CT/MPR clearly identifies all levels of involvement including rotary subluxation. CT/MPR also allows assessment of the spinal nerve canal/foramen and the alignment of the foramina transversaria. CT/MPR is an essential addition to the evaluation of rheumatoid cervical myelopathy.

The rehabilitation nurse may care for patients with arthritis in a variety of settings. When the patient has advanced RA, the problem of cervical myelopathy may require surgical intervention and use of the halo-body jacket immobilization orthosis. Expert pre- and postoperative management requires a knowledge of surgical nursing as well as rehabilitation nursing, in the traditional sense, to prevent complications and promote optimum recovery. When dealing with people who have lived with RA for many years, the rehabilitation nurse must continue to assess the patient's knowledge of the disease and use of self-management strategies and community resources.

The use of cyclophosphamide has been associated with the delayed appearance of neoplasms. We report a woman who developed myelodysplastic syndrome leading to acute myelocytic leukemia, 4 years after receiving 13 g of cyclophosphamide over 6 months for severe polyarteritis nodosa. Cytogenetic abnormalities typical of damage induced by alkylating agents, including partial deletions of chromosomes 5 and 7, were present. This case represents the first reported occurrence of cyclophosphamide associated malignancy in polyarteritis nodosa.

We studied the distribution and characteristics of circulating rheumatoid factors (RF) and anti-nuclear antibodies (ANA) in 30 rheumatoid arthritis (RA) patients who had polyarthritis alone (group I), 28 RA patients with polyarthritis and extra-articular disease (group II), 28 RA patients with systemic vasculitis (group III) and 60 healthy matched controls. IgG RF occurred more frequently and in higher serum titres in group III (100%) than RA patients in group I (40%), or in group II (18%) or in normal controls (5.8%). The serum titre of IgM RF was higher in vasculitis patients than in other RA patients. ANA were found in 74% of all RA patients and although the frequency did not differ in the three patient groups, the serum titre was significantly higher in the vasculitis group. Antibodies to extractable nuclear antigen were found only in group III (18.7%). Antibodies to histones were also more prevalent in group III than in the other RA groups. The serological abnormalities in rheumatoid vasculitis differed quantitatively as well as qualitatively from other RA patients.

A 3 year old black male with ambiguous genitalia had a 46, XY karyotype in a bone marrow culture and an intermediate buccal smear result, suggestive of a mosaic of chromatin positive and chromatin negative cells. Upon re-evaluation at age 15 years, he has a 30% positive buccal smear and a 46, XX karyotype in cultures of peripheral blood lymphocytes, skin fibroblasts, bone marrow, and testis. No Y-body fluorescence was detectable in interphase cells from the testicular biopsy or the various cultures. The testicular biopsy appeared similar to that of XXY males, and primary hypogonadism was documented by elevated LH (107 mIU/ml) and FSH (57 mIU/ml) levels in conjunction with low testosterone (142 ng/100 ml). Administration of hCG produced qualitatively normal acute responses of testosterone and estrogens. The cytogenetic data provide support for the theory that at least some XX males once had a Y-containing cell line which was subsequently lost.

A study comparing direct immunofluorescence assay using a new monoclonal antibody specific for a varicella-zoster virus glycoprotein complex, the Tzanck smear, and virus isolation for detection of varicella-zoster virus in 56 patients with clinically apparent herpes zoster is presented. Of 47 patients with clinical herpes zoster and with cultures negative for herpes simplex virus, 30 (64%) had positive Tzanck smears, direct immunofluorescence assay results were positive in 26 (55%), and cultures were positive in only 12 (26%). Both direct immunofluorescence assay and the Tzanck smear were found to be superior to culture technics; however, direct immunofluorescence assay was found to have greater specificity.

To investigate whether nicotinic acetylcholine receptors might be present on blood mononuclear cells we studied the binding [125I]alpha-bungarotoxin to mononuclear cells from three normal controls and seven myasthenia gravis patients. The medulloblastoma cell line, TE671, which expresses a functional nicotinic acetylcholine receptor having pharmacological properties similar to that of skeletal muscle receptor, was used as a positive control for alpha-bungarotoxin binding. None of the mononuclear cell samples studied exhibited specific binding of alpha-bungarotoxin.

Cervical spine disease in patients with erosive polyarticular arthritis often presents difficulties in endotracheal intubation at the time of surgery. After extensive experience with the use of the fiberoptic bronchoscope in such situations, the authors have identified a previously unrecognized and unanticipated tri-plane deviation in which the larynx is displaced caudally, deviated to the left, rotated to the right, and anteriorly angulated. A review of 710 consecutive fiberoptic intubations identified 15 arthritis patients with laryngeal deviation. Documentation was available in seven patients showing that the larynx was initially in a normal position, but was progressively displaced as the cervical spine disease worsened. Vertical penetration of the dens was the most significant underlying pattern of cervical spine disease. Computerized tomography with multiplanar reconstruction elucidated two patterns of deformity but was not necessary to detect the laryngeal deviation. One cause of the deviation was a scoliotic deformity of the trachea and larynx secondary to shortening of the neck resulting from the vertical penetration. The second mechanism was a rotational deformity of the cervical spine occurring from asymmetric bony erosions. Knowledge of this deformity permits it to be easily predicted preoperatively so that appropriate management can be planned.

