Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results.

The current study is a retrospective clinical and radiographic review of all children treated with intramedullary Steinmann pins for fixation of diaphyseal forearm fractures at one institution. Thirty patients were reviewed. Twenty-five patients had fractures of both bones, three had Monteggia fracture-dislocations, and two had isolated radial fractures. Eight fractures were open. The average age of the patients at the time of surgery was 9 years 3 months (range, 4 years 1 month-14 years 3 months). Time to union averaged 6 weeks but a slightly longer healing time was seen in patients older than 10 years of age. Subjective, objective, and radiographic evaluation at 3 years 6 months average followup revealed no significant side to side differences. There were six complications (two pin site infections, two cases of fracture displacement after pin removal, one extensor pollicus longus tendon rupture requiring repair, and one refracture), none of which affected outcome at followup. When combined with an open reduction, one intramedullary Steinmann pin provides adequate stability in most diaphyseal forearm fractures in children with excellent results and few complications.

Matched hemiresection interposition arthroplasty of the distal radioulnar joint.

Since 1986 the senior author has performed a matched hemiresection with retinacular/capsular interposition for patients with painful disorders of the distal radioulnar joint. A retrospective review of 55 wrists was performed by an independent hand surgeon and hand therapist. Forty-nine of 54 wrists in the surviving patients were clinically and radiographically reviewed with an average follow-up interval of 36 months. Subjective assessment included a visual analog rating of pain improvement and satisfaction with treatment. Objective assessment included examination of range of motion, strength, stability, and standardized functional testing with the Jebsen and Minnesota Rate of Manipulation tests. Thirty-five patients reported pain improvement and 41 patients were satisfied. The range of supination and pronation increased from 54 degrees and 67 degrees, respectively, to 72 degrees and 72 degrees. Functional ability as measured by the Jebsen test was similar to the contralateral wrist. Patients had most difficulty turning large objects. The clinical, objective, functional, and x-ray films results correlated poorly with pain improvement and patient satisfaction. Complications included one infection, one reflex sympathetic dystrophy, one neuroma of the dorsal sensory branch of the ulnar nerve, and four cases of ulnar-carpal impaction. Pain relief was the primary determinant of patient satisfaction and should be considered the indication for surgery.

Right atrial mass biopsy guided by transesophageal echocardiography.

A 69-year-old woman was found to have a right atrial mass on transthoracic echocardiogram. Biopsy of the mass was performed using transesophageal echocardiography for visual guidance. Pathologic study revealed an organizing thrombus. This case illustrates the clinical utility of transesophageal echocardiography in the biopsy of right atrial masses.

An in vitro demonstration of oestrogenicity with potential for exploitation as a quantitative assay for oestrogenic potency.

The pre-implantation embryo of the mouse undergoes a histochemically detectable change in the properties of its trophoblastic cell-surface coat in the immediate pre-implantation period. This change is oestrogen-dependent in vivo and can be induced in vitro in a concentration-dependent manner by oestradiol-17 beta. There is evidence that this coat change is of functional importance in the process of implantation, and its demonstration is of potential value as the basis of an in vitro assay of oestrogenicity.

Starr-Edwards aortic prosthesis: a 20-year retrospective study.

Over the years the Starr Edwards prosthesis has demonstrated a high durability and improved survival in patients with severe aortic stenosis or insufficiency. While the ideal valve prosthesis is not yet available, the Starr-Edwards valve in most instances demonstrates an adequate hemodynamic performance, does not degenerate throughout the human life span, is biocompatible, and is inserted reliably without requiring unique technical dexterity. Despite occasional valve-related complications with early models, beneficial effects of valve replacement are clearly seen in patients with a reversible myocardial dysfunction, a lower level New York Heart Association functional class (II to III), and who survive the early postoperative period and the first year. Long-term complications seen with the Starr-Edwards valve are primarily thromboembolism, endocarditis, hemolysis, and anticoagulation related complications. Despite good operative results, the major cause of deaths in these patients remains cardiac.

