Functional contribution of T1 to the brachial plexus in infants.

To determine the contribution of the T1 root to movements of the upper limb in infancy, 40 infants presenting with obstetrical brachial plexus palsy who underwent resection and reconstruction of all brachial plexus roots with the exception of the T1 root were assessed in the early postoperative period. The movements of the limb were recorded using the Hospital for Sick Children active movement scale and demonstrated considerable variability. All movements of the upper limb were observed in this group with the exception of external rotation of the shoulder and elbow flexion. Classical accounts of the function of T1 have limited its activity to the small muscles of the hand and were based on anatomical dissection, brachial plexus injuries and electrical stimulation. By contrast, this study isolated the physiological activity of T1 and analysed the functional contribution of this root to arm movement. We show a greater than generally recognized contribution of T1 to the function of the upper limb in infants.

Conversion tables for the Corah and Modified Dental Anxiety Scales.

UNLABELLED: Dental anxiety assessment can be achieved by using brief multi-item scales. Corah's Dental Anxiety Scale has been used extensively since the 1970s. However the scale has some flaws which led to the design of the Modified Dental Anxiety Scale incorporating some minor but important improvements. To enable comparison between studies who have adopted one but not both scales a conversion algorithm was required. OBJECTIVE: To produce regression equations and tables to enable researchers to convert derived scores from one scale to another. BASIC RESEARCH DESIGN: Cross-sectional survey. CLINICAL SETTING: 18 dental practices in Northern Ireland. PARTICIPANTS: Patients (n = 1,028) were invited to participate. MAIN OUTCOME MEASURES: Corah and Modified Dental Anxiety Scales. RESULTS: Twenty four patients refused (response rate 98%) providing 1,004 patients for analysis. Mean scores for both scales were close to those reported elsewhere. The correlation between the two scales was high (r = 0.89). Regression equation and summary tables presented for conversion purposes. CONCLUSIONS: More accurate estimates of scale scores can be derived with this procedure than simple prorating.

Does completing a dental anxiety questionnaire increase anxiety? A randomised controlled trial with adults in general dental practice.

UNLABELLED: The assessment of dental anxiety can be achieved by using brief multi-item scales. OBJECTIVE: To test the null hypothesis that completing the Modified Dental Anxiety Scale had no immediate influence on patient state anxiety. OUTCOME MEASURE: Speilberger State Anxiety Inventory-6 item Short Form. STUDY DESIGN: Randomised controlled trial. PARTICIPANTS: Patients (n = 1,028) attending 18 dental practices in Northern Ireland were invited to participate. RESULTS: Twenty-four patients refused (response rate 98%) providing 1,004 patients (mean age = 41 years, range = 16 to 90 years; 65% female) for analysis. Patients who completed the dental anxiety scale were found to have a virtually identical state anxiety score: mean (SD) = 11.36 (4.33) compared to those who completed the state anxiety assessment only: mean (SD) = 11.01 (4.35). The mean (CI95%) difference was 0.35 (0.89 to -0.18), t = 1.29, df1002, p = 0.2. CONCLUSION: The completion of a brief dental anxiety questionnaire before seeing the dentist has a non significant effect on state anxiety.

Risk perception of oral cancer in smokers attending primary care: a randomised controlled trial.

To encourage the public to attend and accept oral cancer screening, further understanding is required of the ability of structured information to alter patient knowledge and risk perceptions. Previous work has shown the benefit of written information for those at high risk of oral cancer, especially for tobacco smokers. This study investigated three hypotheses: first that a patient information leaflet (PIL) would enhance risk perceptions, and second that the effect of the leaflet on knowledge would be confirmed as in previous studies and third that these improvements would be associated with smoking behaviour. Patients (N = 995) attending 20 general dental practices in Northern Ireland were invited to participate, 28 refused (response rate = 97%). Patients were randomised into two groups. The experimental group received a PIL and then completed a self-report questionnaire, whereas the control group followed same procedure without the PIL. Measures included a 36 item oral cancer knowledge scale and two items to assess risk perception. Usable data were available from 944 patients; mean (SD) age = 42 (15), 65% female. Risk perceptions of oral cancer were minimally effected by the PIL (p = 0.023). This effect was demonstrable in smokers. Smokers were sixteen (95% CI: 8-30) times more likely to believe that they were at greater risk of oral cancer than non-smokers. A clear benefit of the PIL on patients' oral cancer knowledge was found, particularly for smokers and those with a history of smoking. These findings demonstrate that public awareness of smokers can be raised with written information although health beliefs such as risk perceptions require more intensive intervention.

The role of the brachioradialis H reflex in the management and prognosis of obstetrical brachial plexus palsy.

