Fracture stability after pinning of displaced supracondylar distal humerus fractures in children.

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeon's discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.

Preoperative nursing assessment of the adult patient.

The preoperative patient assessment must be very focused, providing detail and specificity in several essential assessment areas. The preoperative patient assessment helps to determine whether the patient is a high surgical risk. Patients who are determined to be high surgical risks are at a higher risk for perioperative and postoperative mortality and morbidity.

Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment.

A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.

Restriction fragment length polymorphism analysis and random amplified polymorphic DNA analysis of Campylobacter jejuni strains isolated from patients with Guillain-Barré syndrome.

Campylobacter jejuni serotype O19 strains associated with the Guillain-Barré syndrome (GBS) and other strains were examined by restriction fragment length polymorphism (RFLP) analysis of polymerase chain reaction products of the flaA genes and by random amplified polymorphic DNA (RAPD) analysis. RFLP analysis showed that regardless of LIO serotype, geographic origins, or association with GBS, the O19 isolates shared an identical digestion pattern by each of four restriction endonucleases, DdeI, MboI, MseI, and AluI. In contrast, among C. jejuni O1 or O2 strains, RFLP patterns were different even among strains of the same LIO serotype. The results of the RAPD analysis were consistent with the flaA RFLP data. These data indicate that all of the O19 strains that were tested were closely related to one another whether they were or were not associated with GBS.

Randomised placebo-controlled trial of human recombinant insulin-like growth factor I plus intensive insulin therapy in adolescents with insulin-dependent diabetes mellitus.

BACKGROUND: Good glycaemic control in insulin-dependent diabetes mellitus (IDDM) to prevent complications may be difficult to achieve during adolescence, because abnormalities in production of growth hormone or insulin-like growth-factor-I (IGF-I) can lead to lower insulin sensitivity. Recombinant human IGF-I (rhIGF-I) given as an adjunct to insulin therapy in IDDM, might improve glycaemic control in adolescents; we investigated the effects of the addition of IGF-I in a randomised, double-blind, placebo-controlled trial. METHODS: 53 patients with IDDM (26 male, 27 female) with a median age of 16.1 years (range 10.8-20.6) and diabetes of more than 2 years' duration were randomly assigned subcutaneous rhIGF-I (20 or 40 microg/kg daily [n=18, n=18, respectively]) or placebo (n=17), both in addition to multiple-injection insulin therapy for 24 weeks. The primary endpoint, glycated haemoglobin (HbA1c) and routine biochemistry were measured every 4 weeks. Retinal photographs and glomerular-filtration rates were assessed at base line and at the end of the study. Data were analysed by intention to treat. FINDINGS: With a dose of 40 microg/kg rhIGF-I daily, we found significant reductions in HbA1c compared with placebo (p=0.03), without changes in body-mass index, rate of hypoglycaemia, insulin dose, or circulating concentrations of IGF-binding proteins 1 and 3. The greatest median change in HbA1c of -0.6% (range -2.8 to -1.5%) was seen with rhIGF-I 40 microg/kg at week 12, but was not sustained at week 24. The greatest reductions in HbA1c at week 24 were seen among patients with the greatest changes in IGF-I concentrations (r=-0442, p=0.002). Retinal photographs, renal function (glomerular filtration rate and urinary albumin excretion), and routine biochemistry showed no adverse events. INTERPRETATION: Our data confirm that rhIGF-I as an adjunct to insulin therapy can improve HbA1c values in adolescents with IDDM without overt toxic effects, but they raise questions about whether these effects can be sustained in cases of poor compliance or reduced bioefficacy.

Analysis of HL and O serotypes of Campylobacter strains by the flagellin gene typing system.