Cervical spine involvement with psoriatic arthritis has been reported to occur in about 35% of patients and to be primarily ankylosing in nature. This previously described pattern is characterized by syndesmophytes, ankylosis and ligamentous ossification. Our study defines the incidence and clinical characteristics of a rheumatoid-like form of inflammatory cervical spine involvement. This pattern is characterized by apophyseal and odontoid erosions, and axial and subaxial subluxations. Clinical histories were obtained from 28 patients with both psoriasis and inflammatory arthritis between the years of 1971 and 1984. Cervical spine involvement was found in 75% of the group, 13/21 had ankylosing and 8/21 inflammatory characteristics. Three of our patients developed cervical myelopathy, one in the ankylosing and 2 in the inflammatory subgroup.

An association of ocular colobomata and congenital heart disease was observed in seven patients. Two of these were maternal half sisters whose mother also had ocular colobomata. All the patients had normal karyotypes. There was a high incidence of other associated abnormalities involving the central nervous, skeletal, and urogenital systems. Discovery of an ocular coloboma should alert the clinician to search for other abnormalities.

We measured acetylcholine receptor antibody (AchR Ab) and IgG secreted in vitro by blood lymphocytes from myasthenia gravis patients and controls. Eleven of 20 patients secreted AchR Ab. Controls did not secrete AchR Ab. IgG secretion was lower in patients who were nonsecretors of AchR Ab (351 +/- 127 ng/ml/10 days) than in secretors (3,563 +/- 949) and both groups differed from controls (1,305 +/- 353). Absence of secretion of AchR Ab and low IgG secretion correlated with long disease duration. The data suggest that nonspecific suppression of B cell mediated immune function may occur in long-standing myasthenia gravis.

Three siblings, born nonconsectively to an unrelated couple, have had bilateral dysplastic kidneys. The first child had associated skeletal anomalies, the second, ureteral atresia, and the third, no other anomalies. The occurrence of dysplastic kidneys in three siblings is compatible with an autosomal recessive inheritance pattern. In addition the variety of presenting syndromes in the children suggests that variable pathogenetic mechansims were responsible for the appearance of dysplastic kidneys. The third child is alive with kidneys that markedly decreased in size over the neonatal period but is growing well at 41 months of age indicating that the presence of bilateral dysplastic kidneys does not necessarily preclude a favorable prognosis.

The risk of pregnancy was evaluated in 31 patients with mixed connective tissue disease (MCTD), 31 patients with systemic lupus erythematosus (SLE) and 51 controls. The fertility rates in MCTD and SLE were unaltered by disease; however, parity was decreased and fetal wastage was increased both before and even more so after onset. It is our observation that pregnancy carries the same risks in MCTD as it does in SLE.

Permanent reduction of the work force in a 247-bed tertiary-care hospital in Rhode Island is described. All hospital departments were directed to reduce their salary and wage budgets by a given amount. Each department submitted recommendations for reducing the budget; these were subject to approval of the hospital administration. The pharmacy staff was reduced from 24.6 full-time equivalents (FTEs) to 23.2 FTEs. Termination of employees was a last resort; affected employees were chosen carefully and were given a thorough explanation of the reasons for their termination.

A nine-month on-the-job training program for hospital pharmacy technicians is described. The first three months of the program are devoted to didactic training and the remaining six months to acquiring practical experience. Candidates for the program are provided through state-sponsored public assistance or manpower training programs. A minimum of six individuals are needed to begin a program to ensure that during at least three complete it. Forth technicians have completed the program during the past six years, and eight are currently employed by the hospital. Thirteen others are known to be employed at other institutions or in health-related occupations.

Our study of 20 patients correlates the clinical picture of each patient with the pathology of synovial tissue obtained at the time of revision arthroplasty. While 12 patients had rheumatoid arthritis and 8 had osteoarthritis, the histopathology was identical. Additionally, while 15 of the 20 had an etiology for the revision, 5 patients were revised for pain alone with no explanation other than the synovitis. The characteristic histologic findings included lining cell hyperplasia, vascular congestion, giant cells, brightly birefringent high density polyethylene chards and cysts that represented ghosts of methyl methacrylate debris.

A girl had cleft palate, micrognathia, Wormian bones, congenital heart disease, dislocated hips, absent tibiae, bowed fibulae, preaxial polydactyly of the feet, and abnormal dermal patterns at birth. She was born after a pregnancy complicated by exposure to multiple medications. This combination of malformations may represent a distinct entity unrelated to the medication or may be a complication of the intrauterine drug exposure.