The H reflex was investigated to determine if it can be useful in the prognosis of obstetrical brachial plexus palsies. The H reflex is an electrically stimulated monosynaptic or oligosynaptic response which can be recorded in peripheral nerves in all muscles of infants up to approximately two years of age. It is essentially the electrophysiologic counterpart of the deep tendon reflex, and its presence indicates intact afferent and efferent axons at the particular spinal segment. Our objectives were to document the Brachioradialis H (Br H) reflex latency and amplitude in normal upper extremities of infants, to evaluate the presence or absence of the Br H reflex in obstetrical palsy neonates and infants between one and seven months of age and to determine if this test was a valid predictor of final clinical outcome. A prospective study of 109 patients was performed to measure the Br H reflex in the affected and the contralateral normal limb. The results from the abnormal limb were compared to the final clinical decision made by nine months for or against surgical intervention. In the normal limbs, a Br H latency of 10.7 +/- 0.8 msec was determined with an amplitude of 1.2 +/- 1.2 mV. The chi 2 analysis in infants from one month to seven months old revealed a strong relationship between an absent Br H reflex and little or no clinical improvement (p < 0.0001), with a sensitivity for predicting poor outcome of 85.7%. The odds ratio (with a 95% confidence interval) of a child with an absent Br H reflex not significantly improving by nine months was 8.4 times higher than if the Br H reflex was present. The false positive rate was 42% however, indicating that a significant number of patients improved clinically, despite having a nonrecordable Br H reflex at age seven months or less. The low false negative rate of 14.3% suggested that in the presence of a Br H reflex, the majority of patients recover. Therefore, the presence of the Br H reflex is a helpful test in the prognostication of good recovery in obstetrical upper plexus palsy patients.

Safety and pharmacokinetics of EMLA in the treatment of postburn pruritus in pediatric patients: a pilot study.

The purpose of this study was to determine the safety and pharmacokinetics of a eutectic mixture of local anesthetics (EMLA) used to ameliorate postburn pruritus after application onto newly formed, intact skin in children. EMLA was applied once to an itchy site where healed skin had formed. Serial blood samples were collected to measure lidocaine, prilocaine, o-toluidine, and methemoglobin. Maximal plasma concentration, minimal plasma concentration, time to achieve the maximal plasma concentration, elimination half-life, and area under the concentration-time curve were calculated. Vital signs, oxygen saturation, clinical signs of hypoxia, and itch intensity were measured. Five children had 15.7 +/- 2.54 g (+/- SD) of EMLA applied to a skin surface area of 93.0 +/- 37.0 cm2. Lidocaine and prilocaine concentrations were below toxic levels; o-toluidine was not detected. Methemoglobin remained between 1 and 3%; patients did not exhibit any clinical signs of hypoxia. Mean oxygen saturation was 98.9 +/- 0.01%. The mean number of pruritic episodes and antihistamine breakthrough doses were greater in the 2 prestudy control days compared with study day 3 (P = 0.01 and P = 0.03, respectively). Skin at the site of EMLA application remained anesthetized for 12 to 13 hours. In this small pilot study, EMLA seems to be a safe, novel treatment for postburn pruritus in burned children when applied to newly healed, intact skin.

Aerosolization of epidermal cells with fibrin glue for the epithelialization of porcine wounds with unfavorable topography.

Aerosolized epidermal cell suspension was previously found to be effective for the epithelialization of full-thickness wounds. This suspension is less expensive than and requires a shorter preparation time than the currently used cultured epithelial autografts. Still, convex and irregular wounds present unfavorable conditions for homogenous dispersion of the aerosolized cell suspension. The authors hypothesized that the addition of fibrin glue to the aerosol of cells would reduce cell movement and ensure homogenous dispersion of the cells, thereby promoting wound epithelialization. The objectives of the study were to evaluate the healing of wounds with unfavorable topography after autotransplantation of an epidermal cell aerosol with and without fibrin glue. Six Yorkshire piglets were studied. An epidermal suspension was made from full-thickness groin skin. Dispase was used to separate the epidermis from the dermis, and trypsin was used to separate the epidermal cells from one another. Twenty-four hours later, full-thickness wounds with unfavorable topography were created adjacent to the vertebral column of six pigs. Twelve wounds were treated with an aerosol of epidermal cell suspension mixed with fibrin glue (study group), and 12 wounds were treated with the same suspension without the fibrin glue (control group). The percentages of total wound contraction and the epithelialized and nonepithelialized areas were evaluated 1, 2, 3, and 4 weeks after aerosolization. The histologic characteristics of the newly formed skin were examined by light microscopy using slides stained with hematoxylin and eosin. Study wounds were characterized by central epithelialization, whereas control wounds were characterized by peripheral epithelialization. Study wounds contracted at a slower rate than control wounds, but wound size was the same in both groups after 4 weeks. The addition of fibrin glue facilitated epithelialization: Study wounds showed 75.5 +/- 22.4 percent (mean +/- SD) and 94.2 +/- 8.8 percent epithelialization after 3 and 4 weeks, respectively, compared with 46.3 +/- 9.5 percent and 47.9 +/- 13.1 percent epithelialization of the control wounds at the same times. These differences between the study and control groups were statistically significant (p < 0.001, paired t test). The addition of fibrin glue to an aerosol of epidermal cells significantly enhances the epithelialization of wounds with unfavorable topography in pigs.

