Osteochondritis dissecans of the femoral head in children and adolescents: a report of 17 cases.

Osteochondritis dissecans of the femoral capital epiphysis is uncommon and is usually reported as a case report or in association with other diseases. This study reports 17 cases with the primary underlying diagnosis of Legg-Calvé-Perthes disease in seven, idiopathic in six, avascular necrosis following trauma in three, and avascular necrosis with previous infection in one. Twelve cases had long-term follow-up. Two cases in which no surgery was performed were followed for an average of 12.5 years; 10 cases in which surgery was performed were followed for an average of 16.1 years. Excision of the osteochondritis fragment was performed in six cases. It was necessary only to dislocate the hip to excise the lesion in five cases. No morbidity resulted from temporary surgical dislocation. Excision of the osteochondritis dissecans fragment allowed these six patients to return to fairly normal living during the time of follow-up.

Ulcerative tracheobronchitis years after colectomy for ulcerative colitis.

Two men with severe ulcerative colitis developed ulcerative tracheobronchitis 4 and 8 years after total colectomy. Intense plasma cell infiltration of tracheal mucosa and submucosa and destruction of mucous glands occurred, with partial relief of symptoms with corticosteroids. We compare them with the only other case reported, also years after colectomy.

Hands across the equator: the Hereford-Muheza link eight years on.

Short elective sabbatical visits have been arranged between Herefordshire Health Authority in England and Muheza Health District in Tanzania over the past eight years. Any employee can apply, and the 64 who have participated include midwives, physiotherapists, engineers, and nurse tutors. The possibility of being chosen adds to the attractiveness of working in both districts, and costs have been small. The visits are believed to have led to new ideas and a willingness and confidence to consider change.

Wegener's granuloma. A series of 265 British cases seen between 1975 and 1985. A report by a sub-committee of the British Thoracic Society Research Committee.

In order to describe the British experience of Wegener's granulomatosis Hospital Activity Analysis was used to collect cases diagnosed in England, Wales and Scotland between 1975 and 1985. Where possible clinical details, histological material and chest radiographs were obtained. Two hundred and sixty five patients were considered to have Wegener's granulomatosis. In 109 a single pathologist confirmed the diagnosis by finding both granulomas and vasculitis in biopsy material. The diagnosis was made on clinical grounds or clinical grounds together with histological diagnosis in the local hospital in 156 patients. Wegener's granulomatosis was confined to the lung or upper respiratory tract in 22 per cent of patients and renal disease occurred in 58 per cent. Laboratory tests showed a pattern of mild anaemia, polymorph leucocytosis, eosinophilia and an elevated ESR and hypergammaglobulinaemia, with no specific pattern of changes. Histological confirmation was most frequently obtained by examination of nasal biopsy specimens, but multiple biopsies were often required. Renal biopsies showed focal proliferative glomerulonephritis but granulomatous glomerulonephritis was uncommon. Of available chest radiographs 61 per cent were abnormal, large opacities being most common. Small irregular opacities were found less often and other abnormalities were uncommon. Treatment varied widely and 10 per cent of patients received no drug therapy. This large series illustrates that even without specific treatment, patients with Wegener's granulomatosis can survive for several years and with modern treatment survival for more than a decade is possible. Conclusions about the effectiveness of the various therapies cannot be drawn from this retrospective study. Renal failure and disseminated vasculitis were the commonest causes of death; death was considered to result from complications of treatment with cytotoxic drugs or prednisolone in 6 per cent of patients.

A new portal venous shunt for bypass in orthotopic hepatic grafting.

A new heparin bonded portal venous cannula is described for use during orthotopic hepatic transplantation. This new shunt has a "shoulder" 4 centimeters from the caged tip, allowing it to be securely maintained within the portal vein. With a 60 degree curvature 7 centimeters from the tip, the shunt can conveniently be positioned away from the operative field.

Caregivers as comptrollers: women and long-term care and cost containment.

The emphasis on cost containment that was the hallmark of the Reagan Administration and the shifting of the burden for long-term care onto the informal sector have had a particularly negative impact on women. Women through caregiving are used to help control the public cost of long-term care. This unwritten policy is unlikely to be successful because of a number of factors: (1) the economic condition of women; (2) the lack of available and affordable community services; and (3) the types of social relationships we now have.

The impact of DRGs on community-based service providers: implications for the elderly.

We investigated changes in community-based agencies following the implementation of the Medicare prospective payment system for hospitals utilizing DRGs (diagnosis-related groups). Data were collected in 1986 and 1987 from 771 community service providers. There were five major findings: 1) hospital discharge planners, nursing homes, and home health agencies experienced DRG effects before other types of community providers studies; 2) the "reach" of DRG impact is widespread; 3) providers report a change in clientele toward a heavier-care client; 4) the impact of DRGs affects the types of services agencies provide; and 5) community providers have experienced a decrease in their ability to refer their clients both to hospitals and to each other.

The emergence of adult day care centers as post-acute care agencies.

