Proximal femoral osteotomy in children with cerebral palsy: the perspective of the trainee.

BACKGROUND: There are a range of implants for fixation of proximal femoral osteotomies (PFOs) in children. We investigated the training experiences and preferences of orthopaedic residents and fellows who were learning PFO, using a fixed angled blade plate (ABP) or a locking, cannulated blade plate (LCBP). We also studied short-term technical and radiographic outcomes. METHODS: This was a prospective, parallel-group, cohort study of 90 consecutive children and adolescents with cerebral palsy who underwent bilateral PFOs with ABP or LCBP. Surgical trainees completed a questionnaire to document the ease or difficulty of each operative step. RESULTS: There were 48 boys and 42 girls, with a mean age of eight years and a mean follow-up of 25 months. Trainees preferred the LCBP system for: insertion of the guidewire, the seating chisel and the blade plate, as well as overall technical ease of use (p < 0.001). Radiographic outcomes were similar with no between-group differences for migration percentage (p = 0.996) or neck shaft angle (p = 0.849), but there was a higher prevalence of technical errors in the ABP group. CONCLUSIONS: Trainee surgeons expressed a preference for LCBPs when learning PFO in children with cerebral palsy. Radiographic outcomes were similar in both groups, with close attending surgeon supervision.

The radiological assessment of pelvic obliquity in cerebral palsy and the impact on hip development.

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe's angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

The transverse Vulpius gastrocsoleus recession for equinus gait in children with cerebral palsy.

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

Ibrutinib inhibits collagen-mediated but not ADP-mediated platelet aggregation.

The BTK (Bruton's tyrosine kinase) inhibitor ibrutinib is associated with an increased risk of bleeding. A previous study reported defects in collagen- and adenosine diphosphate (ADP)-dependent platelet responses when ibrutinib was added ex vivo to patient samples. Whereas the collagen defect is expected given the central role of BTK in glycoprotein VI signaling, the ADP defect lacks a mechanistic explanation. In order to determine the real-life consequences of BTK platelet blockade, we performed light transmission aggregometry in 23 patients receiving ibrutinib treatment. All patients had reductions in collagen-mediated platelet aggregation, with a significant association between the degree of inhibition and the occurrence of clinical bleeding or bruising (P=0.044). This collagen defect was reversible on drug cessation. In contrast to the previous ex vivo report, we found no in vivo ADP defects in subjects receiving standard doses of ibrutinib. These results establish platelet light transmission aggregometry as a method for gauging, at least qualitatively, the severity of platelet impairment in patients receiving ibrutinib treatment.

Gastrocsoleus recession techniques: an anatomical and biomechanical study in human cadavers.

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies. We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (sd 2.0, (12 to 19), which increased to 17.1 mm (sd 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (sd 2.0, (18 to 25), which increased to 26.4 mm (sd 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001).

A messenger at the door: cytomegalovirus retinitis in myeloma patients with progressive disease.

Cytomegalovirus (CMV) retinitis is an uncommon manifestation of CMV disease and is a marker of severe and profound immunosuppression in human immunodeficiency virus-positive patients. Here, we describe 2 cases of CMV retinitis in myeloma patients with progressive disease, following autologous stem cell transplantation and immunomodulatory therapy for myeloma. To our knowledge, this is the first report of CMV retinitis in this patient population. This report illustrates the need for close monitoring of relapsed and refractory myeloma patients for new presentations of opportunistic infections secondary to severe immunosuppression.

Clinical characteristics and outcomes of patients with acute lung injury and ARDS.

BACKGROUND: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are critical illnesses associated with significant morbidity and mortality. AIMS: This was designed to assess various etiologies of ALI/ARDS, to determine the correlation between the diagnostic criteria and need of mechanical ventilation, and to correlate biochemical factors with the outcome of patients. SETTINGS AND DESIGN: An observational, prospective study was conducted in a medical intensive care unit (MICU) of a tertiary care hospital, for a period of 1 year. MATERIALS AND METHODS: This study encompassed 58 consecutive cases of ALI/ARDS admitted to a MICU as per AECC guidelines. Patients excluded were with cardiac failure, chronic kidney diseases with fluid overload, and age below 12 years. STATISTICAL ANALYSIS: The data were analysed applying χ2 -test, multivariate logistic regression analysis of significance, using computer-based program SPSS. RESULTS: There were more males (74%) than females, and presentation was more common in the younger age group, with a total mortality of 57%. Factors attributable for ALI/ARDS were malaria in 16 patients (27.6%), leptospirosis in 12 (20.7%), malaria with dengue in 3 (5.2%), undiagnosed fever in 16 (27.6%), pneumonia in 8 (13.8%), urinary tract infection in 2 (3.4%), and pancreatitis in 1 (1.7%) patient. Out of 41 patients with PaO 2 /FiO 2 <200, 40 patients required invasive ventilation, and out of 17 patients with PaO 2 /FiO 2 >200, 11 patients though initially managed on noninvasive ventilation (NIV) subsequently required invasive ventilation, and remaining six were successfully managed on NIV. Out of 41 patients requiring mechanical ventilation, 36 had LIS >2.5, whereas only 3 out of 17 patients with LIS <2.5 required mechanical ventilation. CONCLUSION: Malaria, leptospirosis, and undiagnosed fever were the main etiologies followed by pneumonia, urinary tract infections, and pancreatitis. Both the PaO 2 /FiO 2 ratio and lung injury score (LIS) at the time of admission were significant predictors of the outcome and of necessity of mechanical ventilation. PaO 2 /FiO 2 was a better predictor of duration of stay at the intensive care unit than the LIS. Sepsis, acidosis, hypotension, and multiorgan failure were individual predictors of mortality in patients with ALI/ARDS while age, sex, anemia, thrombocytopenia, renal failure, hepatic failure, and X-ray picture were not predictors of the outcome.

