An Investigation of the Relationship Between the Second-to-Fourth Digit Ratio and Sagittal Synostosis.

BACKGROUND: The most common presentation of nonsyndromic craniosynostosis is that of the sagittal suture. Amongst this subgroup there is a significant male preponderance. Although the etiology is largely unknown, androgen exposure in utero has been suggested as a contributing factor. The second-to-fourth digit ratio (2D:4D) is a sexually dimorphic trait, reflective of the levels of androgen and estrogen exposure in utero, with a lower 2D:4D ratio associated with higher androgen exposure.This study aimed to examine the difference in 2D:4D ratio between participants with sagittal synostosis (SS) and gender- matched controls, hypothesizing that alterations in androgen exposure would be reflected in participants' 2D:4D ratio. METHOD: Participants with nonsyndromic SS and gender-matched controls were prospectively recruited from outpatients clinics. Photographs were taken of the right hand, and 3 independent researchers measured the length of the fingers and 2D:4D ratio, with the mean 2D:4D ratio then calculated. RESULTS: Fifty-six participants were recruited to both groups, with 35 males and 21 females in each. The mean age of the study and control groups were 5.6 and 6.3 years, respectively. There was no difference in the 2D:4D ratio between groups overall ( P = 0.126). However, males with SS had a significantly higher 2D:4D ratio in comparison to male controls (0.969 ± 0.379 versus 0.950 ± 0.354, P = 0.038). CONCLUSIONS: Our results suggest that 1 single hormonal pathway is not responsible for suture fusion. Subsequently we consider that an imbalance between testosterone and estrogen signaling may contribute to the development of sagittal craniosynostosis.

A Review Of Referral Patterns For Sagittal Synostosis In Ireland: 2008-2013.

Sagittal synostosis (SS) is the commonest form of craniosynostosis. Children with sagittal synostosis in Ireland are treated in the National Paediatric Craniofacial Centre (NPCC) in Temple Street Children's University Hospital. This retrospective study analysed the correlation between referral patterns to the unit and age at operation. The notes of 81 patients referred over a 5-year period (April 2008 - April 2013) to the NPCC with non-syndromic SS were reviewed and demographics and referral information were recorded. Of 81 patients reviewed, 60 (74%) were referred before 6 months of age, while 21 (26%) had late referrals. Neonatologists referred 100% of infants before 6 months, paediatricians referred 71%, and GPs 64%. Later referral was associated with a more complex referral pathway, including multiple-steps of referral and unnecessary investigations. Improved clinician knowledge and emphasis on the importance of early referral may lead to a reduction in late referrals.

Cranial fasciitis located at the temporal region in a 2-year-old girl.

INTRODUCTION: Cranial fasciitis is an exceedingly rare, benign, fibroblastic tumour of the skull of young children. It was first described in 1980 by Lauer and Enzinger as a subset of nodular fasciitis. There are fewer than 55 cases described in the literature. CASE REPORT: We describe the presentation of a 2-year-old girl with a rapidly growing left temporal lesion, initially treated as an intramuscular haemangioma with propanolol. Following failure of response to this management, radiological and histological investigations indicated cranial fasciitis, and multidisciplinary surgery was undertaken via a bicoronal incision. Gross total resection was carried out, and the lesion was found to be adherent to but not infiltrating the dura. The petrous bone and zygomatic arch appeared destroyed, leaving a large temporal bony defect. This was repaired with a split calvarial graft from the outer table of the right parietal bone. DISCUSSION: Histology confirmed a diagnosis of cranial fasciitis. She had an uneventful post-operative course and was discharged home well. A CT scan 8 months post-operatively showed no residual lesion and it was noted that the reconstruction had fully integrated and the zygomatic arch had reformed.

Current practice in the treatment of AO type 31-A2 hip fractures: does sub-specialty and experience of surgeon determine type of fixation?

