Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle.

We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis. This procedure provides satisfactory results in the medium term.

Randomised trial of magnesium in in-hospital cardiac arrest. Duke Internal Medicine Housestaff.

BACKGROUND: The apparent benefit of magnesium in acute myocardial infarction, and the persistently poor outcome after cardiac arrest, have led to use of magnesium in cardiopulmonary resuscitation. Because few data on its use in cardiac arrest were available, we undertook a randomised placebo-controlled trial (MAGIC trial). METHODS: Patients treated for cardiac arrest by the Duke Hospital code team were randomly assigned intravenous magnesium (2 g [8 mmoles] bolus, followed by 8 g [32 mmoles] over 24 h; 76 patients) or placebo (80 patients). Only patients in intensive care or general wards were eligible; those whose cardiac arrest occurred in emergency, operating, or recovery rooms were excluded. The primary endpoint was return of spontaneous circulation, defined as attainment of any measurable blood pressure or palpable pulse for at least 1 h after cardiac arrest. The secondary endpoints were survival to 24 h, survival to hospital discharge, and neurological outcome. Analysis was by intention to treat. FINDINGS: There were no significant differences between the magnesium and placebo groups in the proportion with return of spontaneous circulation (41 [54%] vs 48 [60%], p = 0.44), survival to 24 h (33 [43%] vs 40 [50%], p = 0.41), survival to hospital discharge (16 [21%] vs 17 [21%], p = 0.98), or Glasgow coma score (median 15 in both). INTERPRETATION: Empirical magnesium supplementation did not improve the rate of successful resuscitation, survival to 24 h, or survival to hospital discharge overall or in any subpopulation of patients with in-hospital cardiac arrest.

Indicators of abuse or neglect in preschool children's drawings.

1. Research designed to examine the systematic ability of children's drawings to disclose abuse or neglect has been equivocal. 2. The use of art to understand preschool-aged children is particularly advantageous because very young children usually are not able to communicate their feelings clearly. 3. The study shows that the family drawings of abused or neglected preschool children can be differentiated from those of children not identified as abused or neglected.

Aggregate degradation by growth plate proteases.

For long bone growth to occur, calcification of the matrix must begin in the lower hypertrophic zone of the growth plate. It generally is accepted that physeal proteoglycans help regulate mineralization, and that, at least in vitro, smaller proteoglycan fragments are less inhibitory of mineral formation. It also has been shown that proteoglycan degrading enzymes are concentrated in the hypertrophic zone, where calcification occurs. Thus, one can hypothesize that these enzymes are involved in the calcification process. Proteoglycans appear mainly as the aggregate form in the physis, and this study demonstrates the ability of the naturally occurring physeal enzymes to degrade proteoglycan aggregate, without first disaggregating it. Because the matrix constituents probably limit hypertrophic cell size and shape, this degradation may have some relationship to the rate of growth of the physis.

Effects of hormone replacement therapy on muscle performance and balance in post-menopausal women.

1. A randomized controlled trial of the effect of oral hormone replacement therapy plus calcium compared with calcium alone on balance, muscle performance and falls was conducted over 48 weeks in 116 post-menopausal women (aged 45-70 years), all of whom had suffered a distal radial fracture during the previous 3 months. Treatment was with Prempak C or Premarin 0.625 mg in the test group with 1 g calcium daily (Sandocal) in both groups. Measurements were made of balance, assessed as sway, leg extensor power and self-paced walking speed, at 12-week intervals over 24 weeks. Hand grip strength was measured every 12 weeks for 48 weeks, and falls in the preceding 12 weeks were recorded at each visit. 2. There was no relation between initial levels of oestradiol and any other variable assessed, except body mass. Levels of follicle-stimulating hormone in the test group were in the premenopausal range. There was no significant change attributable to hormone replacement therapy at any time point in any of the outcome variables. The only significant difference was an increase of 4.2% (95% confidence interval 0.7-7.6%) in leg extensor power in the control group (calcium alone) compared with the group treated with hormone replacement therapy. 3. Of the total group, 37% fell again during the year, with three patients suffering a further fracture. Frequent fallers swayed significantly more often than the others, but there was no evidence that their muscle strength was poorer or that the group treated with hormone replacement therapy fell less frequently. 4. Hormone replacement therapy did not increase muscle performance, improve balance or reduce falls over a year in middle-aged women.

Collecting duct carcinoma. An unusual renal tumour.

Collecting duct carcinoma is a rare form of renal tumour. Its recognition is important both clinically and histopathologically since it can mimic other renal neoplasms in appearance. Nephrectomy is the treatment of choice and, as the tumour usually pursues an aggressive course, adjuvant chemotherapy or immunotherapy may also be considered appropriate. We report two such cases.

