Bladder exstrophy closure in the newborn period with external pelvic fixation performed without osteotomy: A preliminary report.

BACKGROUND: Successful primary bladder closure is the most crucial element for urinary continence in patients with classic bladder exstrophy (CBE). In the newborn period, bladder closure can be performed in the first 48 h without pelvic osteotomy or external fixation, but requires postoperative lower extremity immobilization (i.e., spica cast, Bryant's or Buck's traction). OBJECTIVE: To present a novel surgical approach for primary bladder closure for CBE using two-pin external fixation without pelvic osteotomy, and without postoperative lower extremity immobilization. STUDY DESIGN: A retrospective chart review of patients with CBE was performed at the current institution from 2000 to 2016, including all primary bladder closures with external fixation and without osteotomy or lower extremity immobilization. Patients were discharged with the external fixator in place, which was later removed in clinic. Baseline clinical and demographic variables, and follow-up data were recorded. RESULTS: Thirteen patients were analyzed; eight (61.5%) were male. Pre-operative intersymphysial distance was 3.68 ± 1.0 cm (2.0-5.0). Mean follow-up was 56.8 ± 40.3 months (10-131). One patient had a partial bladder neck dehiscence, due to pin displacement on postoperative day 1: he had the lowest gestational age of 34 weeks (Summary table). DISCUSSION: This approach used external fixation to bring the pubic bones together intra-operatively, and to decrease the tension in closing the pelvic ring and abdominal wall without osteotomy. External fixation with osteotomy and long-term immobilization, or using a spica cast without osteotomy offered the added advantage of improved wound care, due to lack of lower limb immobilization, less patient discomfort, and facilitation of mother/caregiver and newborn bonding. CONCLUSION: The two-pin external fixator without osteotomy as an adjunct to primary bladder closure in CBE patients was technically feasible. At the current institution this approach had an equivalent success rate to previous reports in the literature for primary bladder closure, decreased the length of hospital stay, and precluded the need for lower extremity immobilization. Early data for bladder capacity were encouraging.

Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus.

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved.

Outcome after later combined brachial plexus and shoulder surgery after birth trauma.

Of 22 infants aged between 11 and 29 months who underwent a combined reconstruction of the upper brachial plexus and shoulder for the sequelae of a birth injury, 19 were followed up for two or more years. The results were evaluated using a modified Gilbert scale. Three patients required a secondary procedure before follow-up. Three patients had a persistent minor internal rotation contracture. All improved by at least two grades on a modified Gilbert scale.

Alcohol and gambling pathology among U.S. adults: prevalence, demographic patterns and comorbidity.

OBJECTIVE: This study was designed to determine the prevalence and demographic distribution of problem gambling, pathological gambling, alcohol abuse and alcohol dependence in the United States, and to examine the co-occurrence of gambling pathology and alcohol pathology in the United States. METHOD: A representative sample (N = 2,638) of U.S. adults age 18 and older was surveyed in the year 2000 using computer-assisted telephone interviewing. Respondents' gambling pathology and alcohol dependence were assessed by the South Oaks Gambling Screen (SOGS) and the Diagnostic Interview Schedule (DIS). RESULTS: Current pathological gambling had an overall prevalence of 1.3% as measured by the DIS and 1.9% as measured by the SOGS, with a higher prevalence among minorities and lower socioeconomic status (SES) respondents. Current and lifetime alcohol pathology was more common among males and young adults than among females and older adults. Current pathological gambling and alcohol dependence were correlated, and the highest correlation was found among higher SES respondents. CONCLUSIONS: The rate of current pathological gambling in the United States is higher than reported in past surveys. Minorities and lower SES Americans have higher than average rates of current pathological gambling. However, when higher SES persons are classified as current pathological gamblers, they are more likely than lower SES persons to be dependent on alcohol.

Femur fracture in infants: a possible accidental etiology.

Femoral fractures in nonambulating infants are generally felt to be attributable to abuse in the absence of significant trauma or underlying organic pathology. The investigation of such fractures includes a report to appropriate social service and law enforcement agencies, and legal involvement. This paper describes 2 nonambulatory infants who sustained identical oblique distal femoral metaphyseal fractures extending through the growth plate after playing in an infant stationary activity center called an Exersaucer. It is possible that the twisting motion provided by the Exersaucer (Evenflo, Picqua, OH) might be consistent with the generation of forces necessary to cause these fractures.