A stakeholder approach towards hospital accreditation in India.

Accreditation has been recommended as a mechanism for assuring the quality of private sector health services in low-income countries, especially where regulatory systems are weak. A survey was conducted in Mumbai, India, in 1997-98 to elicit the views of the principal stakeholders on the introduction of accreditation and what form it should take. There was a high level of support for the classical features: voluntary participation, a standards-based approach to assessing hospital performance, periodic external assessment by health professionals, and the introduction of quality assurance measures to assist hospitals in meeting these standards. Hospital owners, professional bodies and government officials all saw potential - though different - advantages in accreditation: for owners and professionals it could give them a competitive edge in a crowded market, while government officials reckoned it could increase their influence over an unregulated private market. Areas of disagreement emerged; for example, hospital owners were opposed to government or third party payment bodies having a dominant role in running an accreditation system. The growing strength of a health service user representative lobby in Mumbai is an additional reason why this would be a suitable place for piloting such a system. The biggest obstacle to introducing accreditation in poorly resourced settings, such as India, is in how to finance it. The provisional support of the principal stakeholders for such a development, demonstrated in this study, will require a commitment from government and policymakers if the potential benefits of accreditation to the health of the population are to be realised.

Bronchopulmonary infection due to Moraxella (Branhamella) catarrhalis at Qatif Central Hospital.

Moraxella (Branhamella) catarrhalis is now recognized as an important cause of respiratory tract infections. Over a two year period, Moraxella (Branhamella) catarrhalis was isolated in pure culture from 3.4% of the sputums collected from patients with symptoms of acute respiratory tract infections. It was the third most important pathogen isolated after Haemophilus influenzae and Streptococcus pneumoniae; 77% of the patients had an underlying chronic pulmonary condition. Prevalence, antibiotic sensitivity, and treatment options, will be discussed.

Biometeorological triggers in childhood asthma.

The relationship between child asthma admissions and biometeorological factors was investigated over a 16-month period. No relationship was found with many commonly suspected precipitants such as temperature, humidity and wind. There was however a strong association with rainfall (P much less than 0.001). Associations occurred with low barometric pressure and counts of coloured basidiospores and green algae, but no significant relationship was found with grass pollen.

Impact of neonatal intensive care.

Mortality in infants less than 33 weeks' gestation and in those of very low birthweight in Brighton has fallen since 1978. This reduction is not due simply to a decline in the incidence of major congenital abnormalities; evidence indicates that it can be attributed to the introduction of respiratory support.

Seasonal variation and time trends of deaths from asthma in England and Wales 1960-82.

Monthly trends in deaths attributed to asthma in the 5-34 year age group were examined for England and Wales over the period 1960-82. Deaths were most frequent in the third quarter (July to September) and peaked in August. Analysis of the 1970-82 period showed that this variation was present in the three constituent age groups 5-14, 15-24, and 25-34 but was most pronounced in the 5-14 year olds.

Seasonal variation and time trends in childhood asthma in England and Wales 1975-81.

In England and Wales hospital admissions for childhood asthma almost trebled over the period 1975-81. This may have reflected a true increase in the incidence of acute asthma, a swing from primary to hospital care, or both. The trend was not due to a change in diagnostic fashion. Monthly admissions showed a pronounced seasonal variation with fewest admissions in winter, rising in spring and early summer to peak in the autumn. A deep admission trough was present in August. The monthly admission profile was very similar throughout England and Wales, suggesting that major "trigger" factors were responsible.

Visceral leishmaniasis contracted in the Mediterranean area.

Two infants who presented with anaemia and hepatosplenomegaly were found to have visceral leishmaniasis. Diagnosis was made immediately after bone marrow aspiration in one infant, but in the other there was considerable delay. Both responded well to a course of sodium stibogluconate.