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In the early days of replantation surgery, if viability was restored the operation was judged a success. Nowadays restoration of viability alone is not sufficient to fulfill the criteria of successful replantation, which are as follows: Lack of severe systemic disturbances due to the replantation, a "functional extremity" according to the definition of Chen et al. (1978), no or little pain at the site of the replantation, good aesthetic results, and an acceptable length of time for rehabilitation and return to normal life. Successful replantation needs a therapy concept that is based on an exact definition of the amputation injury from the viewpoint of the amount of severance, the level of the amputation, and the type of amputation mechanism, complete knowledge of current replantation indications, and exact selection of patients amenable for replantation.

A review of the literature reveals that with conventional treatment alone or in combination with secondary muscle/tendon transfer, about 4-43% of cases show incomplete recovery with severe functional and/or aesthetic impairment (group III). If these patients undergo early microsurgical brachial plexus revision, regeneration without significant functional and/or aesthetic impairment (shift from group III to group II) can be achieved in 80-90% of cases. Moreover, microsurgical reconstruction of the brachial plexus increases the possibilities of secondary muscle/tendon transfers. Therefore, provided patient selection is good, severe obstetrical brachial plexus injuries should be scheduled for early microsurgical revision. There is no need to wait for a frustrating spontaneous recovery. Our concept is based on our experience with more than 1100 patients presenting with brachial plexus lesions between 1981 and 1996 and treated in our institution. There were 217 obstetrical brachial plexus lesions, 133 of which were treated conservatively. In 84 cases operative treatment was necessary. Fifty-one cases underwent early revision of the brachial plexus, and secondary tendon transfer was done in 33 patients.

Elbow flexion plays a key role in the overall function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's chances of regaining bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint as well as some supination function of the forearm can be restored to a varying degree at the same time. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient it is necessary to known the extent of the lesion of the brachial plexus and/or ventral upper arm muscles, to time the operation appropriately, to be aware of all treatment possibilities and to recall the special problems of tendon transfer for brachial plexus patients. Our concept is based on our experience with more than 1100 patients presenting a brachial plexus lesion between 1981 and 1996 and treated in our institution. There were 528 operative revisions of the brachial plexus. Some 225 patients underwent secondary muscle/tendon transfers. In 35 patients elbow flexion was reconstructed by bipolar latissimus dorsi transfer (n = 10), triceps-to-biceps transfer (n = 15), modified flexor/pronator muscle mass proximalization (n = 6) and the multiple-stage free functional muscle transfer after intercostal nerve transfer (n = 4).

A rejection response of peripheral nerve allografts eliminates the Schwann cells without destroying the tubular architecture and leads to a regeneration of inferior quality. Under immunosuppression this rejection is prevented, and allogenic Schwann cells persist in the grafts, leading to a better regeneration result. In adult rats of the strains DA and LEW.1W, a 2,5 cm segment of the sciatic nerve was grafted. Under Cyclosporin A regeneration was allowed to take place for 12 weeks. Thereafter, immunosuppression was discontinued in one group and gradually reduced in another. Regeneration quality was compared after an additional six weeks in comparison to an autologous control. Best regeneration was observed in the autologous control; no statistical differences were observed between the two experimental groups. Gradual reduction of immunosuppression did not result in an atraumatic replacement of donor derived Schwann cells by recipient derived ones. Allogenic nerve grafting needs continuous immunosuppression, which to date precludes it from clinical application.

Due to favourable survival rates in replantation surgery and a high standard of free tissue transplantation, the interval between injury and microsurgical reconstruction has continuously decreased in the past. The acute phase can be defined as the interval ranging from emergency procedures within 24 hours to "urgence différée" procedures within 72 hours. Bearing in mind the infection rates of 1.5% and 17.5% respectively as it has been reported in the literature, we should encourage emergency reconstructions. However, in most cases of upper extremity injuries, reconstruction with conventional flaps is possible. Between 1981 and 1991, 674 free tissue transplantation have been performed in our unit, 61% of the cases of free tissue transplantations to the upper extremity were done in the acute phase, the majority within 72 hours (urgence différée). No significant differences in rates of infections were evident comparing acute phase and urgence différée procedures. Because of this, we still support the concept of urgence différée. In our opinion the following advantages have to be considered: urgence différée allows a second loop operation, the vitality of the extremity can be ascertained, and the reconstructive procedure can be planned more precisely. Last not least, a procedure performed during the day-time assures better operating conditions. This concept is demonstrated with clinical cases.

