The Multiple Sclerosis Severity Score: fluctuations and prognostic ability in a longitudinal cohort of patients with MS.

BACKGROUND: The Multiple Sclerosis Severity Score (MSSS), combining the Expanded Disability Status Scale (EDSS) and disease duration, attempts to stratify multiple sclerosis (MS) patients based on their rate of progression. Its prognostic ability in the individual patient remains unproven. OBJECTIVES: To assess the stability of MSSS within individual persons with MS in a longitudinal cohort, to evaluate whether certain factors influence MSSS variability, and to explore the ability of MSSS to predict future ambulatory function. METHODS: A single-center retrospective review was performed of patients following a single provider for at least 8 years. Mixed model regression modeled MSSS over time. A Kaplan-Meier survival plot was fitted, using change of baseline MSSS by at least one decile as the event. Cox modeling assessed the influence of baseline clinical and demographic factors on the hazard of changing MSSS by at least one decile. Linear models evaluated the impact of baseline EDSS, baseline MSSS, and other factors on the Timed 25-Foot Walk (T25FW). RESULTS: Out of 122 patients, 68 (55.7%) deviated from baseline MSSS by at least one decile. Final T25FW had slightly weaker correlation to baseline MSSS than to baseline EDSS, which was moderately strongly correlated with future log T25FW. CONCLUSION: Individual MSSS scores often vary over time. Clinicians should exercise caution when using MSSS to prognosticate.

Perceptions of allograft safety and efficacy among spinal deformity surgeons.

Since current bone procurement and processing standards have been adopted, published studies have consistently shown that the risk of disease transmission from allograft is small. The purpose of this study was to evaluate allograft use and opinions regarding allograft safety during spinal deformity surgery. A postal survey was sent to 151 pediatric orthopaedists chosen from a cross-referenced listing of active members of both the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America. The survey consisted of six questions covering allograft use during idiopathic and neuromuscular scoliosis cases, concerns about disease transmission, preoperative counseling, concerns about providers, and evaluation of clinical results. The response rate was 80%. Allograft bone use was reported by 96% of those responding for neuromuscular cases and by 62% for idiopathic cases. Infection (68%) and pseudoarthrosis (26%) were the most common topics mentioned among the 41% who addressed potential risks. Variation was found in surgeons' perceptions regarding the safety and efficacy of allograft for scoliosis surgery.

Management of increased vitreous pressure during penetrating keratoplasty using pars plana anterior vitreous aspiration.

PURPOSE: To describe the technique, outcomes, and complication rates for a method of pars plana vitreous aspiration to control excessive vitreous pressure during penetrating keratoplasty. METHODS: All cases of penetrating keratoplasty were reviewed retrospectively in a large cornea subspecialty private practice over a 5-year period, and 70 cases of penetrating keratoplasty complicated by excessive posterior pressure were identified. Study eyes were treated with a pars plana vitreous aspiration technique to relieve excessive posterior vitreous pressure. The main study parameters included preoperative best corrected visual acuity (BCVA), postoperative BCVA at the last recorded follow-up visit, refractive cylinder at 1 year, complications related to surgery, and other conditions that may have influenced visual function. The mean follow-up period was 24.5 months with a range of 1 to 61.1 months. RESULTS: Adverse outcomes during the extended period of follow-up included rejection in 11 of 70 eyes, graft failure in 7 of 70 eyes, glaucoma in 4 of 70 eyes, and postoperative cystoid macular edema (CME) in 5 of 70 eyes. Posterior capsulotomies using the neodymium-yttrium aluminum garnet laser were necessary in 10 of 70 patients during the follow-up period. The average magnitude of refractive astigmatism at 1 year after surgery was 3.73 diopters (D) with a range of 0 to 8 D. There were no known retinal complications other than CME and no complications that could be directly attributed to the pars plana vitreous aspiration technique. CONCLUSIONS: Pars plana anterior vitreous aspiration is a safe and effective technique for controlling increased vitreous pressure, which can complicate penetrating keratoplasty.

Foot and ankle injuries and disorders.