We recently developed a molecular typing system for Campylobacter jejuni and Campylobacter coli based on restriction fragment length polymorphism analysis of the flagellin gene,flaA (I.Nachamkin, K. Bohachick, and C.M. Patton, J. Clin. Microbiol. 31:1531-1536, 1993). We extended the typing system to 83 flagellin types (designated flaA-1,flaA-2, etc.) on the basis of analysis of 404 isolates of C. jejuni and C. coli including common serotypes isolated in the United States, a selection of less common serotypes, and serotype reference strains. Of the 295 strains previously shown to belong to common HL and O serotypes (C. M. Patton, M.A. Nicholson, S.M. Ostroff, A.A. Ries, I.K. Wachsmuth, and R.V. Tauxe, J. Clin. Microbiol. 31:1525-1530, 1993), six flaA types accounted for 53.6% of strains as follows: flaA-1, 21.7%; flaA-7, 14.9%; flaA-27, 5.1%; flaA-49, 4.4%; flaA-13, 3.7%; and flaA-21, 3.7%. Seventy-five percent of the strains were within 15 flaA types, 90% were within 30 flaA types, and all 295 strains were contained within 52 flaA types. Within each HL or O serotype, there usually were multiple flaA types. For 12 common HL serotypes and 7 common O serotypes, more than 50% of these isolates were a single flaA type. A database was developed by using commercially available restriction fragment length polymorphism analysis software (ProRFLP; DNA ProScan, Inc., Nashville, Tenn.) that should allow other investigators to perform typing with this system.

Rapid identification of Campylobacter species by restriction fragment length polymorphism analysis of a PCR-amplified fragment of the gene coding for 16S rRNA.

Restriction fragment length polymorphism analysis of a PCR-amplified DNA fragment of the gene coding for 16S rRNA was performed on 148 previously characterized strains of Campylobacter, Helicobacter, Arcobacter, and Wolinella succinogenes and 13 Campylobacter-like isolates. These strains included clinical, animal, and environmental isolates. PCR amplification generated a 283-bp fragment from all species. The amplicon from each strain was digested with six restriction endonucleases (AccI, AvaI, DdeI, HaeIII, HpaII, XhoI). DdeI was useful for the initial grouping of the strains. Additional discrimination within the different DdeI groups was obtained with AccI, HaeIII, HpaII, and XhoI digestions. The PCR-restriction fragment length polymorphism analysis allowed for the discrimination of members of the genus Campylobacter from members of closely related genera and discrimination between Campylobacter species. The proposed method is simple and rapid and can be useful for the routine identification of Campylobacter-like organisms in clinical or epidemiologic studies.

Genotypic and phenotypic characterization of Helicobacter cinaedi and Helicobacter fennelliae strains isolated from humans and animals.

By DNA-DNA hybridization, we classified 26 human strains, 4 dog and cat strains, and 4 hamster strains putatively identified as Helicobacter cinaedi as well as 2 human strains and 2 animal strains of Helicobacter fennelliae. All but one human strain belonged to the same hybridization group as the type strain of H. cinaedi. The animal strains also appeared to belong to this hybridization group. Both human strains of H. fennelliae were shown to be H. fennelliae by DNA-DNA hybridization, but both animal strains were less than 15% related to the type strain. All strains were also characterized by plasmid profiles and ribotyping. Plasmids were found in 23% of the human strains, 100% of the hamster strains, and 33% of the dog and cat strains. Human strains were essentially identical by ribotyping, but were clearly differentiated from the hamster and dog and cat strains. Some strains may be difficult to culture on primary isolation; we found that our strains grew well on anaerobic CDC agar, brucella agar, and tryptic soy agar II. Our H. cinaedi and H. fennelliae strains differed from those previously described because some were resistant to cephalothin: some H. cinaedi strains were also resistant to nalidixic acid. All isolates were also characterized by antimicrobial susceptibility testing. We found that human strains of H. cinaedi were more resistant to clindamycin and erythromycin than were animal isolates; 19% of the human strains were resistant to ciprofloxacin. Therefore, we recommend that antimicrobial susceptibility results be obtained before initiating therapy for H. cinaedi and H. fennelliae infections.

Identification of Campylobacter fetus by PCR-DNA probe method.

A PCR method for rapid identification of Campylobacter fetus subsp. fetus was evaluated. A fragment of the gene coding for 16S rRNA was amplified from crude cell lysates of 18 C. fetus strains and 30 strains representing other Campylobacter species and subspecies. The amplicons were probed by dot blot hybridization with a digoxigenin-labeled C. fetus-specific oligonucleotide probe. The probe reacted only with C. fetus subsp. fetus and C. fetus subsp. venerealis and may be useful for rapid identification in clinical laboratories.

Evaluation of disk method for hippurate hydrolysis by Campylobacter species.