In order to determine donor-site morbidity after elevation of the gracilis flap, 53 patients from four different departments were examined. The patients filled out a questionnaire about their complaints. 36 patients underwent dynamometric measurements. The adduction strength of the hip-joint was decreased by 11% after elevation of the gracilis muscle. This decrease in strength was not noticed by the patients. 53% of the patients complained about hypesthesia or dysesthesia corresponding to the cutaneous territory of the obturator nerve. The contour of the thigh was adversely affected after elevation of a musculocutaneous flap. The gracilis flap has a low but definite donor-site morbidity, especially concerning the esthetic aspect.

The aim of this study is to gain further knowledge concerning the regeneration of reinnervated, freely transplanted muscles. Therefore, we used a rat model, consisting of eight rats per group, in which the latissimus dorsi muscle was transplanted orthotopically, after a period of time of two and twelve weeks harvested, then evaluated histologically and enzyme-histochemically. As controls we used a group of non-operated muscles. At date of removal, the patency of the vascular anastomoses was checked clinically and histologically. Additionally, electrophysiological measurements and conventional and enzyme-histochemical histologies were performed. Two weeks after the free neurovascular flap transplantation, the muscle was not innervated yet, histologically a dissolved pattern of type 1 and type 2 muscle fibers was found. After twelve weeks of time, the muscles were reinnervated again, muscle contraction was positive after electrical stimulation and the typical pattern of fibers was reestablished.

The reconstruction of lost muscle functions in cases of brachial plexus lesion is possible even in those cases where primary nerve reconstruction was not performed or unsuccessful. If there are only few motor nerves available, we prefer free latissimus dorsi transplantation or pedicled latissimus dorsi transposition for replacement of biceps and finger flexors. The combination of elbow flexion and finger flexion becomes possible when the transposed motor is passed around a suitable pulley in the elbow region like the flexor carpi ulnaris or carpi radialis.

The monoclonal antibody Ki-67 reacts with a human nuclear cell proliferation-associated antigen that is expressed in all cells that are not in G0. Recently, we could demonstrate that Ki-67 detects a double band in Western blots of proliferating cells with apparent molecular weights of 345 kilodaltons and 395 kilodaltons, respectively. Furthermore, initial molecular biologic data favored the view that the epitope detected by Ki-67 might be encoded by a repetitive 66 bp element.In order to verify this assumption, parts of the Ki-67 cDNA were bacterially expressed, and the fusion proteins obtained were used to elicit new monoclonal antibodies. The specificities of the new reagents were tested by immunohistochemistry, Western blot, and enzyme-linked immunosorbent assay techniques.The somatic cell fusions revealed a number of antibodies with immunoreactivities comparable to Ki-67. Three antibodies, designated MIB 1-3, were further characterized. Besides the fact that their immunostaining reactivity is identical with that of Ki-67, all new antibodies react in Western blots with native Ki-67 antigen. Furthermore, Western blot and competitive binding assays by enzyme-linked immunosorbent assay clearly demonstrate that MIB 1 and MIB 3, like the original Ki-67 antibody, react with an epitope that is encoded by the 66 bp repetitive element mentioned above. MIB 2, however, reacts with an epitope distinct from this latter structure. In addition, after antigen unmasking by microwave treatment, MIB 1 and MIB 3 detect the Ki-67 antigen in paraffin sections.Our results demonstrate that it is possible to use bacterially expressed parts of the Ki-67 antigen as immunogen to elicit antibodies that react with the native antigen. While MIB 1 and MIB 3 detect the same or a very similar epitope as the original antibody Ki-67, MIB 2 clearly differs in its fine specificity. Our results provide a circle of evidence that the cDNA sequence thus far determined encodes for the Ki-67 antigen. Furthermore, the new antibodies may become powerful tools for routine histopathology and for further functional characterization of the Ki-67 antigen.