BACKGROUND: Debate surrounds the optimal treatment of AO type 31-A2 fractures of the hip. Two principal treatment modalities are the compression hip screw (CHS) and cephallomedullary device (CMD). The use of CMD's is steadily increasing, for fixation of this fracture type, despite a lack of supportive evidence. METHODS AND MATERIALS: 100 trauma consultants were asked for their opinion towards treatment of an AO type 31-A2 fracture. Subspecialty and length of time in post were also recorded. RESULTS: A significant proportion of consultants opted to use a CMD. Consultants who had been in post for a shorter time, and those in specialties other than lower limb were more likely to use a CMD. DISCUSSION: NICE guidelines suggest CHS for AO type 31-A2 fractures. CONCLUSION: CMD accounts for a large percentage of treatment in our study, despite NICE guidelines, and other studies suggest their use is rising. We suggest there is a trend of less experienced consultants, and consultants whose specialties are those other than lower limb, using CMD more often. This may be creating an increased cost burden to the NHS, with no evidence to support their use.

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series.

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.

Ligation of CD38 suppresses human B lymphopoiesis.

CD38 is a transmembrane glycoprotein expressed in many cell types, including lymphoid progenitors and activated lymphocytes. High levels of CD38 expression on immature lymphoid cells suggest its role in the regulation of cell growth and differentiation, but there is no evidence demonstrating a functional activity of CD38 on these cells. We used stroma-supported cultures of B cell progenitors and anti-CD38 monoclonal antibodies (T16 and IB4) to study CD38 function. In cultures of normal bone marrow CD19+ cells (n = 5), addition of anti-CD38 markedly reduced the number of cells recovered after 7 d. Cell loss was greatest among CD19+ sIg- B cell progenitors (mean cell recovery +/- SD = 7.2 +/- 11.7% of recovery in control cultures) and extended to CD19+CD34+ B cells (the most immature subset; 7.6 +/- 2.2%). In contrast, CD38 ligation did not substantially affect cell numbers in cultures of normal peripheral blood or tonsillar B cells. In stroma-supported cultures of 22 B-lineage acute lymphoblastic leukemia cases, anti-CD38 suppressed recovery of CD19+ sIg- leukemic cells. CD38 ligation also suppressed the growth of immature lymphoid cell lines cultured on stroma and, in some cases, in the presence of stroma-derived cytokines (interleukin [IL] 7, IL-3, and/or stem cell factor), but did not inhibit growth in stroma- or cytokine-free cultures. DNA content and DNA fragmentation studies showed that CD38 ligation of stroma-supported cells resulted in both inhibition of DNA synthesis and induction of apoptosis. It is known that CD38 catalyzes nicotinamide adenine dinucleotide (NAD+) hydrolysis into cyclic ADP-ribose (cADPR) and ADPR. However, no changes in NAD+ hydrolysis or cADPR and ADPR production after CD38 ligation were found by high-performance liquid chromatography; addition of NAD+, ADPR, or cADPR to cultures of lymphoid progenitors did not offset the inhibitory effects of anti-CD38. Thus, anti-CD38 does not suppress B lymphopoiesis by altering the enzymatic function of the molecule. In conclusion, these data show that CD38 ligation inhibits the growth of immature B lymphoid cells in the bone marrow microenvironment, and suggest that CD38 interaction with a putative ligand represents a novel regulatory mechanism of B lymphopoiesis.

Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence.

Lateral epicondylosis is common, with various treatment modalities. Platelet-rich-plasma injections from autologous blood have recently been used in centres worldwide for the treatment of tennis elbow. We review and present the recent published evidence on the effectiveness of PRP injections for lateral epicondylosis. Nine studies met our inclusion criteria including 6 RCT's for the purpose of analysis. PRP injections have an important and effective role in the treatment of this debilitating pathology, in cases where physiotherapy has been unsuccessful.

Transfusion management in pediatric and adolescent scoliosis surgery. Efficacy of autologous blood.