Evaluation of treatment modalities for septic arthritis with histological grading and analysis of levels of uronic acid, neutral protease, and interleukin-1.

We compared the effectiveness of antibiotics alone and in combination with arthroscopy, arthroscopy with debridement, arthrotomy, or needle aspiration for the treatment of septic arthritis. Each modality has its proponents, but, to our knowledge, no comparative studies have been conducted in animals. We used biochemical and histological analysis to compare these methods of treatment in an experimental model. The right hind knee of thirty goats was injected with 1 x 10(5) Staphylococcus aureus bacilli. The left hind knee was not inoculated and served as the normal control. Seventy-two hours after inoculation, a two-week course of treatment with intramuscular administration of cefuroxime sodium, either alone or in combination with another mode of treatment, was initiated in each of five groups. The cartilage was evaluated histologically with biochemical, enzymatic, and interleukin-1 analyses. Despite the early therapeutic intervention, on the average, there was a 25 per cent loss of uronic acid (t test, p < 0.001) and a 43 per cent increase in neutral protease activity (signed-rank test, p = 0.003) in the treatment groups. There were no significant intergroup differences with regard to the histochemical-histological rating or the levels of uronic acid, neutral protease, or interleukin-1.

Plasma D-dimer as a marker for postoperative deep venous thrombosis. A study after total hip or knee arthroplasty.

Plasma levels of D-dimer have been found useful as a marker of deep venous thrombosis in those patients in whom thrombosis is suspected, but their usefulness in postoperative screening is less clear. We have investigated the relationship of D-dimer to deep venous thrombosis in 90 patients after total hip and knee arthroplasty. From the first postoperative day the D-dimer levels were found to be highly significantly raised in patients with deep venous thrombosis. A combined result over the first six postoperative days in excess of 1200 ng/ml correlated with thrombosis with a specificity of 100%, sensitivity of 45%, positive predictive value of 60%, and negative predictive value of 100%. However, individual estimations were not discriminatory.

The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women.

The prevalence of basal thumb osteoarthritis was assessed in 143 post-menopausal women. The radiological prevalences of isolated carpometacarpal and scapho-trapezial osteoarthritis were 25% and 2% respectively. The prevalence of combined carpometacarpal and scapho-trapezial osteoarthritis was 8%. 28% of women with isolated carpometacarpal osteoarthritis and 55% with combined carpometacarpal and scapho-trapezial osteoarthritis complained of basal thumb pain.

The epidemiology of hip fractures and methods of prevention.

Hip fractures are common in the elderly, affecting 1 in 4 women by the age of 90 years and 1 in 8 men. These fractures have caused an "epidemic" during the last 20 years because the age specific rate for such fractures has doubled, and there has been a significant increase in the size of the elderly population in Europe. Hip fracture patients occupy a quarter of all orthopedic beds, the treatment is costly and the rehabilitation slow. Fifteen percent die in hospital; 33% are dead by one year. Of survivors only 2/3 return to their own home. There is now a move to prevent such fractures. Hip fractures arise in the elderly for two reasons: deteriorating bone stock and increasing falls. Hip fracture prevention needs to address both issues, but most work has looked at bone stock. Predictions of hip fracture risk even if based on bone density are poor, so preventive measures need to target the whole population. Bone density rises to a peak at 35 to 40 years in both sexes; men have a higher bone density at all times than women. Thereafter there is a steady loss of 1-2% per year. Women have 10 years of accelerated loss after the menopause. Hip fracture prevention starts by ensuring that peak bone mass is reached. This is under genetic influence but may be maximized by adequate dietary calcium and physical activity in adolescence. Smoking, alcohol and steroid use reduce bone density and their use should be moderated. In women amenorrhea reduces bone density. For women, estrogen may stop menopausal loss and maintain bone density for at least 15 years and in retrospective studies can reduce the fracture risk by 50%. Calcitonin may be an alternative. Five years beyond the menopause primary or secondary prevention may be started. Estrogen is still the best therapy but may be less popular because of the return of menstrual periods. Calcitonin or oral calcium supplements may also be of benefit. Drugs in combination may be more effective than alone. Over age 70, when calcium absorption diminishes, vitamin D, calcium and calcitonin may be effective. For men, treatment options are calcium, calcitonin or, later on, vitamin D. The role of exercise in bone density protection is unclear but should be encouraged for general health reasons. Bisphosphonates are new drugs that may be useful. Falls become increasingly common in the elderly such that up to 80% of all 80-year-olds may sustain at least one fall per year.(ABSTRACT TRUNCATED AT 400 WORDS)

Serious group A streptococcal infections complicating cryotherapy to lip haemangiomas.

Cryotherapy is a safe and effective way of treating haemangiomas of the oval cavity and lips without complications in adults in a reported series. Two cases of serious group A streptococcal infection after cryotherapy in two children are reported. In conclusion it is likely that these children were undiagnosed carriers for the organism. Pre-operative nasopharyngeal swabs would have identified this and prevented the complications which occurred.