Rheumatic disorders of the hand and wrist in childhood and adolescence.

Rheumatic diseases are common in the pediatric population. Because the hand surgeon is often the first specialist to whom children with rheumatic disease involving the upper extremity are referred, it is important they are aware of the wide variety of disorders that can present with joint complaints to facilitate prompt referral and treatment of these patients.

The prognostic value of concurrent Horner's syndrome in total obstetric brachial plexus injury.

The prognostic value of concurrent Horner's syndrome in infants with total birth palsy was investigated. The records of 48 cases with total palsy were reviewed. Poor spontaneous return of the motor function of the limb was found for both with and without concurrent Horner's syndrome. Fisher's exact test (P=0.02) indicated that the presence of concurrent Horner's syndrome is a significant prognostic factor for poor spontaneous recovery of the limb.

Predictive value of computed tomographic myelography in obstetrical brachial plexus palsy.

Preoperative radiologic studies to detect root avulsions of the brachial plexus caused by birth trauma are considered useful in assisting with surgical planning for reconstruction. In this study, the predictive value of computed tomographic (CT) myelography in detecting nerve root avulsions at our institution was determined. Sixty-three consecutive patients with an obstetrical brachial plexus palsy who had had both preoperative CT myelography and reconstructive surgery were selected. All CT myelograms were analyzed post hoc by a single neuroradiologist in a manner blind to the surgical findings. At each root level of the brachial plexus, the presence of a pseudomeningocele was noted along with the presence or absence of rootlets within each identified pseudomeningocele. Extraforaminal root avulsions later determined at surgery were reviewed by a single surgeon in a manner blind to the radiographic results. Surgical and radiographic findings were then compared at each corresponding root level. A total of 281 roots were examined. The sensitivity, specificity, positive predictive value, and likelihood ratio for root avulsions with pseudomeningoceles were 0.63, 0.85, 0.40, and 4.2, respectively. For pseudomeningoceles for which rootlets traversing the sac could not be identified, these values were 0.37, 0.98, 0.74, and 18.5, respectively. The presence of pseudomeningoceles with or without rootlets was not a sensitive indicator of root avulsions. Root avulsions were better predicted by identifying the absence of rootlets in a pseudomeningocele. This absence on CT myelography may be used to suggest an extraforaminal root avulsion due to its high specificity and high likelihood ratio.

Increased tight junction permeability can result from protein kinase C activation/translocation and act as a tumor promotional event in epithelial cancers.

Exposure of LLC-PK1 epithelial cell cultures to phorbol ester tumor promoters causes immediate translocation of protein kinase C-alpha (PKC-alpha) from cytosolic to membrane-associated compartments. With a very similar time course, a dramatic and sustained increase in tight junctional (paracellular) permeability occurs. This increased permeability extends not only to salts and sugars but macromolecules as well. Fortyfold increases of transepithelial fluxes of biologically active EGF and insulin occur. Recovery of tight junction barrier function coincides with proteasomal downregulation of PKC-alpha. The failure to downregulate activated membrane-associated PKC-alpha has correlated with the appearance of multilayered cell growth and persistent leakiness of tight junctions. Accelerated downregulation of PKC-alpha results in only a partial and transient increase in tight junction permeability. Transfection of a dominant/negative PKC-alpha results in a slower increase in tight junction permeability in response to phorbol esters. In a separate study using rat colon, dimethylhydrazine (DMH)-induced colon carcinogenesis has been preceded by linear increases in both the number of aberrant crypts and transepithelial permeability, as a function of weeks of DMH treatment. Adenocarcinomas of both rat and human colon have been found to have uniformly leaky tight junctions. Whereas most human colon hyperplastic and adenomatous polyps contain nonleaky tight junctions, adenomatous polyps with dysplastic changes did possess leaky tight junctions. Our overall hypothesis is that tight junctional leakiness is a late event in epithelial carcinogenesis but will allow for growth factors in luminal fluid compartments to enter the intercellular and interstitial fluid spaces for the first time, binding to receptors that are located on only the basal-lateral cell surface, and causing changes in epithelial cell kinetics. Tight junctional leakiness is therefore a promotional event that would be unique to epithelial cancers.

