Women's health measures in two North Carolina regions sampled from the Basic Automated Birth Yearbook (BABY) datasets: experimental findings, methodological limits and future directions.

PURPOSE: To compare selected characteristics in two North Carolina counties to document women's health services at the geographical extremes of the state. METHODS: Using aggregated 2004 data obtained from the North Carolina State Center for Health Statistics, obstetric and perinatal characteristics were experimentally analyzed for the westernmost and easternmost counties in North Carolina (Cherokee and Dare County, respectively). FINDINGS: During the experiment period, 489 infants were delivered in Dare County (population 33,518), while 259 births were recorded in Cherokee County (population 25,289). Prenatal care was established by most women in both counties by the second gestational month. Women in Cherokee County were younger and less educated at delivery than women in Dare County, and smoking prevalence was higher in Cherokee County than in Dare County (31.3% vs 12.9%; p <0.01). Cherokee County infants required assisted ventilation and other medical interventions more often than babies born in Dare County (p <0.01) yet significantly fewer cesarean deliveries were performed in Cherokee County than Dare County (25.5% vs 35.2%; p = 0.04). CONCLUSION: This pilot study showed a significantly higher rate of tobacco use, and lower maternal education level in Cherokee County was associated with a higher incidence of multiple maternal complications and neonatal interventions compared to Dare County. Interestingly, the cesarean delivery rate was lower in Cherokee County despite these factors. We found < 10% of babies born in the study regions required any neonatal intervention. Early and almost universal access to prenatal care did not appear to be a problem at either site. Our preliminary comparison identified important limitations in this government-sponsored dataset that rendered logistic regression analysis methodologically impossible. Changes in process could improve surveillance based on patient-level data and facilitate multivariate analysis. Specific interventions to optimize women's health services form the basis of future experimental research, including larger regional populations.

Dynamics of indigenous and inoculated yeast populations and their effect on the sensory character of Riesling and Chardonnay wines.

To study the impact of yeast populations on wine flavour and to better understand yeast growth dynamics, wines were produced by the (i) indigenous microflora, (ii) vigorous yeast starter EC1118 and (iii) slowly fermenting yeast Assmannshausen. Sensory analysis revealed that wines differed depending on the fermentation type. However, these yeast-related differences did not exceed the varietal character. Both added starter cultures clearly dominated the Saccharomyces population from the middle of fermentation onwards. The starter cultures differed in their repression of indigenous non-Saccharomyces yeast. EC1118 limited growth of non-Saccharomyces yeasts more strongly than Assmannshausen. Sulphite addition further repressed growth of non-Saccharomyces yeasts. On completion, more than one Saccharomyces strain was present in each fermentation, with the largest variety in the non-inoculated and the smallest in the EC1118-inoculated fermentation. Results from the two genetic assays, karyotyping, and PCR using delta-primers were not fully equivalent, limiting the usefulness of delta-PCR in studies of native Saccharomyces yeasts.

Home care business opportunities in Europe.

The demand for home care services will continue to grow exponentially around the world. This demand is being driven by demographics, technology, and personal choice. Providers of home care have a great deal to teach and learn from each other. The opportunities for collaboration and joint ventures are great now and will continue to increase with the passing of time. This article has been extracted from a 1996 panel discussion at the International Home Care Forum held in Nashville, Tennessee.

Cuneiform osteotomy of the femoral neck in severe slipped capital femoral epiphysis.

From 1978 through 1988, 27 severe slipped epiphyses (Grade III) in 23 adolescent patients were treated with a cuneiform osteotomy of the proximal neck of the femur. Average time of followup was 8 years 5 months. The results were graded by the criteria of Southwick, with emphasis on pain, function, range of motion, and radiographic appearance. Arbitrarily, no hips were rated excellent, because the authors thought that this rating should be reserved for normal hips that have not had any disease process nor surgical procedure. There were 19 good, 4 fair, and 4 poor results. The 4 poor results were in patients with avascular necrosis. The avascular necrosis rate was 15%. Eight hips had some joint space narrowing during the postoperative followup period. All joint space narrowing was resolved by 20 months postoperatively. All patients, including those with avascular necrosis, improved in joint flexion and joint internal rotation. Although the avascular necrosis rate of 15% is significant, the authors believe that the potential for restoring hip anatomy and providing a normally functioning hip in the adolescent patient makes this procedure a viable treatment option.