This chapter analyses the mechanics of walking and running gait and delineates the terminology used to describe foot and ankle injuries. A helpful anatomic review precedes explanations of the mechanisms of sports injuries in this area. The author documents the correct diagnoses and treatments for foot and ankle sprains, fractures, and stress injuries.

Floppy eyelid syndrome in a child with chronic unilateral conjunctivitis.

PURPOSE: To report a 2-year-old child who had chronic unilateral conjunctivitis and spontaneous left upper eyelid eversion during sleep consistent with the floppy eyelid syndrome. METHODS: The patient's parents used a video camera to document nocturnal ectropion of the left upper eyelid. Examination demonstrated left upper eyelid swelling and left palpebral conjunctival hyperemia with papillary hypertrophy. RESULTS: All signs and symptoms of the floppy eyelid syndrome resolved with taping of the left upper and lower eyelids to close the palpebral fissure and to prevent ectropion during sleep, and with application of ocular lubricants. CONCLUSIONS: Floppy eyelid syndrome may manifest in childhood without other contributing conditions and should be considered in the differential diagnosis of chronic papillary conjunctivitis in patients at any age.

Proposed curriculum model for resident education in pediatric orthopaedic surgery.

A curriculum developed for pediatric orthopaedic residency training is described. The curriculum is practice based, emphasizing those components thought to be necessary for orthopaedic practice. Highly technical or esoteric topics are deemphasized, because they are not relevant to practice capabilities at the end of residency training. The curriculum is designed to serve as a guide for educational direction in pediatric orthopaedic residency training, and not as a description of competency. Resource materials are being developed to provide the educator with relevant clinical material, objectives, and bibliography. The advantages of a practice based curriculum warrant further development of this model for other orthopaedic subspecialties.

Comparison of astigmatism after penetrating keratoplasty by experienced cornea surgeons and cornea fellows.

PURPOSE: We compared surgically induced astigmatism after penetrating keratoplasty performed by supervised cornea fellows and experienced cornea surgeons. METHODS: Data were collected by retrospective chart review of 166 cases (166 eyes) of penetrating keratoplasty: 63 performed by two cornea surgeons and 103 by four cornea fellows. Astigmatism was calculated using scalar and vector methods. Vector analysis was performed on 109 of 166 eyes. Two techniques were compared: intraoperative keratometry and suture adjustment and the torque-antitorque running suture technique with no intraoperative keratometry or suture adjustment. RESULTS: Mean surgically induced scalar astigmatism changed from preoperative astigmatism by 3.27 diopters (fellows) and 2.94 diopters (attending surgeons). In 109 cases, surgically induced vector cylinder changed from peroperative astigmatism by 4.21 diopters at 98 degrees (fellows) and 4.25 diopters at 114 degrees (surgeons). Surgically induced vector astigmatism changed from preoperative astigmatism by 4.67 diopters at 93 degrees in the first 6 months (fellows) and by 3.79 diopters at 103 degrees in the second 6 months. Analysis of x-axis and y-axis components of the surgically induced vector cylinder showed that the majority of the astigmatism was induced in the y-axis and that this difference was significant (P < .001) in all comparisons, independent of technique or surgeon group. CONCLUSIONS: Penetrating keratoplasty performed by supervised cornea fellows resulted in similar rates of surgically induced vector astigmatism, surface asymmetry, and surface regularity as that by experienced surgeons. Fellows induced significantly more with-the-rule astigmatism, but this tendency decreased with further training. Penetrating keratoplasty astigmatic outcomes were not significantly different whether or not intraopertive keratometry and suture adjustment were utilized. This study supports the concept that increased experience with corneal transplantation improves the outcome of penetrating keratoplasty by using the criterion of postoperative astigmatism as a measures.

Corneal perforation associated with argon laser photocoagulation for a retinal tear.

PURPOSE: To report a corneal perforation during argon laser photocoagulation around a retinal tear following pneumatic retinopexy. METHODS: The patient was examined and found to have a corneal perforation with pigment in the base of the wound. To help explain this phenomenon, we evaluated the ability of argon blue-green laser to create a corneal perforation in a cadaver eye. RESULTS: In a cadaver eye, we induced a corneal perforation with argon laser only when a pigmented substance was present on the corneal surface. CONCLUSIONS: We hypothesize that pigmented material such as an eyelash or mascara caught between the cornea and contact lens interface may have facilitated this rare complication. Clinicians should be wary of any pigmented substance on the surface of the cornea or ophthalmoscopic lens when performing argon laser photocoagulation.