Isolation of stable hemolysin and catalase variants of Staphylococcus aureus S6C includes one with an exoprotein-deficient phenotype.

Previous studies suggested that the exoprotein-deficient phenotype of a Delta 1058::Tn551 insertion/deletion mutant of Staphylococcus aureus S6C was not owing to the insertion/deletion event, but instead was owing to the inherent instability of the agrC gene during transduction of the Delta 1058::Tn551 region into S6C. The purpose of the following study was to examine S6C as a potential source of exoprotein-deficient mutants that would account for their appearance after transposition and transduction. Four stable variants of S6C were isolated that differed in their hemolysin and catalase activities. Surprisingly, the agr regulatory molecule, RNAIII, was undetectable in one of these variants, which most likely accounted for the exoprotein-deficient phenotype of this variant. When the original Delta 1058::Tn551 mutation was transduced into the hemolytic, catalase-positive variant of S6C, none of the transductants exhibited an exoprotein-deficient phenotype. These data suggest that, while the exoprotein-deficient phenotype of the S6C variant is most likely due to mutations in the agr regulatory system, these mutations are not caused by the transduction of the Delta 1058::Tn551 region into S6C, but instead already exist in an exoprotein-deficient variant of S6C.

Clinical and biologic activity of the farnesyltransferase inhibitor R115777 in adults with refractory and relapsed acute leukemias: a phase 1 clinical-laboratory correlative trial.

R115777 is a nonpeptidomimetic enzyme-specific inhibitor of farnesyl protein transferase (FT) that was developed as a potential inhibitor of Ras protein signaling, with antitumor activity in preclinical models. This study was a phase 1 trial of orally administered R115777 in 35 adults with poor-risk acute leukemias. Cohorts of patients received R115777 at doses ranging from 100 mg twice daily (bid) to 1200 mg bid for up to 21 days. Dose-limiting toxicity occurred at 1200 mg bid, with central neurotoxicity evidenced by ataxia, confusion, and dysarthria. Non-dose-limiting toxicities included reversible nausea, renal insufficiency, polydipsia, paresthesias, and myelosuppression. R115777 inhibited FT activity at 300 mg bid and farnesylation of FT substrates lamin A and HDJ-2 at 600 mg bid. Extracellular signal-regulated kinase (ERK), an effector enzyme of Ras-mediated signaling, was detected in its phosphorylated (activated) form in 8 (36.4%) of 22 pretreatment marrows and became undetectable in 4 of those 8 after one cycle of treatment. Pharmacokinetics revealed a linear relationship between dose and maximum plasma concentration or area under the curve over 12 hours at all dose levels. Weekly marrow samples demonstrated that R115777 accumulated in bone marrow in a dose-dependent fashion, with large increases in marrow drug levels beginning at 600 mg bid and with sustained levels throughout drug administration. Clinical responses occurred in 10 (29%) of the 34 evaluable patients, including 2 complete remissions. Genomic analyses failed to detect N-ras gene mutations in any of the 35 leukemias. The results of this first clinical trial of a signal transduction inhibitor in patients with acute leukemias suggest that inhibitors of FT may have important clinical antileukemic activity. (Blood. 2001;97:3361-3369)

Improving shoulder and elbow function in children with Erb's palsy.

Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.

[Surgical treatment of children with brachial plexus paralysis]. / Tratamiento quirúrgico de los niños con parálisis del plexo braquial.

OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.

Health-care charges generated by patients with diabetes.

For assessment of health-care charges generated by patients with diabetes, 50 patients (25 who were older than 65 years and 25 who were age 65 or younger) whose primary care had been delivered between 1990 and 1995 by a single diabetologist were randomly selected. Institutional health-care bills were accessed from all but three medical center billing offices (dermatology, psychiatry, and radiation oncology areas did not respond). For each dollar billed by endocrinology, the hospital billed 25.90 dollars, other medical specialties 2.70 dollars, surgery 1.10 dollars, radiology 0.70 dollars and pathology 0.60 dollars. The charges generated by the endocrinologist-diabetologist account for approximately 3% of the total charges for the care of the patient with diabetes mellitus in a fee-for-service practice. Although the endocrinologist-diabetologist provides the most cost-effective medical service for patients with diabetes, low reimbursement jeopardizes the practice of this subspecialty.