Developmental dysplasia of the hip.

OBJECTIVE: The definition and early treatment of congenital dysplasia of the hip are controversial. The purpose of this study was to discuss the reasons for changing the acronym to developmental dysplasia of the hip (DDH) and to address its early detection and treatment. DESIGN: This multicenter study was designed to provide an updated assessment of the definition, pathologic anatomy, prevalence, etiology, natural history, early detection, and treatment of DDH. RESULTS: DDH more accurately describes the condition previously termed congenital dysplasia of the hip. The disorder is not always present at birth (congenital) and an infant may have a normal neonatal hip screening examination and subsequently develop a dysplastic or dislocated hip. Developmental dysplasia encompasses the wide spectrum of hip problems seen in infants and children. Physicians should understand that a normal neonatal screening examination does not assure normal hip development. The diagnosis of developmental dysplasia is made by physical examination. The Ortolani and Barlow maneuvers were designed to detect a subluxatable, dislocatable, or dislocated hip in the neonatal period. In the older child, limited abduction becomes a more reliable sign. The examination is variable depending on the type of dysplasia and changes with growth. The ultrasound is proving to be a sensitive tool in confirming the diagnosis in newborns and infants from birth to 4 months of age. The ultrasound is also valuable in older infants in terms of documenting that the dysplasia is responding to treatment. However, the ultrasound depends on an experienced sonographer and, in some cases, may be too sensitive, resulting in overtreatment. After 3 to 4 months of age, an anteroposterior pelvis radiograph can confirm the diagnosis. CONCLUSIONS: All newborns should have a neonatal hip screening physical examination. After screening, the hips should be re-examined during health examination visits at 2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year of age. If any question arises during these visits or if there are associated risk factors, we recommend an ultrasound if the infant is < 4 months of age or an anteroposterior pelvis radiograph if > 4 months of age.

Digital radiography in pediatric orthopaedics: a prospective, controlled, and randomized trial.

A prospective, controlled, and randomized trial of digital radiography was conducted to evaluate its advantages in children. Matched pairs of radiographs of the feet were taken in 20 children, and pelvic radiographs were taken in another 20 children. Each pair comprised a digital and conventional film. Half of the digital films were made with a 50% radiation dose reduction. The films were scored for quality. Statistically significant advantages were seen for the digital radiographs as compared with the conventional technique. Visualization of soft tissue and bony detail was enhanced in both foot and pelvic radiographs. This was true even with a 50% dose reduction in many of the parameters scored. We conclude that digital radiography offers advantages over conventional radiography, and recommend its use.

The radiographic anatomy of the thoracic pedicle.

A cadaveric study of the radiographic characteristics of the thoracic pedicle was performed. Dried vertebrae at T6 and T7 were mounted and x-rayed at varying angles. The relationship of the pedicles to wire markers, methyl methacrylate cores, and Cotrel Dubousset hooks was analyzed. The oval image of the pedicle on radiographs is its waist. This image narrows with axial rotation of the x-ray beam. The relationship of a correctly placed pedicle hook to its pedicle is radiographically unchanged by rotation. Conversely, an incorrectly placed hook cannot be made to appear in position by rotating the x-ray beam.

Reverberation reduction in ultrasonic B-mode images via dual frequency image subtraction.

The authors demonstrate the feasibility of an approach, dual-frequency subtraction imaging, for suppressing artifacts produced by reverberation of strong echoes among specular reflectors. This method is based upon the principle that specularly reflected echoes from flat boundaries are frequency-independent whereas the diffusely scattered echoes from small scatterers are frequency-dependent. The approach was assessed on phantoms including one consisting of two parallel plastic plates between layers of foam sponges using a prototype experimental system. Preliminary results show that this method is superior to simple thresholding techniques or signal compression and holds great promise for suppressing reverberation artifacts in ultrasonic images.

Electrogenic L-malate transport by Lactobacillus plantarum: a basis for energy derivation from malolactic fermentation.