Corneal astigmatism after phacoemulsification and lens implantation through unsutured scleral and corneal tunnel incisions.

PURPOSE: We compared the changes in corneal astigmatism after phacoemulsification and intraocular lens implantation in 93 consecutive eyes with unsutured 4-mm superior scleral tunnel incisions to those through 105 consecutive eyes with unsutured 3.2- to 3.5-mm temporal corneal tunnel incisions. METHODS: Keratometry measurements were obtained preoperatively and at postoperative day 1, week 1, and week 6. Group differences in scalar and vector astigmatism were compared by using analysis of variance methods. RESULTS: Mean scalar astigmatism in the scleral incision group changed from preoperative astigmatism by 0.65 diopter at postoperative day 1, 0.37 diopter at postoperative week 1, and 0.13 diopter at postoperative week 6. Mean scalar astigmatism in the corneal incision group changed from preoperative astigmatism by 0.39 diopter at postoperative astigmatism by 0.39 diopter at postoperative day 1, 0.21 diopter at postoperative week 1, and 0.13 diopter at postoperative week 6. Mean vector astigmatism in the scleral incision group changed 1.26 diopters at 80 degrees at postoperative day 1, 1.05 diopters at 83 degrees at postoperative week 1, and 0.42 diopter at 103 degrees at postoperative week 6. Mean vector astigmatism in the corneal incision group changed 0.77 diopter at 90 degrees at postoperative week 1, and 0.61 diopter at 89 degrees at postoperative week 6. The differences were statistically significant (P = .003) only by vector analysis at the postoperative day 1 examination. CONCLUSIONS: We found significantly greater with-the-rule change in astigmatism in the scleral incision group than in the corneal incision group on the first postoperative day. The effect disappeared by the sixth postoperative week.

Corneal pharmacokinetics of topical clarithromycin.

PURPOSE: To evaluate the pharmacokinetics of topically applied clarithromycin, a new macrolide antibiotic, at various concentrations in a rabbit model. METHODS: Clarithromycin in dosages of 10, 20, and 40 mg/ml was administered topically every 2 hours for 48 hours to three groups of 16 New Zealand albino rabbits. Both corneas were treated. Right corneas were deepithelialized with n-heptanol. At 6, 12, 24, and 48 hours, tissue concentrations were determined in four animals from each group. RESULTS: Tissue drug concentrations increased with drug dosage and duration of therapy. Drug concentrations were significantly higher at 48 hours than at 6 hours, 12 hours, and 24 hours for both epithelialized and deepithelialized eyes in the 20 mg/ml and 40 mg/ml treatment groups (all P < or = 0.0015). A steady state concentration was not achieved in any group. Tissue drug concentrations were higher in deepithelialized corneas for each dose after 6 hours, although differences were not significant (all P > 0.059). Highest mean drug concentration at 48 hours was 241 micrograms/g in animals receiving 40 mg/ml of clarithromycin. After 6 hours, tissue concentrations in some groups were above MIC90 for many Chlamydia sp., Streptococcus sp., and Staphylococcus sp., and by 12 hours, concentrations were greater than MIC90 in all groups for many nontuberculous mycobacteria. CONCLUSIONS: Topical clarithromycin achieves therapeutic levels in corneal tissue in a rabbit model. Clarithromycin might be a useful broad-spectrum antibiotic for topical use in humans.

Chemical induction of stress proteins does not induce splicing thermotolerance under conditions producing survival thermotolerance.

Cell survival during a severe heat stress can be enhanced when heat shock proteins are induced prior to the severe heat treatment. Induction can be accomplished either by heat or chemical treatments. The increase in survival at these severe elevated temperatures after pretreatment has been referred to as thermotolerance, which we now refer to as survival thermotolerance. It has also been shown previously that mild heat treatment allows splicing in cells subjected to a severe heat treatment, now referred to as splicing thermotolerance. The experiments shown here demonstrate that even though chemical induction of the heat shock proteins leads to survival thermotolerance, this same treatment does not induce splicing thermotolerance. These are the first results that demonstrate at least two distinct aspects of thermotolerance.