Straightening of aberrant carotid arteries with age in velocardiofacial syndrome.

Two cases of velocardiofacial syndrome demonstrated spontaneous straightening over a 4-year period of previously deviated carotid arteries on contrast enhanced computed tomography. Based on this finding, uncomplicated traditional pharyngeal flaps were performed on both patients. It is unknown whether straightening of aberrant vessels with age is the rule or the exception in this patient population.

Neuroma-in-continuity resection: early outcome in obstetrical brachial plexus palsy.

The short-term effect of neuroma-in-continuity resection in obstetrical brachial plexus palsy was evaluated to test the hypothesis that the neuroma does not contribute to useful limb function. Twenty-six patients with obstetrical brachial plexus palsy underwent resection of the neuroma-in-continuity and interpositional nerve grafting, and 17 patients underwent neurolysis only. The preoperative and postoperative active movement scores were recorded using an eight-point scale for 15 joint motions in each patient. Data analysis examined the change in total limb motion scores over time within patients undergoing neuroma-in-continuity resection and a comparison with those patients undergoing neurolysis. Compared with preoperative assessment, limb motion scores after neuroma resection were significantly decreased at 6 weeks, not significantly different by 3 months, and significantly improved at 12 months postoperatively. In comparison to patients undergoing neurolysis only, limb motion scores after neuroma resection were not significantly different at 3, 6, and 12 months postoperatively. These findings are unlikely to be accounted for by axonal regeneration across interpositional nerve grafts. Nerve regeneration or recovery in the nongrafted segment of the plexus must be sufficient to reproduce preoperative motion. Resection of the neuromas-in-continuity in obstetrical brachial plexus palsy does not significantly diminish motor activity.

Autotransplantation of epithelial cells in the pig via an aerosol vehicle.

A new method of delivery of epithelial suspensions with use of an aerosolization apparatus was examined in the pig. Full-thickness pig skin was harvested, and an epithelial suspension was created using standard techniques of dispase and trypsin. Twenty-four hours after skin harvest, four full-thickness wounds were created on the flanks of the pig. The control wound was sprayed with a solution without epithelial cells. The three experimental wounds were sprayed with epithelial cell suspensions (integral 10(6) cells/suspension). Weekly evaluation with photographs, biopsies, and tracings were done for 4 weeks. At 10 weeks, the entire process was repeated with new wounds on the pig's back. Thirty-five wounds in five pigs were evaluated: 10 control (5 flank, 5 back) and 25 experimental (15 flank, 10 back). Control wounds healed by contraction alone, with epithelium at the edges only. After 4 weeks, an open area remained. Central epithelial islands developed in experimental wounds at 2 weeks. These islands coalesced to close the wounds by 4 weeks. Histology at 1 week showed groups of epithelial cells deeply embedded in granulation tissue. These groups became immature epithelial layers on the surface by 2 weeks, and all layers of epithelium were present by 4 weeks. Overall, flank experimental wounds epithelialized sooner, but contracted at the same rate as control wounds. In conclusion, epithelial cells can be delivered by an aerosolization apparatus and remain viable and proliferative in a pig model.

The prognostic value of concurrent phrenic nerve palsy in newborn children with Erb's palsy.

The prognostic value of concurrent phrenic nerve palsy in newborn babies with Erb's palsy was investigated. The records of 191 babies with Erb's palsy were reviewed retrospectively at two institutions. Poor spontaneous return of the motor function of the limb was found for infants both with and without concurrent phrenic nerve palsy. Concurrent phrenic nerve palsy in newborn babies with Erb's palsy has no prognostic value in predicting spontaneous motor recovery of the limb.

Ring avulsion injuries and the basketball player.

As basketball increases in worldwide popularity, more epidemiological data on injury rate and type will be documented. A serious ring avulsion injury (Urbaniuk Class I) is here reported in an adolescent incurred while attempting a slam dunk. The management of this injury is discussed as well as safety concerns for coaches and supervisory staff.

Case report: unilateral combined facial nerve and brachial plexus palsies in a neonate following a midlevel forceps delivery.

A case is described in which the 2.7-kg fetus of a nonobese primigravid patient, delivered by midlevel forceps manipulation sustained neurapraxias of both the marginal mandibular branch of the seventh cranial nerve and the upper trunks of the ipsilateral brachial plexus. The pregnancy was uneventful, but labor was complicated by an occipitoposterior presentation and a prolonged second stage. Examination of the neonate revealed bruising and skin markings consistent with injury by obstetric forceps and the anatomic location of these marks suggested that cervical and mandibular compression from the forceps, rather than traction by the accoucheur, would account for the observed findings. A review of the English language literature over the past 30 years revealed only four cases in which a combination of facial nerve and brachial plexus injuries could both be linked to obstetric instrumentation.