Carditis in Lyme disease susceptible and resistant strains of laboratory mice infected with Borrelia burgdorferi.

The clinical and pathologic evolution of cardiac Lyme disease was evaluated in four-week-old susceptible C3H/He (C3H) and resistant C57Bl/6 (B6) mice on days 3, 6, 10, 15, 30, 60, and 90 after intradermal inoculation with Borrelia burgdorferi strain N40. Culture, DNA polymerase chain reaction, in situ nucleic acid hybridization, immunoperoxidase histochemical analysis, and silver stain were used to detect spirochetes. Spirochetes were first detected by culture on day 6 in two of four C3H mice. The hearts of all mice of both genotypes were culture positive by day 10 and infection persisted through day 90. The spirochetes had a predilection for connective tissue in the heart base, especially around the aorta, epicardium of the upper ventricles and atria, myocardial interstitium, and endocardium. Carditis was first detectable on day 10, reaching a maximum severity on day 15, then resolved, except for persistence of periaortic lymphoplasmacytic infiltrates through day 90 in C3H mice and through day 60 in B6 mice. The C3H mice developed more severe disease than the B6 mice, and this was associated with the earlier appearance, greater numbers, and later clearance of spirochetes in C3H mice. Electrocardiographs of infected and control mice revealed bradycardia and tachycardia in many C3H mice, but in very few B6 mice. Serum creatinine phosphokinase levels did not become elevated at any interval.

Role of pin protrusion in the etiology of chondrolysis: a surgical model with radiographic, histologic, and biochemical analysis.

We studied a model of pin protrusion in rabbit hips to determine if chondrolysis is produced. Enzymatic degradation of the articular cartilage remote from the pin site and mechanical destruction of the acetabulum occurred. Loss of proteoglycans in the articular cartilage averaged approximately 30%, and matched the increase in neutral protease activity. This presumably accounts for the loss of height that occurs in chondrolysis, but throughout the study, the joint space did not narrow; instead, it increased. This suggests that some other factor is needed to produce chondrolysis, such as a slip or an immune response.

Treatment of proteoglycan aggregates with physeal enzymes reduces their ability to inhibit hydroxyapatite proliferation in a gelatin gel.

In vitro, cartilage proteoglycans (PGs) are effective inhibitors of hydroxyapatite formation and growth. Their inhibitory ability decreases with decreasing PG size and charge density. It has been suggested that the enzyme-mediated alteration in the size and conformation of PGs in the growth plate may similarly facilitate the calcification process. In this study, a gelatin gel system was used to monitor hydroxyapatite formation and growth in the presence of proteoglycan aggregates, before and after enzyme treatment. To reproduce the physeal degradation cascade, an enzyme preparation was used that contained all of the growth plate enzymes. At a concentration of 500 micrograms/ml, the untreated proteoglycan aggregates reduced the amount of mineral formed by 30%. When the aggregates were treated with the heat-inactivated enzyme, the same extent of inhibition was found. In contrast, treating the aggregates with the crude growth plate enzyme preparation removed all the inhibitory ability, such that 500 micrograms/ml of proteoglycan preparation yielded 10% more mineral than the controls. Treatment of the aggregates with chondroitinase ABC and trypsin, similarly removed all the inhibitory ability. These data, suggest that enzymatic degradation of proteoglycans may contribute to the regulation of growth plate calcification.

Kinetics of Borrelia burgdorferi dissemination and evolution of disease after intradermal inoculation of mice.

Borrelia burgdorferi dissemination to selected target organs was examined on days 1, 2, 3, 4, 7, 10, 15, 21, and 30 after intradermal inoculation of 4-week-old C3H mice. Infection was determined by culture (blood, spleen, kidney, ear punch); polymerase chain reaction (PCR) for outer surface protein A (OSP A) DNA (ear punch); histology and spirochete histochemistry (spleen, kidney, skin, heart, joints); and OSP A DNA in situ hybridization (joints, heart). Blood or spleen of most mice were culture positive by day 3 and ear punch by day 10. Polymerase chain reaction performed on ear punches was also positive by day 10. Inflammation of joints and tendons began on days 4 through 7 and heart on days 7 through 10, which coincided with colonization of tissues with spirochetes. Spirochetes were multifocal in distribution, with a predilection for collagenous connective tissue of joints, heart, arteries, nerves, muscle, skin, and other tissues. Relative numbers of spirochetes peaked at 15 days, then decreased by 21 days. Gamma M immunoglobulin (IgM) antibody was detectable on immunoblots as early as day 4, with subsequent declining reactivity, and IgG antibody was detectable by day 7, with expanding reactivity to multiple antigens through day 30.