STUDY DESIGN: A retrospective review of consecutive pediatric and adolescent patients who required posterior spinal fusion to correct scoliosis. OBJECTIVES: To 1) measure the participation of pediatric patients in predeposit programs for autologous and directed blood donation 2) to assess the success of autologous predonation in preventing allogeneic blood use, 3) to determine whether transfusion indications differed between patients who received allogeneic blood and those who received autologous blood, and 4) to assess factors that predict transfusion requirements during scoliosis surgery. SUMMARY OF BACKGROUND DATA: Authors of recent studies in adults have questioned whether transfusion of autologous blood is a cost-effective therapy when compared with the less-expensive alternative--transfusion of allogeneic blood. In children, the efficacy of autologous blood has not been assessed in a large population of surgical patients. In adults, the frequency of patient participation, the success of autologous donors in avoiding allogeneic transfusion, and the proportion of collected autologous units used during the perioperative period are measures used to establish the efficacy of autologous predonation programs. METHODS: Hospital and clinic records for each patient who underwent posterior spinal fusion from September 1, 1989 through September 1, 1994 were reviewed. Blood bank consultation, autologous donation records, anesthesia records, surgical reports, and hospital records were reviewed. Seventy percent of patients (164 of 243) participated in autologous donation. RESULTS: More than 90% of autologous donors successfully avoided receiving allogeneic blood. Patients with idiopathic scoliosis (n = 168) were more likely to participate in autologous donation (n = 144) and to avoid allogeneic blood (n = 135). Patients with neurologic causes of scoliosis more commonly used allogeneic or directed donation (56 of 75 patients). Nineteen patients with neuromuscular causes of scoliosis participated in autologous donation, but more than one half of this group (10 of 19 patients) required allogeneic blood in addition to autologous units. CONCLUSIONS: Using measures of efficacy similar to those reported in studies of adults, autologous blood was found to be more effective in meeting the transfusion needs of pediatric patients who required posterior spinal fusion than in meeting those needs in adult surgical patients in previous studies.

Analysis of changes in coagulation factors after postoperative blood loss in burn and non-burn patients.

A prospective study of the postoperative kinetics of coagulation factors was undertaken in 23 burn patients and in six non-burn patients. All procedures resulted in a large volume blood loss. Fibrinogen, platelets and factors V, VIII and IX were measured serially. Burn patients returned all parameters to preoperative levels by 48 h postoperation, while non-burn patients showed a slower rate of return of platelets and factor V. This study suggests that burn patients may safely undergo re-operation at 48 h intervals for successive wound debridements if clinically necessary.

Postoperative care following single-stage laryngotracheoplasty.

Single-stage laryngotracheoplasty (SSLTP) provides a method of correcting mild-to-moderate laryngotracheal stenosis while avoiding the risks of prolonged laryngeal stenting. Pediatric patients are orally intubated for 5 to 7 days postoperatively to ensure an adequate airway while edema resolves and healing begins. During this period, continuous neuromuscular blockade has been advocated in infants and young children to avoid endotracheal tube trauma to the fresh graft and potentially life-threatening accidental decannulation. Pulmonary atelectasis is the most common morbidity associated with prolonged neuromuscular blockade. Neuromuscular weakness also may follow prolonged paralysis and prolong hospitalization. This paper compares the postoperative course of 17 patients who underwent 18 SSLTP procedures by the senior author. The first 8 patients received continuous neuromuscular blockade in the early postoperative period. To reduce perceived morbidity, the last 9 patients were managed with a protocol that incorporated daily 4- to 8-hour "interruptions" of paralysis. Seven patients tolerated this protocol modification. As a group, these patients had less postoperative pulmonary atelectasis prior to extubation (p < .05) and were extubated sooner than patients receiving continuous neuromuscular blockade (p<.05) without compromising the surgical success of the procedure. Intermittent paralysis permitted for more accurate assessment of pain control and protected against accidental drug accumulation. Although self-extubation did not occur, diligent nursing care with adequate sedation and analgesia is necessary to avoid the risk of accidental extubation.

Changes in coagulation factors in patients with burns during acute blood loss.