The anti-implantation action of tamoxifen in mice.

The process of implantation of the blastocyst in utero in the mouse is normally triggered by oestradiol-17 beta. It can, however, be prevented by the drug tamoxifen whose actions in other species are classified as anti-oestrogenic, but which the mouse is held to be a weak oestrogen. Results are presented which support the claim that the anti-implantation action of tamoxifen is dose dependent, oestrogenicity dominating at high doses and anti-oestrogenicity being of major importance at lower doses.

Progression of aortic stenosis.

We assessed progressive stenosis of the aortic valve in 11 adult patients (mean age of 48 years) with aortic stenosis who had undergone two cardiac catheterizations without intervening aortic valve surgery. The mean time between cardiac catheterization was 59 months (range 20 to 133). No patients had mitral valve disease. Two patients had coronary artery disease. The results showed that progressive stenosis of the aortic valve occurred in 10 of 11 patients with a significant decrease in the calculated mean aortic valve area from 1.2 +/- 0.2 sq cm to 0.7 +/- 0.1 sq cm (P less than 0.005); a significant increase in mean left ventricular peak systolic pressure from 149 +/- 8 mm Hg to 199 +/- 3 mm Hg (P less than 0.01), and a significant increase in mean left ventricular aortic pressure gradient from 31 +/- 4 mm Hg to 75 +/- 13 mm Hg (P less than 0.005). On an individual basis, the change in left ventricular pressure and the left ventricular-aortic gradient did not always reflect the decrease in aortic valve area because of variations in cardiac output. The shortest period of time in which progression of aortic stenosis occurred was 27 to 29 months. Thus, progressive stenosis of the aortic valve occurs in adults with isolated aortic valvular stenosis. Significant decrease in the aortic valve area can develop in as short a period as 27 to 29 months.

Sensitivity and specificity of echocardiography in the assessment of valve calcification in mitral stenosis.

Eighty-seven patients (64 females and 23 males) with mitral stenosis were studied by M-mode echocardiography to assess the sensitivity and the specificity of the echocardiographic technique in the identification of valve calcification. The mitral valves were examined at operation, and the amounts of calcium were graded as heavy, light, or absent. We compared this with the amount of calcification assessed by radiographic, previously accepted echocardiographic, and newly derived echocardiographic criteria. In identifying the presence or absence of valve calcification, radiography was the least sensitive (53.7 per cent), but the most specific (90.9 per cent) technique, and has the highest predictive accuracy (90.6 per cent). Previously accepted echocardiographic criteria had the highest sensitivity (92.6 per cent), but the lowest specificity (12.1 per cent), and the lowest predictive accuracy (63.3 per cent). The newly derived echocardiographic parameter MT/ST (ratio between the maximal thickness of the left ventricular margin of the interventricular septum) was both sensitive (75.9 per cent) and specific (81.8 per cent) and also had a predictive accuracy (87.2 per cent) similar to that of radiographic techniques. The MT/ST ratio is demonstrated to be the most useful non-invasive method for assessing valve calcification in mitral stenosis.

Surgical treatment of idiopathic hypertrophic subaortic stenosis (IHSS). Postoperative results in 30 patients following ventricular septal myotomy and myectomy (Morrow procedure).

