Open reduction internal fixation after displacement of a previously nondisplaced acromial fracture in a multiply injured patient: case report and review of literature.

SUMMARY: A twenty-eight-year-old multiple trauma patient had a nondisplaced acromion fracture that was not detected until after it had displaced. Open reduction internal fixation was performed without complication and the patient achieved excellent shoulder abduction strength. Nondisplaced acromion fractures may displace if not protected. Open reduction internal fixation of displaced acromion fractures should be considered if deltoid muscle strength is important to the patient.

Supracondylar humerus fractures in children. Comparison of operative treatment methods.

A retrospective analysis was performed of 87 children treated operatively for supracondylar humerus fractures by 18 different surgeons during a 6-year period. No patient suffered from compartment syndrome or Volkmann's ischemic contracture. Early postoperative fracture displacement occurred in four (7%) of 60 patients with Type III fractures, and in one (4%) of 23 patients with Type II fractures. Displacement occurred in one (2%) of 52 Type III fractures stabilized with crossed medial and lateral Kirschner wires, whereas displacement occurred in two (28%) of seven Type III fractures stabilized with lateral wires only. Thirty-four patients could be located for long-term followup; complete examination of both upper extremities was performed on these 34 patients at an average of 33 months postoperatively. The long-term results were excellent in 19 (56%), good in seven (21%), fair in one (3%), and poor in seven (21%) patients. Five additional patients were not available for followup at the time of the current study, but had followup of at least 6 months available. Of the 39 patients with followup of at least 6 months, five patients' fractures (13%) healed with coronal plane malalignment greater than 10 degrees which resulted in gunstock deformity. There was no statistically significant relationship between treatment method and gunstock deformity. However, none of the patients with gunstock deformity had compromised activity because of the deformity, and all had full elbow extension and at least 130 degrees elbow flexion.

Pediatric applications of pinhole magnification imaging.

Pinhole magnification imaging is an important technique for practitioners of pediatric nuclear medicine. This article reviews basic principles of pinhole magnification imaging and ways for optimizing image acquisition with this technique. Applications to skeletal scintigraphy, scrotal scintigraphy and renal cortical scintigraphy are discussed and illustrated.

Pediatric skeletal scintigraphy: applications of pinhole magnification.

Pinhole magnification scintigraphy is an effective means of evaluating the pediatric skeleton because it provides optimal high-resolution images. This technique is indicated when diagnostic uncertainty persists after high-resolution imaging with parallel hole collimation. Pinhole magnification scintigraphy requires approximately 20 minutes of acquisition time per image and meticulous attention to details such as choice of pinhole insert, collimator positioning, and patient immobilization. However, the technique is superior to planar imaging in demonstrating acute osteomyelitis in bone adjacent to growth centers and epiphyseal involvement that is either primary or the result of local spread of infection. In addition, pinhole imaging has proved highly reliable in the early diagnosis of Legg-Calvé-Perthes disease and is useful in depicting osteonecrosis related to specific causes such as corticosteroid treatment or trauma. Scintigraphic manifestations of femoral head ischemia or infarction and findings indicative of osteomyelitis associated with a hip effusion are well demonstrated with pinhole imaging. This technique also helps characterize osteoid osteomas and may be used intraoperatively to confirm the complete excision of this benign tumor. Finally, pinhole magnification scintigraphy clearly depicts fractures of the femoral neck and allows a high degree of confidence in diagnosing injuries to the small bones of the hands and feet.

A prospective comparison of high-resolution planar, pinhole, and triple-detector SPECT for the detection of renal cortical defects.

To compare the detection rate of renal cortical defects with Tc-99m dimercaptosuccinic acid (DMSA) using triple-detector SPECT, pinhole, and planar cortical scintigraphy, the authors prospectively studied 80 kidneys in 40 patients (26 males, 14 females) who ranged in age from 3 months to 26 years (mean: 7.5 years). They found single or multiple definite defects in 30 kidneys using SPECT, 23 using pinhole imaging, and 17 using planar imaging (McNemar's test, two-tailed, P < 0.001 and P = 0.03, respectively). SPECT was significantly better than pinhole imaging at demonstrating definite defects (P = 0.008). This study indicates that SPECT, and to a lesser extent pinhole, are superior to planar imaging for conclusively demonstrating renal cortical defects.

Ictal and interictal technetium-99m-bicisate brain SPECT in children with refractory epilepsy.