L-Malate transport in Lactobacillus plantarum was inducible, and the pH optimum was 4.5. Malate uptake could be driven by an artificial proton gradient (delta pH) or an electroneutral lactate efflux. Because L-lactate efflux was unable to drive L-malate transport in the absence of a delta pH, it did not appear that the carrier was a malate-lactate exchanger. The kinetics of malate transport were, however, biphasic, suggesting that the external malate concentration was also serving as a driving force for low-affinity malate uptake. Because the electrical potential (delta psi, inside negative) inhibited malate transport, it appeared that the malate transport-lactate efflux couple was electrogenic (net negative) at high concentrations of malate. De-energized cells that were provided with malate only generated a large proton motive force (greater than 100 mV) when the malate concentration was greater than 5 mM, and malate only caused an increase in cell yield (glucose-limited chemostats) when malate accumulated in the culture vessel. The use of the malate gradient to drive malate transport (facilitated diffusion) explains how L. plantarum derives energy from malolactic fermentation, a process which does not involve substrate-level phosphorylation.

Digital radiography can reduce scoliosis x-ray exposure.

Digital radiology is a new computerized system of acquiring x-rays in a digital (electronic) format. It possesses a greatly expanded dose response curve that allows a very broad range of x-ray dose to produce a diagnostic image. Potential advantages include significantly reduced radiation exposure without loss of image quality, acquisition of images of constant density irrespective of under or over exposure, and reduced repeat rates for unsatisfactory films. The authors prospectively studied 30 adolescents with scoliosis who had both conventional (full dose) and digital (full, one-half, or one-third dose) x-rays. They found digital made AP and lateral image with all anatomic areas clearly depicted at full and one-half dose. Digital laterals were better at full dose and equal to conventional at one-half dose. Cobb angles were easily measured on all one-third dose AP and on 8 of 10 one-third dose digital laterals. Digital clearly depicted the Risser sign at one-half and one-third dose and the repeat rate was nil in this study, indicating digital compensates well for exposure errors. The study indicates that digital does allow radiation dose to be reduced by at least one-half in scoliosis patients and that it does have improved image quality with good contrast over a wide range of x-ray exposure.

Management of scoliosis due to syringomyelia in childhood and adolescence.

To determine the effect of syringomyelia treatment (drainage) on the efficacy of orthotic management and safety of operative management of an associated scoliosis, the records of four boys with scoliosis due to syringomyelia were reviewed. The average follow-up was 8 years. On presentation, all had an abnormal neurologic examination. Each syrinx was treated by laminectomy and insertion of a syringosubarachnoid shunt. After drainage, three of four improved neurologically. Two older patients underwent uneventful posterior spinal fusion with Harrington distraction instrumentation after their drainage procedures. One boy developed kyphosis at the site of his laminectomy. Two young patients, whose curves were initially well controlled with bracing, developed continued curve progression over time. Drainage of the syrinx delayed but did not prevent curve progression in immature patients, but did allow use of distraction instrumentation without complication for operative management of the associated scoliosis.

Operative treatment of ankle fractures in children.

Fractures of the ankle (distal tibia) that involve the physis or the articular surface are one of the more common injuries for which operative treatment is indicated in children. It should be considered if accurate reduction of the articular surface, the physis, or both cannot be achieved by closed means. Operative treatment often will be required in Salter-Harris type III and IV fractures, juvenile Tillaux, and triplane fractures.

Chemiosmotic energy from malolactic fermentation.

By using the luciferase-luciferin ATP assay and whole cells of Leuconostoc oenos, we have demonstrated that malolactic fermentation does yield ATP. This energy-yielding mechanism did not occur in a cell extract and was inhibited in the presence of dicyclohexylcarbodiimide or an ionophore such as monensin. A lactate:proton efflux mechanism for this proposed pathway is presented.

Evaluation of Malolactic Bacteria Isolated from Oregon Wines.