Attachment, attractiveness, and social interaction: a diary study.

To what extent are attachment styles manifested in natural social activity? A total of 125 participants categorized as possessing secure, avoidant, or anxious-ambivalent attachment styles kept structured social interaction diaries for 1 week. Several theoretically important findings emerged. First, compared with secure and anxious-ambivalent persons, avoidant persons reported lower levels of intimacy, enjoyment, promotive interaction, and positive emotions, and higher levels of negative emotions, primarily in opposite-sex interactions. Analyses indicated that avoidant persons may structure social activities in ways that minimize closeness. Second, secure people differentiated more clearly than either insecure group between romantic and other opposite-sex partners. Third, the subjective experiences of anxious-ambivalent persons were more variable than those of the other groups. Finally, the authors examined and rejected the possibility that attachment effects might be confounded with physical attractiveness. These findings suggest that feeling and behaviors that arise during spontaneous, everyday social activity may contribute to the maintenance of attachment styles in adulthood.

Emergency control of Aedes aegypti in the Dominican Republic using the Scorpion 20 ULV forced-air generator.

In an effort to develop a more effective measure for use in emergency control of the dengue vector Aedes aegypti. applications of a combination of a larvicide (Bacillus thuringiensis israelensis [B.t.i.]) and an adulticide (permethrin) were made using a truck-mounted forced-air generator (Scorpion 20) and evaluated in the Dominican Republic. This method has the potential to simultaneously control adults and larvae. In bioassay cages placed in household water containers at the time of application, larval mortalities were 95.1 and 100% for 2 application rates of permethrin mixed with B.t.i. Adult mortalities were not as impressive, probably because of resistance to permethrin. Higher adult mortality in caged specimens (78.5%) and a substantial reduction in the natural population (68.4%) of Ae. aegypti were obtained following a 2.1-g AI/ha application of deltamethrin alone.

Langenskiöld classification of tibia vara: an assessment of interobserver variability.

Six pediatric orthopaedic specialists and six senior orthopaedic residents independently classified 60 radiographs of infantile tibia vara according to the six-stage Langenskiöld classification. Correlation coefficients and percentage agreement were similar in both groups. Interobserver agreement was good for early and late stages, but was poor for intermediate stages. We caution clinicians that small but frequent discrepancies in radiographic staging impart a dubious prognostic value to the Langenskiöld classification.

Barrier spraying to control the malaria vector Anopheles albimanus: laboratory and field evaluation in the Dominican Republic.

To develop a new strategy for control of exophilic/exophagic malaria vectors which rest on peridomestic foliage, Anopheles albimanus was used for laboratory bioassays of mosquito adulticides applied to various vegetation types. Of the three classes of insecticide tested, the pyrethroid (permethrin at 112 g/ha) showed greater foliar persistence than either the carbamate (bendiocarb at 340 g/ha) or the organophosphorus compound (malathion at 277 g/ha). Field evaluation of barrier spraying against An.albimanus was evaluated in rural villages of southwest Dominican Republic during 1989. The pyrethroid deltamethrin was sprayed aerially for ultra-low volume application at treatment rates of 17-19 g a.i./ha in a radius of 500 m around two villages. An.albimanus were monitored by light-traps and human bait collections at both treated villages, compared with two similar untreated villages, up to 9 nights posttreatment. Densities of female An.albimanus were significantly reduced in the sprayed villages for at least 8 or 9 nights. Further evaluation of barrier spraying is recommended to determine optimal pyrethroid formulations and applications rates, their impact on non-target fauna and efficacy against malaria transmission.

Field evaluations in malaise and canopy traps of selected targets as attractants for tabanid species (Diptera: Tabanidae).