UNLABELLED: Identification of epileptogenic foci in patients with refractory epilepsy remains a significant diagnostic challenge. Magnetic resonance imaging studies frequently fail to reveal an anatomic origin for the seizures, and scalp electroencephalography is often limited to identification of the involved hemisphere. Functional imaging modalities such as PET and SPECT are more promising tools for this application because they reflect the functional pathology associated with the seizure. These changes are more pronounced ictally, but until recently, no radiopharmaceutical was available that could be used routinely for ictal SPECT. The present study was therefore undertaken to determine whether 99mTc-bicisate could be used in ictal SPECT in pediatric patients with refractory epilepsy, to compare the patterns of ictal and interictal blood flow in these patients and to compare the localization information provided by ictal SPECT with that available from other techniques. METHODS: Technetium-99m-bicisate/SPECT was compared prospectively with scalp EEG for its ability to identify a possible seizure focus in pediatric patients with refractory epilepsy. Ictal and interictal SPECT studies were performed in 10 patients (3-19 yr old, mean age 10.9 +/- 4.3 yr; 7 female, 3 male) in whom MRI scans revealed no lesions that might be responsible for the seizures. RESULTS: Ictal SPECT was performed in all patients, and all ictal studies revealed focal perfusion abnormalities. By comparison, four of the interictal SPECT studies showed regional hypoperfusion that corresponded to the regions of hyperperfusion in the ictal studies, and three showed regional hyperperfusion corresponding to the hyperperfused regions in the ictal studies. Three interictal studies revealed no abnormal perfusion. Scalp EEG provided localization information in five patients. CONCLUSION: These initial results suggest that ictal SPECT with 99mTc-bicisate is a more promising tool for the identification of epileptogenic foci than interictal SPECT or scalp EEG in patients without focal abnormalities on MRI.

Renal dysplasia in infants: appearance on 99mTc DMSA scintigraphy.

Infantile renal dysplasias, including multicystic dysplastic kidneys (MCDK), are reported rarely to accumulate radiopharmaceuticals on renal scintigraphy. 99mTc DMSA is a highly sensitive tracer for detecting functioning renal cortical tissue and may be more suited to studying renal dysplasia than 99mTc DTPA. We reviewed the ultrasound studies and 99mTc DMSA scintigrams of 42 infants (age range 1-12 months) with known or suspected MCDK. Overall, uptake on 99mTc DMSA scintigraphy was evident in 6/41 (15%) dysplastic kidneys. Of the 18 patients who underwent nephrectomy, histopathological examination revealed that uptake correlated closely with the presence of mature renal cortical tissue in the affected kidney. Our study shows that a small, but significant number of MCDK will show low-grade uptake on DMSA scintigraphy. This finding may be relevant given the reliance placed on renal scintigraphy in planning treatment for infants with suspected MCDK, particularly with the increasing trend for the non-operative management of this condition.

Big fish in a small pond: advantages and disadvantages of a first-mover strategy.

The case of a free-standing psychiatric hospital moving into a small rural market as the sole provider of hospital-based psychiatric services is examined as an example of a first-mover strategy. The theoretical bases for a first mover advantage are considered together with an analysis of the situational factors necessary to the strategy's success. The case study illustrates some of the potential consequences of success, namely the attraction of a new competitor with a broader scope of services. The case also illustrates other lessons for market niche competitors in enhancing their likelihood of survival and success in their selected market.

Weighting criteria in the diagnosis of a personality disorder: a demonstration.

This study focused on how clinicians combine symptom information about narcissistic personality disorder (NPD) to make a diagnosis. A sample of 59 psychiatrists and clinical psychologists were asked to read and diagnose 20 case histories of which 6 cases had criteria for NPD embedded as sentences. The number of criteria and the face validity of the criteria were varied across case histories. Three models of how criteria might be combined to form a diagnosis were compared: the polythetic model, the additive model, and the weighting model. The results were most consistent with the weighting model.

Variations on the family resemblance hypothesis as applied to personality disorders.

Diagnosis and classification of the personality disorders is controversial and problematic. Diagnostic reliability is uneven because of overlapping of traits and the lack of clear boundaries between categories. This study demonstrates that personality disorder diagnosis is dependent on the total number of defining features. Clinicians tend to ignore the presence of conflicting features when making a diagnosis. A new research instrument, artificially created case histories that allow the specific manipulation of defining features (i.e., diagnostic criteria), is described.