Research on the effects of the Medicare Prospective Payment System utilizing DRGs on community service providers indicates that a heavier-care clientele is changing the nature of the community-based long-term care system. This article reports on the impact of DRGs on one provider type, adult day care centers, and the resulting shift toward post-acute care to meet the demands of this new heavier-care clientele. The 39 adult day care centers reported on are part of a larger sample of providers studied over three years in 12 communities within five states.

Financing and home health agencies.

Home health agencies are examined with reference to changes that have occurred in their financing as a result of DRGs. Comparisons are made based on organizational affiliation and findings indicate agencies that become affiliated with larger and more complex organizations are more frequently proprietary agencies. In other ways, however, nonprofit and proprietary agencies are becoming more similar. Both types of agencies are increasingly interested in reducing reliance on government funding.

Sputum wax-worms after plombage.

Paraffin wax plombage was one of several plombage operations used for pulmonary tuberculosis about 40 years ago, and Shepherd included seven patients treated with wax plombage in her review of plombage in 1985. We describe another patient with wax plombage who coughed up wax 28 years after plombage, followed by much larger amounts of wax 15 years later. The pieces of wax were like worms and spirals, and we discuss possible causes for these shapes.

"Medicalization" of community services for the elderly.

Research on medical care cost containment has indicated that the community-based service system is undergoing a process of restructuring within the context of an increasingly competitive environment and strong pressures to "medicalize" medical care services.

Effects of age, stimulus selection, and retrieval environment on odor identification.

Age differences in odor identification were investigated by using relatively familiar and unfamiliar chemical stimuli and enhancing the retrieval environment by restrictive reminding of memories evoked by stimulus during initial presentation. Age differences were seen in initial identification, in learning the labels of items in the stimulus set, in presentation. Age differences were seen in initial identification, in learning the labels of items in the stimulus set, in forgetting over a 24-hr period, but not in forgetting over a 7-day period. Old (n = 20) and young (n = 20) study participants benefitted equally from enrichment of retrieval environment with restrictive reminding of memories evoked at initial presentation. Item analysis indicated that selection of stimuli had a significant effect on age differences in odor identification.

Protection by verapamil of mitochondrial glutathione equilibrium and phospholipid changes during reperfusion of ischemic canine myocardium.

Pretreatment of the ischemic myocardium with verapamil protects against mitochondrial respiratory depression observed during ischemic arrest as well as during reperfusion. Since ischemic mitochondrial function appears not to be altered further by reperfusion, the purpose of this study is to identify a biochemical event affecting mitochondria that is specifically associated with reperfusion injury. It has been proposed that increased cellular Ca2+ influx and oxygen toxicity may result from reintroduction of coronary flow. Increased cytosolic Ca2+ is transmitted to the mitochondria with subsequent activation of Ca2+-dependent events, including phospholipase A2. Net production of lysophospholipids (and loss of total diacylphospholipids from the mitochondria) will proceed when reacylation mechanisms are inhibited. Since acyl-CoA:lysophospholipid acyltransferase is a sulfhydryl-sensitive enzyme and since increased activity of glutathione peroxidase shifts the levels of the mitochondrial sulfhydryl buffer, glutathione, towards oxidation, levels of glutathione and its oxidation state were measured during reperfusion in the absence or presence of verapamil pretreatment. Ischemia lowers total glutathione and reduces the redox ratio (reduced glutathione: oxidized glutathione) by 85%. Reperfusion partially returns the redox ratio to control by causing oxidized glutathione to disappear from the matrix. Verapamil maintains both the concentration and the redox potential of glutathione at control levels. Concomitant with alterations in reduced glutathione:oxidized glutathione is a decrease in ischemic mitochondrial phospholipid content. During reperfusion, phosphatidylethanolamine and its major constituent fatty acids (C 18:0 and C 20:4) are specifically lost from the mitochondrial membrane. Accompanying the significant loss of arachidonic acid during reperfusion is the decreased content of 11-OH, 12-OH, and 15-OH arachidonate. These lipid peroxidation products are not increased in ischemia. It is proposed that oxidation of matrix glutathione to glutathione disulfide during ischemia results in formation of glutathione-protein mixed disulfides and inhibition of sulfhydryl-sensitive proteins, including acyl-CoA lysophosphatide acyltransferase. Thus, metabolic events occurring within the ischemic period set the stage for prolonged dysfunction during reperfusion.

Benign focal amyotrophy: metrizamide CT evidence of cord atrophy. Case report.

Benign focal amyotrophy is an uncommon variant of neuron disease characterized by the gradual development of atrophy usually involving one upper extremity with a subsequent nonprogressive course. Previous descriptive reports have included normal radiological studies. We present a case of benign focal amyotrophy with a metrizamide CT myelographic finding of segmental cord atrophy in a distribution consistent with the patient's clinical findings.

Normative data of hemoglobin concentration and free erythrocyte protoporphyrin in a private pediatric practice.

Free erythrocyte protoporphyrin (FEP) and hemoglobin concentrations in 788 children were investigated during routine check-ups in a private pediatric practice. FEPs greater than 3.0 ZPP/gm hemoglobin were found in 29.8 percent of 9-month-olds and in 9.6 percent of the total group tested. Correlations between FEP levels and hemoglobin concentrations are presented.