Various configurations of an inflated vinyl beach ball covered with black fabric were evaluated in Malaise and canopy (modified Manitoba) traps for possible use as an insecticide-impregnated visual target (T) for Tabanidae. In Malaise traps, T attracted 2x more flies than no T. When inflated with carbon dioxide, T was not significantly different from T filled with air, no matter which type of trap it was in. In canopy traps, 2 or 4 white spots applied to T did not increase its attractiveness to tabanids. When treated with octenol, T was 2-5x more attractive than an untreated T in canopy traps. However, when an octenol treatment was aged for 48 h, it was less effective than a fresh treatment. Overall, the 3 most frequently collected species, in order of abundance, were: Tabanus lineola hinellus, Hybomitra vicina and Chrysops atlanticus. Significantly more T. l. hinellus and H. vicina were collected at T with octenol than at T without octenol. Attempts to detect an insecticidal effect on flies captured in both types of trap that had been baited with Ts treated with permethrin were unsuccessful.

Penetration of ultra-low volume applied insecticide into dwellings for dengue vector control.

Determinations on the penetration of ultra-low volume applied insecticide into dwellings was accomplished with a model house in Frederick, MD, USA, and native houses in Santo Domingo, Dominican Republic. Results from the model house tests show that aerosol droplets, with a volume median diameter of 4 microns, penetrated and remained suspended in low recesses of the building during the first 2 min after spraying. Similar results were found with tests in Santo Domingo, where man-made or natural obstructions were determined to be critical factors in aerosol penetration.

In vitro ruminal metabolism of larkspur alkaloids.

Larkspur (Delphinium sp) poisoning of range cattle is a serious, recurring problem in the western United States. Numerous stratagems have been recommended to ameliorate larkspur intoxication, but none are completely effective. Previous studies in this laboratory indicated bovine ruminal microflora are capable of chemically modifying Delphinium alkaloids. Research reported herein was undertaken to further evaluate whether differences in ovine and bovine rumen metabolism might explain differences in susceptibility to larkspur intoxication and whether existing metabolic activity can be enhanced by sustained exposure to Delphinium alkaloids. Comparison of ovine and bovine rumen metabolism of Delphinium geyeri alkaloids in vitro failed to demonstrate differences in the rate of alkaloid metabolism. Rumen liquor collected sequentially from a fistulated cow dosed with dried Delphinium geyeri did not vary in ability to metabolize larkspur alkaloids.

Malaria transmission potential by Anopheles mosquitoes of Dajabon, Dominican Republic.

A field and laboratory study was conducted to determine some of the parameters relevant to malaria transmission by Anopheles mosquitoes in Dajabon Province, Dominican Republic. Although all 4 species occurring in the area, i.e., An. albimanus, An. crucians, An. grabhamii and An. vestitipennis, were included in the investigations, most of the work focused on the first and last named species because of their abundance. Gonotrophic cycles were determined to be 2.6 and 3.2 days for An. albimanus and An. vestitipennis, respectively. Mean parity rates for the 2 species were 37.3 and 20.7%, respectively, in outdoor samples. The human blood index, as determined by ELISA, was 0.08 for An. albimanus and 0.12 for An. vestitipennis. Only An. albimanus was confirmed positive for Plasmodium falciparum circumsporozoite protein, using ELISA. The vectorial capacity of An. albimanus was determined to be 0.019 and that of An. vestitipennis 0.005.

Insecticide susceptibility of Aedes aegypti from Santo Domingo, Dominican Republic.

The insecticide susceptibility of Aedes aegypti adults and larvae from Santo Domingo, Dominican Republic, was investigated using World Health Organization standard procedures. A field strain was more resistant to insecticides than a colony strain that originated from the same place. Larvae produced from ovitrap-collected eggs were resistant to temephos (78.2% mortality on exposure to 0.025 mg/liter). Mortality rates after exposure of adults to discriminating concentrations showed that wild populations were resistant to DDT, malathion, propoxur, permethrin and deltamethrin. The problem of resistance was considered serious enough to warrant consideration of control measures other than the use of chemicals.

Studies of the susceptibility of Anopheles albimanus and Anopheles vestitipennis from Dajabon, Dominican Republic, to insecticides.

Insecticide susceptibility of Anopheles albimanus and An. vestitipennis in Dajabon Province, Dominican Republic, was investigated. Only 74.3% of An. albimanus exposed to 4% DDT for 1 h died. The mortality in this species following exposure for 1 h to 0.25% permethrin was also 74.3%. However, this species was susceptible to malathion, fenitrothion and propoxur. The mortality obtained following exposure of An. vestitipennis to 4% DDT and 0.1% propoxur, both for 1 h, was 71% and 100%, respectively. However, the number of specimens exposed to propoxur was small.