Afghan percutaneous osteotomy.

An alternate technique to corticotomy for osteotomies to be used with external fixation is described. Percutaneous subperiosteal dissection is followed by passage of a Gigli saw and bone division. In contrast to corticotomy, the endosteum is divided, but the surrounding soft tissue envelope is less disrupted. In > 50 percutaneous Afghan osteotomies of the distal femur or proximal tibia, prompt healing has occurred in all cases, with no neurovascular complications. Two patients who had previously undergone corticotomy reported less pain after Afghan osteotomy. The technique is not applicable to the mid-femur because of the proximity of the profunda femoral artery.

Musculoaponeurotic fibromatosis (extraabdominal desmoid tumor) in a child with idiopathic multicentric osteolysis.

The fibromatoses are a group of benign proliferations of fibrous tissue with clinical behavior ranging from that of truly malignant tumors to that of benign reactive fibrous proliferations. Some of the superficial fibromatoses are fairly common, but the deep ones, also known as desmoid tumors or musculoaponeurotic fibromatoses, are rare. Idiopathic multicentric osteolysis is a rare skeletal disorder of childhood that causes progressive destruction of bones and renal failure. We recently saw a young girl with both extraabdominal musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis. The classification, diagnosis, and treatment of the deep fibromatoses are reviewed, and the possible association between the minor bone changes occasionally reported in musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis is discussed.

Splicing thermotolerance maintains Pre-mRNA transcripts in the splicing pathway during severe heat shock.

Thermotolerance, the ability of cells and organisms to withstand severe elevated temperatures after brief exposure to mild elevated temperatures, has been studied in numerous laboratories. Survival thermotolerance is defined as the increase in cell or organism survival at severe elevated temperatures after a pretreatment at mild elevated temperatures. This study examines splicing thermotolerance in Drosophila melanogaster, the ability to splice pre-mRNAs made at the severe temperature (38 degrees C) after a brief pretreatment at a milder temperature (35 degrees C). It is probably one of a number of mechanisms by which cells adapt to heat shock. These experiments demonstrate that pre-mRNAs synthesized at the severe temperatures in splicing thermotolerant cells, although protected in splicing-competent complexes, are not actually processed to mature mRNAs until the cells are returned to their normal temperature. We have also studied the kinetics of acquisition and loss of splicing thermotolerance. As little as 10 min of pretreatment at 35 degrees C was sufficient to provide full splicing thermotolerance to a 30-min severe heat shock of 38 degrees C. Pretreatments of less than 10 min provide partial splicing thermotolerance for a 30-min severe heat shock. Full splicing thermotolerance activity begins to decay about 4 h after the cessation of the 35 degrees C incubation and is completely lost by 8 h after the pretreatment. The kinetics experiments of pre-mRNAs synthesized during the 38 degrees C treatment in splicing thermotolerant cells indicate that one or more splicing thermotolerance factors are synthesized during the 35 degrees C pretreatment which interact with pre-mRNA-containing complexes to keep them in a splicing-competent state. These kinetic experiments also indicate that in cells which are partially splicing thermotolerant, the pre-mRNAs synthesized early during the 38 degrees C incubation are protected, whereas those synthesized late are not. In the absence of splicing thermotolerant factors, the pre-mRNA-containing complexes leave the normal splicing pathway and are allowed to exit to the cytoplasm.

Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy.

Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12-25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

Clubfoot release without wide subtalar release.

Fifty-two feet treated by clubfoot release without wide subtalar release were evaluated 4.2-10.8 years after surgery. Eleven feet (21%) had undergone additional operative procedures at the time of review, and 82% of feet had good or excellent functional ratings at that time. The mean talocalcaneal index was 49 degrees (range 12-76 degrees), indicating that correction of the subtalar joint occurred in some patients. This procedure satisfactorily corrects many feet but undercorrects some. Overcorrection was rare. Foot progression angles were also determined and are reported in an accompanying article.