A prospective study was undertaken to determine the change in coagulation factors in patients undergoing tangential excisions of burn wounds when red blood cells preserved with ADSOL (adenine, dextrose, saline, and mannitol) and crystalloid solution were used for volume replacement. Nine patients with burns were studied, three on two separate occasions. No patient had a history of a bleeding disorder or had taken aspirin within 10 days of surgery. Results of preoperative coagulation studies were all within normal limits. The initial levels of coagulation factor and rates of removal were compared with those of 12 patients without burns who were undergoing elective surgery and who also had massive intraoperative blood loss. Coagulation factor levels measured included the platelet count, fibrinogen, factors V, VIII, and IX. These were determined before blood loss and each time loss and replacement of one third of a patient's calculated blood volume occurred during a tangential excision of a burn wound. The data showed that patients with burns have significantly higher baseline levels of platelets, fibrinogen, and factor VIII than patients without burns do. The removal rates of platelet and factor IX are significantly lower among patients with burns than among patients without burns. No patient in the study group developed a coagulopathy or received fresh frozen plasma or platelet supplementation. These findings suggest that the intraoperative blood losses that occurred during tangential excisions of burn wounds were made safe by the higher than normal preoperative levels of platelets, fibrinogen, and factor VIII and by the slow wash-out curve for platelets and factor IX. Prophylactic use of either fresh frozen plasma or platelet concentrates is not indicated unless a specific deficit or coagulopathy has been identified.

Application of digital signal processing to hearing aids: a critical survey.

An audiologic rationale for the application of digital signal processing techniques to hearing aids is developed. These techniques enable complex processing beyond that possible in presently available analog aids. A critical survey of algorithms for filtering, nonlinear processing, noise reduction, speech enhancement, and feedback reduction is presented. The paper concludes with a discussion of practical considerations for implementation.

The effects of intermittent compression on edema in postacute ankle sprains.

The purpose of this study was to compare the effects of three treatment protocols on pitting edema in patients with first- and second-degree sprained ankles. Thirty subjects with postacute (greater than 24 hours postinjury) ankle sprains and pitting edema but not requiring cast immobilization were randomly assigned to an elastic wrap group (N = 10), an intermittent compression group (N = 10), or an elevated control group (N = 10). Pretreatment and posttreatment volumetric measurements of the subjects' ankles were obtained by the water displacement method. After the pretreatment measurement, the groups were treated for 30 minutes. All subjects' ankles were elevated by raising the foot section of an adjustable table to a 45 degrees angle during treatment. For the first treatment group, the intermittent compression device was set at 40-50 mm Hg, with a 60-second on time and a 15-second off time. For the second treatment group, an elastic wrap was applied from the heads of the metatarsals to 12.7 centimeters above the malleoli. Control group subjects received only the elevated position as their treatment. A three by two repeated measures ANOVA with a follow-up post hoc test revealed that the elevated control group subjects had the least amount of edema (p < .0006). The two compression protocols produced increased edema in the subjects' sprained ankles following treatment. In conclusion, elevation is the most appropriate of the three treatment protocols if the major therapeutic objective is to minimize edema in the postacute phase of rehabilitation. J Orthop Sports Phys Ther 1991;14(2):65-69.

Anesthesia for magnetic resonance imaging in children: a low incidence of protracted post-procedure vomiting.

STUDY OBJECTIVE: To determine the incidence and severity of vomiting in pediatric patients who have had inhalation anesthesia for magnetic resonance imaging (MRI). DESIGN: A retrospective study of consecutive pediatric patients who had anesthesia for MRI. SETTING: A large university hospital with an integrated clinic facility. PATIENTS: 234 children who required an MRI under general anesthesia over a 30 month period (July 1989 to February 1992). MEASUREMENTS AND MAIN RESULTS: The duration of inhalation anesthesia was 105 +/- 33 minutes. Following anesthesia, the time to oral intake was 92 +/- 69 minutes. Eighteen patients (9%) experienced one or more episodes or emesis. In 14 of the 18 patients, vomiting occurred once and did not delay the intake of oral fluids or the discharge time from clinic when compared with the rest of the patients. Only one patient had frequent vomiting (more than three episodes), and all vomiting resolved spontaneously without anti-emetic therapy in less than eight hours following anesthesia. CONCLUSIONS: Protracted post-procedure vomiting is an infrequent complication of inhalation anesthesia for MRI. Inhalation anesthesia may be a less important cause of postoperative vomiting than factors such as the type of operative procedure, use of opioids, or presence of postoperative pain.