Although breast self-examination (BSE) continues to be recommended as an adjunct to clinical screening techniques for the early detection of breast cancer, little is known about events that might negatively influence long-term adherence. The primary aim of this investigation was to determine if regularity of BSE would decline after a benign breast biopsy. Analyses are based on 655 women: 83 women who self-discovered the breast problem by BSE, 179 women in whom the problem was discovered by the health care system, and a control group of 393 women who had no history of breast problems. Frequency of BSE was assessed over two six-month periods and collapsed into three categories--nonpractitioner, irregular practitioner, and regular practitioner. Results indicated that the percentage of women in the self-discovered group who reported decreased regularity of BSE was over three times higher than that found in the control group. The largest percentage increase in BSE frequency was evidenced by the health care-discovered group. Logistic regressions revealed that the biopsy experience was a more powerful indicator of subsequent BSE practice than either sociodemographic characteristics or whether one engaged in other preventive health behaviors. The data provide substantial evidence that a benign biopsy can affect BSE practice, with the direction and magnitude of the change influenced by mode of discovery of the breast problem, perceived degree of confidence in ability to perform BSE, and level of practice before the biopsy. Postbiopsy educational strategies incorporating these findings and targeted at specific subgroups are outlined.

Negative attitudes toward obese patients by health professionals have been attributed to termination of weight reducing attempts. This study measured attitudes concerning the obese held by professional participants in a continuing education conference on causes and treatment of obesity. Substantial variation was found on items comprising obesity-related belief dimensions: (a) Disparaging image of the obese; (b) causes of obesity; and (c) ways to lose weight. Evidence is presented for the association among measures of these dimensions. While background and educational characteristics and conditions of practice were not related to such attitudes, the professional's personal experience with successful weight reduction was the best predictor of favorable attitudes.

This paper describes the relationships of selected dimensions of nurse-client interaction in county health department family planning clinics to the subsequent contraceptive use of the clinic's unmarried teenage clients. The subjects for the study are the clients and professional staff of 78 clinics: 2,900 eligible clients making their first contraceptive visit and 338 clinic staff nurses. Results of interviews demonstrate that client and staff expectations and interactions are significant predictors of adherence to a contraceptive regimen; under circumstances where clients anticipate, and staff employ, authoritative guidance in helping the clients to select a contraceptive method, clinic mean levels of contraceptive use are substantially increased. Overall, 40 per cent of clinic variation in contraceptive compliance is explained by the interaction dimensions and other aspects of clinic organization addressed in this paper. Implications of these results for the structuring of family planning clinic programs directed toward teenage women are briefly considered.

Health services utilization may be influenced by the structure of the health system and the behavior of health professionals as well as by the actions of individual patients. This research examines the responses of obstetricians toward women seeking abortion. The population for this study includes all obstetrician-gynecologists with any private practice in Maryland during 1975 (473). Each responding physician (443) was presented with a case history vignette describing, in a telephone interview, a woman who is pregnant and considering an abortion. The sociodemographic characteristics of the woman were systematically varied to determine effects of patient attributes on physicians' patient management decisions. Decisions to refer the patient or to participate personally in her care were found to be associated most strongly with the patients' financial resources. Three hundred and twelve obstetricians returned a mail questionnaire, probing their own attitudes and characteristics. Physicians' liberal or conservative attitudes toward expansion of reproductive health care services and their level of disturbance by the abortion procedure were also influential in these patient management decisions. Simultaneous examination of both patient and physician characteristics indicated that the former had the greater weight in accounting for referral decisions.

Three patients are reported, two of whom had mothers who revealed ingestion of abortifacient drugs during pregnancy. All patients resemble one another and those described earlier with malformations that were probably either aminopterin- or methotrexate-induced. It is likely that Patients I and II have abnormalities associated with the teratogenic action of these folic-acid antagonists. The etiology of Patient III's defects remains uncertain.

The Health Belief Model (HBM) has been applied to a variety of health conditions: most are less threatening and require less complex responses than those arising in the case of AIDS. The utility of the HBM in understanding preventive behaviors in AIDS is examined in a cohort of homosexual men at two different time points. Longitudinal analyses estimated the relationship of indices assessing susceptibility, severity, benefits, and barriers, as well as sociodemographic factors, to sexual behavior across the next 18 months. Analyses further defined these associations in specific subgroups of participants, such as those initially at lower or higher risk. In general, measures of severity and socioeconomic advantage had the most consistently beneficial effect on various measures of behavior. Little or no beneficial effect was observed for other components of the HBM, notably a measure of perceived susceptibility. These analyses suggest that the special features of AIDS may require development of more adequate theoretical frameworks.