Normal hepatic and splenic size in children: scintigraphic determination.

Measurements were made on sulfur colloid scintigrams of normal pediatric livers and spleens by analyzing 131 scans from 116 patients referred for liver or spleen trauma. Studies were used only if scans were normal, there was no history of malignancy or hepatic or splenic disease either prior to of after the study. Linear correlation was made with age, weight and both age and weight. All measured parameters correlated better with weight than with age, with vertical liver dimension exhibiting the best correlation (r = 0.848). Multivariate analysis demonstrated uniformly better correlation of all measurements with both age and weight. Spleen and liver volumes were calculated assuming simple geometry, and showed excellent correlations. Graphical presentation of data will be useful in the clinical determination of hepatomegaly or splenomegaly in routine scintigraphy.

Vesicoureteral reflux in asymptomatic siblings of patients with known reflux: radionuclide cystography.

The familial nature of vesicoureteral reflux among siblings of patients with vesicoureteral reflux has been reported to be from 8% to 32%. These included both symptomatic and asymptomatic siblings. The incidence of vesicoureteral reflux in asymptomatic siblings, however, has not been studied extensively. Sixty asymptomatic siblings of patients known to have vesicoureteral reflux were studied with radionuclide voiding cystography. Their ages ranged from 2 months to 15 years (mean, 4.2 years). Vesicoureteral reflux was detected in 27 of 60 (45%) of the siblings. Vesicoureteral reflux was unilateral in 15 and bilateral in 12 of the siblings. Radionuclide cystography is more sensitive than radiographic cystography and results in a very low radiation dose to the patient. The gonadal dose with radionuclide cystography is only 1.0 to 2.0 mrads. Because of these features, radionuclide cystography is a nearly ideal technique for the diagnosis of vesicoureteral reflux in siblings of patients with known vesicoureteral reflux. All siblings (symptomatic or asymptomatic) of patients with known vesicoureteral reflux should have a screening radionuclide cystography.

Comparison of ultrashort-lived iridium-191m with technetium-99m for first pass radionuclide angiocardiographic evaluation of right and left ventricular function in adults.

Ultrashort-lived iridium-191m (Ir-191m, physical half-life = 5.0 seconds) has been used in angiocardiography, primarily in pediatric patients. A theoretical obstacle to more widespread use of Ir-191m is the belief that its physical half-life is too short to permit evaluation of left ventricular function in adult patients. To evaluate its usefulness in adults, first pass ejection fractions of the left and right ventricles determined with use of Ir-191m and technetium-99m (Tc-99m) were compared in 33 adult patients. An osmium-191m----iridium-191m (Os-191----Ir-191m) generator was employed to deliver doses of 150 to 250 mCi (5.5 to 9.2 GBq) of Ir-191m for intravenous injection. The whole body radiation absorbed dose with Ir-191m was 15 to 25 mrad. High quality angiocardiograms were obtained with both Tc-99m and Ir-191m. Total counts per image for the right ventricle were 51,000 +/- 8,000 (mean +/- SD) for Ir-191m and 30,000 +/- 8,000 for Tc-99m. The left ventricular counts were comparable for both radiotracers (25,000 +/- 7,000 for Ir-191m and 25,000 +/- 8,000 for Tc-99m). Right ventricular ejection fractions were similar: 44 +/- 8% for Ir-191m and 47 +/- 9% for Tc-99m. The correlation coefficient was 0.93 with a standard deviation of the regression of 3.1% ejection fraction units. The left ventricular ejection fractions were also similar: 45 +/- 14% for Ir-191m and 46 +/- 13% for Tc-99m. The left ventricular ejection fraction correlation coefficient was 0.96 with a standard deviation of the regression of 3.7%.(ABSTRACT TRUNCATED AT 250 WORDS)

Demonstration of presbycusis across repeated measures in a nonhuman primate species.

The progress of age-related hearing loss in three 31-yr-old, two 24-yr-old, and two 9-yr-old rhesus monkeys (Macaca mulatta) was repeatedly examined over a period of 3 yr. Pure-tone audiograms for seven frequencies, .125, .500, 2.000, 4.000, 16.000, 22.667, and 32.000 kHz, were obtained through the use of the psychophysical tracking method. Analysis indicated the presence of presbycusis in the older animals. Animals demonstrating presbycusis showed a progressive decrement in the ability to detect higher frequencies and an overall hearing loss at all frequencies.