Since 1971 we have employed the Morrow procedure in 30 patients with idiopathic hypertrophic subaortic stenosis (IHSS). All manifested obstruction to left ventricular outflow either at rest or with provocation (Valsalva) and 17 had moderate or severe mitral regurgitation. There were no operative deaths. Obstruction was abolished in all patients except one in whom a trivial 15-mm pressure gradient persisted, and all patients with moderate or severe mitral regurgitation evidenced marked amelioration of the mitral regurgitation. Distinct symptomatic improvement has been experienced by all patients, and 20 are entirely asymptomatic postoperatively. No patient has experienced syncope postoperatively although 15 experienced syncope before operation. In 12 patients the electrocardiogram recorded postoperatively was essentially unchanged from the preoperative record. In 16 patients a left anterior hemiblock was apparent postoperatively. In one patient a complete left bundle branch block appeared postoperatively and one patient demonstrated Wolff-Parkinson-White syndrome. One patient died suddenly and unexpectedly 2 years following operation. This patient continued to have palpitations after operation although all other symptoms as well as the left ventricular outflow obstruction were abolished by operation. It is suggested that propranalol administration be continued postoperatively in those patients experiencing palpitations or manifesting arrhythmias. Asymmetrical septal hypertrophy dislocates the cardiac apex and papillary muscles anteriosuperiorly producing abnormal systolic anterior mitral leaflet mition. The Morrow procedure restores more normal ventricular geometry and thereby eliminates the pathophysiological mechanism of obstruction and mitral regurgitation. The myotomies and myectomy should be extended far inferior through the entire width of the septum onto the free lateral ventricular wall. The procedure can be accomplished easily and safely through a transaortic approach. Since the operative risk at present appears to be negligible, prosthetic material is not required, and the risk of significant injury to the conduction tissue is small, we feel the current status of surgery for IHSS is such that the Morrow procedure should be performed earlier in the course of patients with IHSS manifesting obstruction or mitral regurgitation.

Abolition of the pre-implantation surge of plasma oestrogens in mice with tamoxifen.

PIP: Tamoxifen is estrogenic in the mouse but can also prevent the estrogen-induced preimplantation surface coat change (PSCC) of the trophoblast in mice. Plasma estrogen concentrations were measured after the administration of tamoxifen on Day 2 of pregnancy. Virgin female mice were mated. Tamoxifen was given orally 40-41 hours after mating (postcoitum; pc) in a dose of 1 mg/kg of body weight. At intervals between 72-108 hours pc blood was obtained by cardiac puncture. Plasma samples of 500 microl were stored frozen until assayed for total estrogens. In an untreated group a short-lived surge of plasma estradiol occurred 84 hours pc. In this control group the mean concentration of estrogens at 82 hours pc differed significantly (p .005) from that at 84 hours. In the tamoxifen-treated group this 84-hour peak did not occur. It is concluded that tamoxifen's apparently antiestrogenic effect in preventing the trophoblasts's PSCC and implantation depends on its ability to abolish the Day 4 endogenous surge.^ieng

Tamoxifen inhibition of an in vitro oestradiol-induced surface coat change on mouse blastocysts.

1. Eighty-nine hour post-coitus mouse blastocysts cultured in the presence of oestradiol-17beta underwent a histochemically detectable surface coat change. 2. Tamoxifen was found to inhibit this in vitro-induced change. The role of Tamoxifen as an inhibitor of implantation is discussed.

Clinical significance of the V wave in the main pulmonary artery.

Among 68 patients with mitral insufficiency who had right and left cardiac catheterization and left ventriculography, 6 had retrograde transmission of the left atrial V wave into the main pulmonary artery. All of these patients had mitral insufficiency of acute onset. The remaining 62 patients had chronic mitral insufficiency that was considered severe in 17. Pulmonary vascular resistance was lower in the group with acute insufficiency (mean 139 dynes sec cm-5) than in the group with chronic severe insufficiency (mean 631 dynes cm-5) (P less than 0.005). Nondistensibility of the left atrium and low pulmonary vascular resistance were the two factors favoring retrograde transmission of V waves. Because both factors are present in acute mitral regurgitation, this finding is helpful in differentiating patients with acute mitral insufficiency.

The effect of tamoxifen on the in vitro production of prostaglandins F by the guinea pig uterine tissue.

Tamoxifen, a drug widely known as an antioestrogen is shown to depress the in vitro yield of PGF from pro-oestrus guinea pig uterine homogenates. The possibility that this is a novel antioestrogenic effect of tamoxifen is discussed.