A disk method for hippurate hydrolysis was compared with the ninhydrin tube method by using 140 genetically confirmed Campylobacter strains. Results were similar for 129 (92%) strains when the inoculum size for the disk method was standardized. Six strains (4.2%) showed variable results by each method. Our results conflict with those obtained in studies by others, who found the two methods to be dissimilar.

Novel angiotensin receptor subtypes in fowl.

We reported previously that blood vessels of domestic fowl contain angiotensin (ANG) receptors on 1) endothelium, mediating vasorelaxation via endothelium-derived relaxing factor and guanosine 3',5'-cyclic monophosphate; 2) vascular smooth muscles, mediating neither relaxation nor contraction; and 3) presumably adrenergic nerve endings, transmitting vasopressor action via a release of norepinephrine. We aimed in the present study to determine fowl vascular ANG receptor subtypes and relate them to function. [Val5]ANG II (native fowl ANG II) increased mean arterial pressure of anesthetized, ganglion-blocker-treated fowl. The dose-pressor response curve for fowl ANG II was not altered by pretreatment (i.v.) with the ANG receptor subtype 1 (AT1) antagonist Dup-753 (losartan, 10 mg/kg) or the subtype 2 (AT2) antagonist PD-123319 (10 mg/kg). Furthermore, cumulative doses (1-20 mg/kg) of losartan or PD-123319 did not selectively inhibit ANG II-induced pressor responses. In reserpine- and prazosin-treated anesthetized fowl, [Val5]ANG II caused dose-dependent vasodepressor actions inhibited by neither losartan (10 mg/kg) nor PD-123319 (10 mg/kg). Likewise, [Val5]ANG II-induced vasorelaxation of fowl aortic rings in vitro was not inhibitable by PD-123319 or losartan (10(-5) M). Specific binding of 125I-labeled ANG II to the aortic endothelium was markedly displaced by ANG II, but not selectively by PD-123319 or losartan. Specific binding of 125I-ANG II ligand to the membrane fraction of aortic smooth muscles was displaced (50% inhibitory concentration) by [Val5]ANG II (3.3 x 10(-8) M) and slightly by PD-123319 (3.7 x 10(-5) M), but not by losartan or EXP-3174, an active metabolite of losartan.(ABSTRACT TRUNCATED AT 250 WORDS)

Application of Lior biotyping by use of genetically identified Campylobacter strains.

We used the scheme of Lior to biotype 140 genetically identified Campylobacter strains. Our results confirmed previous studies and extended Lior biotyping to show that nine C. jejuni subsp. doylei strains (100%) were one biotype and nine C. jejuni subsp. jejuni nalidixic acid-resistant strains (100%) were C. jejuni biotype I or II. All C. jejuni subsp. jejuni hippurate-negative strains studied and 6 of 35 C. lari strains (17%) were grouped with C. coli biotypes. These findings may be useful in epidemiologic investigations.

Flagellin gene typing of Campylobacter jejuni by restriction fragment length polymorphism analysis.

We developed and studied a molecular typing approach for Campylobacter spp. with restriction fragment length polymorphism (RFLP) analysis of the flagellin gene flaA in C. jejuni. Using polymerase chain reaction, we amplified the flaA gene from strains comprising different HL:O serotypes by using a primer set directed at the conserved 5' and 3' flaA gene sequence to generate a 1.7-kb amplicon. The amplicon was further digested with the restriction enzyme DdeI, and the fragments generated were analyzed by agarose gel electrophoresis. In 43 non-outbreak strains of six common HL serotypes (HL 1, 2, 4, 5, 9, and 36) in the United States, 18 RFLP patterns were observed. In U.S. outbreak strains previously studied by 10 other typing methods, flaA typing correlated with the HL serotype within each outbreak, and six additional flaA types were identified. Our results suggest that RFLP analysis of the flaA gene from Campylobacter spp. has sufficient discrimination to be useful as a practical typing method for clinical and epidemiologic investigations.

Common somatic O and heat-labile serotypes among Campylobacter strains from sporadic infections in the United States.