Little is known about the therapies that people initiate for their health problems, and the available research on self-medication has focused primarily on adult populations. Only a few studies have specifically addressed mothers' independent use of medications for their children, and none has described such behavior in depth (for example, relating-perceived symptoms and conditions in the child or attempting to provide an explanation for mothers' decisions in these situations). A stratified systematic random sample of 100 mothers of children between 6 months and 12 years old was obtained at each of 3 pediatric ambulatory care clinics. Mothers were interviewed about their use of medications for their children, their concerns about their children's health, and their medication-related attitudes. The study results suggest that income and education are related to the types of medication and medical appliances mothers keep to treat the various health problems of their children. Mothers' perceptions of their children's potential susceptibility to health problems are related to possession of what they believe are relevant remedies for those problems (as well as to keeping a greater variety of medications on hand). Socioeconomic status appears to be one determinant of the number of different remedies (and especially the number of different medical appliances) that are purchased. Certain attitudes held by mothers about medications also play a role in explaining how great a variety of remedies are kept available for children in the event that they become ill, and these medication-related attitudes are highly correlated with socioeconomic status.

Personal interviews concerning health beliefs and behaviors were conducted with a parent and child in each of 250 households. Index scores were constructed for parental and child health beliefs, and these scores were entered, along with demographic variables, in a series of multiple regression analyses predicting child health beliefs and behaviors. The age of the child was the variable most highly associated with three of four child health behaviors and four of six child health beliefs. The children's snacking between meals and cigarette smoking were related to several parental behaviors and, to a lesser extent, parental health beliefs. The children's health beliefs were less predictable than were their health behaviors, and the observed significant relationships were with parental health beliefs and demographics. The implications for the design of health education programs are discussed.

Breast self-examination (BSE) is an important component of any program for the early detection of breast cancer. Compared to clinical breast examination and mammography, BSE is relatively safe, low cost, offers monthly assessment, and does not require overcoming barriers associated with access to the medical care system (unless an abnormality is discovered). Over the past decade, considerable research has been directed at encouraging women to perform BSE. This paper reviews 33 intervention studies that vary in the type and intensity of strategies employed, and in the BSE behaviors assessed. In general, more-intensive interventions result in better outcomes. With regard to BSE frequency, the provision of information seems sufficient to obtain BSE initiation but not necessarily adequate to maintain practice or to establish proficiency. The addition of skills training and corrective feedback leads to significantly improved BSE proficiency. Prompts and reminder aids seem also to contribute to long-term frequency. The search should continue for motivational mechanisms regarding BSE frequency, and for creative approaches to teaching and maintaining proficiency.

The structural conditions under which obstetricians personally opposed to abortion will provide abortion services were examined. The data were obtained during the winter of 1975-1976 as part of a survey of abortion practices among private obstetricians in Maryland. Of the 473 physicians identified as eligible for inclusion in this study, 443 completed a telephone interview, and 318 of those interviewed returned a mail questionnaire. It was hypothesized that personally conservative obstetricians would provide abortion services if these services were supported by prevailing professional norms, whereas personally liberal obstetricians would provide these services irrespective of prevailing professional norms. The data strongly supported the hypotheses. Uniformly, conservative obstetricians were more likely to perform abortions and to demonstrate high levels of commitment to abortion services if they were in a favorable, in contrast to an unfavorable, normative climate. Of 6 comparisons between the abortion activities of conservative obstetricians in conservative versus liberal environments, 4 were significant at greater than the .05 level, all in the direction of greater activity in the more liberal climate. In contrast, the liberal obstetricians were more resistant to the potentially modifying effects on their behavior of an opposing normative climate (as was predicted). With only 1 exception (number of abortions), obstetricians with attitudes favorable to abortion appeared to resolve conflict between their own attitudes and prevailing norms in favor of the former, choosing to provide, rather than to withhold, abortion services. The data suggest that attitudes, as well as religious beliefs, have their greatest effects on the initial decision to perform abortions.

Although religion is the most powerful predictor of whether a doctor will perform any abortions, satisfaction with his or her patients and emotional reaction to the abortion procedure powerfully affect the physician's practice. Doctors who are most satisfied with their patients are less likely to ask unmarried teens for parental consent and to charge lower fees. Physicians who are severely disturbed over abortion perform terminations less frequently and more often ask spousal or parental consent--but charge lower fees and are more likely to accept Medicaid patients.