Oregon is a cool wine-producing region where grapes characteristically contain high concentrations of organic acids. To reduce the natural acidity and increase the microbiological stability and flavor complexity of the wine, malolactic fermentation is encouraged. In this study, strains of Leuconostoc oenos indigenous to Oregon wines were evaluated for their suitability to conduct malolactic fermentation in Oregon wines. Tests determined the malolactic activity of the Oregon isolates in comparison with commercial strains ML-34, PSU-1, MLT-kli, and ens 44-40 under various temperature and pH conditions. Sensitivities to sulfur dioxide, ethanol, and fumaric acid also were determined. Two Oregon strains, Er-1a and Ey-2d, were selected for commercial winemaking tests because they had greater malolactic activity under conditions of low pH (3.0) and low temperature (15 and 8 degrees C), respectively.

The effect of trimethaphan-induced hypotension on canine spinal cord blood flow. Measurement at different cord levels using radiolabelled microspheres.

Controlled hypotension which is used during scoliosis surgery to improve operating conditions and minimize transfusion requirements may decrease spinal cord blood flow (SCBF). Previous studies using hydrogen washout, an invasive technique, have shown that trimethaphan-induced hypotension is associated with a decrease in SCBF, whereas hypotension induced with sodium nitroprusside or nitroglycerin is not. To determine whether the decrease seen with trimethaphan represented a generalized rather than regional spinal cord phenomenon, SCBF was measured at three separate cord levels (T2-3, 7-8, L2-3) using a noninvasive radionuclide-labelled microsphere technique. When the mean arterial pressure was reduced by 50%, SCBF decreased 35 to 45% at all levels of the cord examined, and remained at this reduced level during the period of hypotension. The results confirm that trimethaphan-induced hypotension is associated with a significant reduction in SCBF and that this occurs throughout the spinal cord during the period of hypotension.

Undetected posttraumatic instability of "stable" thoracolumbar fractures.

A review of 106 consecutive patients who had operative stabilization of thoracolumbar fractures revealed that 16 patients had surgery 4 months to 13 years after injury, for chronic instability. In these 16 patients, there were 8 wedge-compression fractures, 6 flexion-distraction injuries, 1 burst fracture, and 1 fracture-dislocation. All six patients with flexion-distraction injuries and the two patients with either a burst fracture or a fracture-dislocation had good results. Only two of the eight patients with wedge-compression fractures had good results. We concluded from this study that: (a) instability that presents without a progressive spinal deformity may go unrecognized; (b) all types of spine fractures can produce chronic, painful instability; and (c) poor results predominate in wedge-compression fractures operated more than 13 months after injury, regardless of the type of surgical treatment rendered.

Foot deformity in hereditary onycho-osteodysplasia.

A 30-year-old woman with hereditary onycho-osteodysplasia was examined. In addition to the classic tetrad of fingernail and toenail dysplasia, patellar aplasia, iliac horns, and radial head hypoplasia and dislocation, she also had scoliosis, proteinuria, and distinctive bilateral foot anomalies. The foot deformity consisted of a ball-and-socket ankle joint, valgus ankle, forefoot supination, and lateral subluxation at the tarsal-metatarsal joints. The literature showed that the radiographic findings of foot deformity in this dysplasia have never been reported in detail before. Evidence suggests that this distinctive pattern of deformity may be more common than previously appreciated.

Angular deformities of the lower limbs in children.

Bowlegs and knock-knees are common concerns in the early years of life. For the majority of children, these problems represent normal physiologic development and they correct spontaneously. A few children will have pathologic malalignment, which may lead to functional or cosmetic problems that may require treatment, usually bracing and occasionally surgery. Physiologic varus and valgus and the common causes of pathologic malalignment, including Blount's disease, rickets, hereditary conditions, infection, and trauma are discussed.

Arthrography in evaluation of birth injuries of the shoulder.

Birth injuries of the shoulder and proximal humerus of infants can be difficult to evaluate on plain radiographs because of lack of ossification in the proximal humeral epiphysis. We here describe arthrography of the infant shoulder and advocate it as a useful diagnostic procedure in the evaluation of humeral fractures and brachial palsies. Two infants with birth injuries of the shoulder are described. The value of dynamic fluoroscopic evaluation of the injured joint in conjunction with arthrography is illustrated in evaluation of a brachial plexus palsy.

Heel reconstruction with the deep circumflex iliac artery osteocutaneous flap.

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.