Somatic O (formerly heat-stable) and heat-labile (HL) serotyping methods are commonly used to type Campylobacter jejuni and Campylobacter coli isolates. Although both systems are effective, the labor and time required for each have limited their application. These systems can be simplified by reducing the number of antisera used. To find an appropriate panel of antisera, we determined the distribution of common serotypes in the United States among a representative sample of 298 Campylobacter isolates. The strains, obtained between July 1989 and June 1990 from persons with sporadic cases of diarrhea, were collected from 19 randomly chosen counties in all geographic (census) regions of the United States. All strains were serotyped by the O and HL systems. By phenotypic methods, 288 C. jejuni, 9 hippurate-negative C. jejuni/C. coli, and 1 Campylobacter lari were identified. Of 57 O antisera, 24 typed 252 (84.6%) strains. Of the 55 HL antisera, 23 serotyped 253 (84.9%) strains. All strains were typeable in the unabsorbed O antisera. In the absorbed HL antisera, four strains were nontypeable and 14 were rough and untypeable. In each geographic region, 9 or more O and HL serotypes were found. Serotypes O:1, O:4, and O:13,16,43,50 and HL 1 were identified in all regions. The combination of both schemes gave greater discrimination than either system alone, but the maintenance of both requires a large resource investment. A serotyping scheme incorporating the 24 most prevalent O and 23 most prevalent HL serotypes could be useful for outbreak support and for surveillance. In the near future, we anticipate using a molecular subtyping method in combination with limited serotyping to distinguish Campylobacter strains.

Evaluation of commercial antisera for serotyping heat-labile antigens of Campylobacter jejuni and Campylobacter coli.

Commercial antisera for serotyping 22 heat-labile antigens of Campylobacter jejuni and Campylobacter coli were evaluated by using 66 isolates from human and nonhuman sources. Test results were compared with results of tests using antisera produced at the Centers for Disease Control (CDC), Atlanta, Ga. All strains (three isolates of each of the 22 serotypes) were typeable with the CDC antisera. Of 66 test strains, 39 (59%) were typed as the same serotype with both sets of antisera. Twenty-four strains (36%), including two heat-labile serotype reference strains, were nonreactive with the commercial antisera, and three strains (4.5%) were typed as serotypes different from those obtained with CDC antisera. Five of the 22 commercial antisera correctly serotyped all homologous strains. Our study indicated that two polyvalent antiserum pools, 7 unabsorbed antisera, and 16 absorbed monovalent antisera are weak and need modification to enhance their antibody titers. Further studies are necessary to explain the antigenic change to a different serotype in three strains.

Evaluation of 10 methods to distinguish epidemic-associated Campylobacter strains.

We compared four phenotypic and six genotypic methods for distinguishing Campylobacter jejuni strains from animals and humans involved in four epidemics. Based on a comparison with epidemiologic data, the methods that correctly identified all strains in three milkborne outbreaks and one waterborne outbreak were heat-stable and heat-labile serotyping; multilocus enzyme electrophoresis (MEE); DNA restriction endonuclease analysis with BglII, XhoI, PvuII, or PstI; and Southern blot and hybridization of PvuII- and PstI-digested DNA with Escherichia coli 16S and 23S rRNA (ribotyping). Biotyping, phage typing, plasmid analysis, and probing of BglII and XhoI DNA digests with C. jejuni 16S rRNA genes failed to correctly separate one or more strains. MEE, restriction endonuclease analysis, and ribotyping were the most sensitive methods and identified nine types among the 22 strains. These methods were also capable of further distinguishing strains within the same serotype. Data from MEE were also analyzed to calculate genetic relatedness among strains. Serotyping was the most discriminating phenotypic method, with eight and seven types distinguished by the heat-stable and heat-labile methods, respectively. MEE and ribotyping had several advantages over the other methods because they measure relatively stable and significant chromosomal differences and are applicable to other species and genera. These methods, however, are complex and not easily quantified; they are currently limited to specialized laboratories. When antisera are available, serotyping appears to be an effective and more practical approach to the identification of epidemic-related strains.

Campylobacter butzleri sp. nov. isolated from humans and animals with diarrheal illness.