The campomelic syndrome is a short-limb, usually fatal, neonatal dwarfism. It is characterized by bowed lower limbs, especially the tibia, usually associated with a cutaneous dimple over the anterior skin. There is delayed calcification of the epiphyses and delayed mineralization of the spine and pelvis. The cartilages of the tracheobronchial tree are hypoplastic, contributing to death from respiratory problems. Other associated abnormalities are unusual appearing facies, cleft palate, absent olfactory nerves and talipes equinovarus. Less commonly seen are cardiac, renal and brain anomalies.

Health educators are frequently exhorted to encourage the development of functional lifestyles among school-aged children. Current efforts, however, often neglect consideration of the full spectrum of relevant age groups and the context imposed by the students' existing health beliefs. Interview data from a probability sample of children 6-17 years of age enable such assessment. Findings indicate that "health" is a meaningful concept and of concern to a majority of students, regardless of age or sex. However, a majority also report engaging in health-related risk-taking behaviours, and yet deny personal responsibility for poor health outcomes. Children of all ages were found to discriminate among illnesses, in terms of both their perceived personal vulnerability to the conditions and the extent to which they worry about them. Finally, by incorporating these attitudinal components as well as other social and demographic characteristics, regression analyses provide exploratory profiles of the current cigarette smoker and user of alcohol. Differences between each risk-taking behaviour are reviewed, as are areas for improving research into children's health beliefs and behaviours.

Health-promotion efforts often employ HRA as a device for providing an individual with quantitative information about the consequences of personal health-related behaviors and as an attempt to motivate the client to adopt recommendations directed at establishing a healthier lifestyle. From a behavioral science perspective, the HRA approach and process contain elements that (at least in retrospective analysis) appear to be founded in relevant bodies of theory. First, HRA seems to be a reasonably efficient mechanism for transmitting information relative to associations between personal health behaviors and mortality risks. Moreover, while general knowledge and advice about the untoward consequences of risk factors (such as smoking, obesity, high blood pressure, etc.) are currently widespread, HRA provides new and specific information: the client's own relative risks. Some individuals who voluntarily participate in HRA bring to the experience an already high level of readiness to take action; for them, the technique may constitute the final necessary stimulus or "cue to action" [12]. Referring to a "borrowing from the future" phenomenon, Green points out that "some educational efforts are really only triggers to behavior that would have changed eventually anyway" [44, p. 159]. Thus, where motivation is sufficiently high, receipt of HRA feedback information may by itself be capable of inducing behavior change. Second, the focus on awareness and personalization of mortality risk fits well with most theoretical formulations concerning attitudes and beliefs involved in health-related decision making. Although the emphasis on mortality and often distant negative outcomes is problematic, increasing the client's perception of personal vulnerability is a psychologically defensible approach, and fear arousal can generate attitude change (although questions of appropriate level, duration of effects obtained, acceptability, etc. still need to be resolved). Third, HRA might be expected to enhance the client's perception of the benefits associated with lifestyle modifications and may even increase personal belief in his or her ability to undertake such changes in behavior. However, in light of the fact that the behaviors to be altered are complex, usually well-established and repetitive, and require different skills to extinguish, the provision of typical HRA feedback should not (on a theoretical basis) ordinarily be expected to accomplish much beyond information transmission, belief or attitude change, and the induction of some level of motivation.(ABSTRACT TRUNCATED AT 400 WORDS)

Variations expressed clinically and radiographically in hemifacial microsomia preclude classifying all the abnormalities as coming from the first and second branchial arches. Anatomic structures arising from the branchial arches are directly involved but the final expression results from the combined impact of the primary anatomic defect and the secondary effects on contiguous structures. The deformities resulting from the latter are probably due to abnormal neuromuscular function.

A 7-year-old male presented with a triple A syndrome, a tirad of ACTH insensitivity, achilasia and alacrima. His clinical course is followed and the literature reviewed.

A multitrait - multimethod design was employed to assess the construct validity of three commonly used methods for assessing patient compliance: physiological assessments (e.g., blood chemistries), ratings by health professionals, and patient self-reports. Subjects were patients receiving ambulatory hemodialysis treatments for end-stage renal disease, whose regimen required them to take medications, to follow dietary restrictions, and to limit fluid intake. Study findings indicated that of the three methods examined, the nurse rating approach was the most valid (although it contained only about 50 percent valid variance). Measures derived from physiological assessments contained a substantial proportion of residual error (over 70 percent), and the patient self-report method contained only about 12 percent valid variance (with about 18 percent method-effects variance, and 68 percent residual-error variance). These results make clear the need for additional research directed at developing valid methods for evaluating patient compliance behaviors.