Hemodynamic responses to nitrous oxide during inhalation anesthesia in pediatric patients.

STUDY OBJECTIVE: To measure the hemodynamic changes produced by nitrous oxide (N2O) during halothane and isoflurane anesthesia in infants and children. DESIGN: A repeated measures design in two groups of infants and small children. SETTING: Operating rooms at a university hospital. PATIENTS: Nineteen healthy unmedicated infants and small children (mean age 12 months) who required elective surgery. INTERVENTIONS: Prior to anesthesia induction, cardiovascular measurements were recorded using pulsed Doppler and two-dimensional echocardiography. Following anesthesia induction with halothane (n = 10) or isoflurane (n = 9) in oxygen (O2) and air, anesthetic measures were stabilized at 1.0 minimum alveolar concentration (MAC) and cardiovascular measures were repeated. After 30% N2O was added to the 1.0 MAC anesthetic concentration, a third set of cardiovascular measurements was recorded. A final cardiovascular data set was measured 5 minutes following an increase in N2O concentration to 60%. MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure (MAP), cardiac index (CI), stroke volume (SV), and ejection fraction (EF) decreased similarly and significantly at 1.0 MAC halothane and isoflurane. Heart rate (HR) increased during isoflurane anesthesia but decreased during halothane anesthesia. The addition of N2O resulted in a decrease in HR, CI, and MAP when compared to 1.0 MAC levels of halothane or isoflurane; however, SV and EF were not significantly changed from levels measured during 1.0 MAC halothane or isoflurane. CONCLUSIONS: The addition of N2O to halothane and isoflurane anesthesia in infants and children decreased HR. This decrease led to a decrease in cardiac output (CO). Unlike with adults, N2O did not produce cardiovascular signs of sympathetic stimulation in infants and children.

The free gingival graft combined with the frenectomy: a clinical review.

Abnormal labial frena are capable of retracting gingival margins, creating diastemas, and limiting lip movement. When these frena are present, the traditional frenectomy alone generally is successful. However, when the frenulum is extensive, the possibility of coronal reformation exists. Several procedures have combined the frenectomy with either a lateral pedicle flap, free papilla graft, or free gingival (mucosal) graft taken from the palate. Three case reports demonstrate the continued efficacy of the traditional palatal free gingival graft when the patient has an extensive frenulum or an area of minimal esthetic concern is involved.

Herbart's mathematical psychology.

J.F. Herbart (1824/1890b) provided a mathematical theory about how mental ideas (Vorstellungen) in consciousness at Time 1 (T1) could compete, possibly driving 1 or more Vorstellungen below a threshold of consciousness. At T1 a Vorstellung A could also fuse with another, B. If at a later T2, A resurfaced into consciousness, it could help B to re-resurface into consciousness. This article describes the historical and mathematical background of Herbart's theory, outlines the mathematical theory itself with the aid of computer graphics, and argues that the theory can be applied to the modern problem of predicting recognition latencies in short-term memory (Sternberg's task; Sternberg, 1966)

Current trends in simulation training in anesthesia: a review.

Anesthesiology as a specialty has made numerous prescient commitments to better patient care. Physicians entering residency are reaching the zenith of their educational odyssey and primarily acquire knowledge and skill through active involvement. Simulation training and associated assessment offers a chance for active involvement to the learner. The goal of the training is to accelerate skill acquisition, improve skill retention and reduce the extinction of skills. Simulation training programs have been shown to increase the skill of anesthesiologists. This increase in skill is expected to translate to evidence of improved patient care. Direct evidence that simulation directly improves patient care continues to be difficult to establish. In the future, the intuitive benefit of simulation as a means to improve the safety and quality of patient care is likely to become established by clinical research.