Seventy-eight aerotolerant Campylobacter isolates were characterized phenotypically and by DNA hybridization (hydroxyapatite method at 50 and 65 degrees C). Two DNA relatedness groups were found. (i) Sixty-four strains belonged to aerotolerant Campylobacter DNA hybridization group 2. These organisms were isolated from humans, primarily with diarrheal illness, and animals on several continents. Strains were aerotolerant at 30 and 36 degrees C and catalase negative or weakly catalase positive, grew in media containing glycine and on MacConkey agar, were susceptible to nalidixic acid, and were resistant to cephalothin. The name Campylobacter butzleri sp. nov. is proposed for this group. (ii) DNA hybridization group 1 consisted of the type strain of Campylobacter cryaerophila and 13 additional strains isolated from 10 animals outside the United States and from three humans within the United States. This group was genetically diverse; five strains were closely related to the type strain of C. cryaerophila (DNA hybridization group 1A), and eight strains were more closely related to one another (DNA hybridization group 1B). Strains in DNA hybridization group 1B were phenotypically diverse, with two of eight strains resembling C. cryaerophila. The seven strains from DNA hybridization groups 1A and 1B which resembled C. cryaerophila and the C. cryaerophila type strain were aerotolerant only at 30 degrees C and catalase positive, did not grow in glycine or on MacConkey agar, were generally susceptible to nalidixic acid, and were resistant to cephalothin. The remaining six strains of DNA hybridization group 1B phenotypically resembled C. butzleri; however, they were generally catalase positive and susceptible to nalidixic acid and cephalothin. DNA hybridization group 1B is not designated as a separate species at this time since it cannot, with certainty, be separated genetically from C. cryaerophila or phenotypically from C. butzleri.

Evaluation of the indoxyl acetate hydrolysis test for rapid differentiation of Campylobacter, Helicobacter, and Wolinella species.

A total of 410 well-defined Campylobacter, Helicobacter, and Wolinella strains, comprising 26 named species, subspecies, and defined groups, were tested for indoxyl acetate hydrolysis by a disk method by using disks prepared at the Centers for Disease Control, Atlanta, Ga. All C. coli (43 strains), C. cryaerophila (34 strains), C. fennelliae (5 strains), C. fennelliae-Campylobacter-like organism 3 (2 strains), C. jejuni (66 strains), C. jejuni subsp. doylei (3 strains), hippurate-negative C. jejuni-C. coli (15 strains), "C. upsaliensis" (39 strains), H. mustelae (5 strains), W. curva (1 strain), and W. recta (1 strain) hydrolyzed indoxyl acetate. Four strains gave weak positive reactions, and the remaining 196 strains, which belonged to 15 species, subspecies, and defined groups, gave negative reactions. Of the 410 study strains, 246 and 125 strains were tested for indoxyl acetate hydrolysis by a disk method and a tube method, respectively, by using commercially produced disks. The disk method, regardless of source, required less time and interpretation than the tube method did. Better differentiation between Campylobacter spp. was obtained with the indoxyl acetate test than with the trimethylamine N-oxide test. The indoxyl acetate disk distinguished C. lari from C. jejuni and C. coli, C. cinaedi from C. fennelliae, and H. pylori from H. mustelae and suggested that W. succinogenes could be differentiated from W. recta and W. curva. The indoxyl acetate disk method could be performed in 5 to 30 min, was easy to read and interpret, and should be useful as a routine diagnostic test for identification of Campylobacter spp.

Clinical and immunologic significance of cholera-like toxin and cytotoxin production by Campylobacter species in patients with acute inflammatory diarrhea in the USA.

The humoral immune response to both Campylobacter jejuni cell surface antigens and to potential toxins of the organism was studied in 64 adults with inflammatory diarrhea. In an enzyme-linked immunosorbent assay (ELISA) for surface antigens, 17 (71%) of 24 persons with Campylobacter enteritis showed seroconversion in more than one immunoglobulin class, versus only 2 (5%) of 40 patients with non-Campylobacter enteritis. In a GM1, ganglioside-based ELISA for detecting serum IgG to cholera-like enterotoxin, only one patient studied showed seroconversion to the enterotoxin. Of 22 Campylobacter isolates studied for production of cholera-like toxin, none of the supernatants from the Campylobacter strains were positive. Supernatants were also tested for enterotoxin and cytotoxic activity on Chinese hamster ovary cells; all isolates were negative for enterotoxin activity. In contrast, cytotoxin was produced by 7 (32%) isolates but was usually low-level and was not neutralized by patient's serum. These findings indicate that production of cholera-like toxin and cytotoxin by Campylobacter strains in the United States occurs in few strains and that host immune response is absent; their biologic significance in the pathogenesis of Campylobacter infections remains unclear.