Fetal hemivertebra: associations and perinatal outcome.

OBJECTIVES: To assess the accuracy of antenatal diagnosis of hemivertebra, to quantify the association with coexisting anomalies and to determine the perinatal outcome. METHOD: This was a retrospective observational study of all cases of suspected fetal or neonatal hemivertebra identified via the UK Southwest Congenital Anomaly Register (SWCAR) between 2002 and 2012. RESULTS: From a total of 88 cases of hemivertebra identified during the study period, data were obtained for 67 of them: 45 (10 isolated and 35 with coexisting anomalies) cases were suspected antenatally and 22 (10 isolated and 12 with coexisting anomalies) were diagnosed postnatally. Of the cases detected postnatally, five (four with coexisting anomalies) were unsuspected and diagnosed at postmortem examination. The most commonly associated anomalies included additional skeletal abnormalities (n = 16), genitourinary abnormalities (n = 10), VATER/VACTERL association (n = 5), cardiac abnormalities (n = 4) and central nervous system abnormalities (n = 4). In cases with coexisting anomalies there was a 48% fetal/neonatal loss, compared to 19% in cases with isolated hemivertebra. CONCLUSIONS: Although antenatal diagnosis of hemivertebra was accurate, a third of the cases were diagnosed only postnatally. These data suggest a difficulty in antenatal diagnosis of the condition. The majority of cases of hemivertebra had coexisting anomalies, and in these cases the rate of perinatal loss was high. These data should be useful in providing additional information for counseling when a diagnosis of hemivertebra is made.

Minidex: very low dose dexamethasone (0.05 mg/kg/day) in chronic lung disease.

OBJECTIVE: Postnatal dexamethasone therapy is controversial. This study aimed to determine the short-term effects of Minidex (low-dose dexamethasone 0.05 mg/kg/day) on ventilator-dependent preterm babies. METHODS: Very preterm babies (less than 30 weeks of gestation or under 1500 g) who were ventilator dependent at over 2 weeks of life and received Minidex therapy (low-dose dexamethasone 0.05 mg/kg/day for 10 days followed by alternate-day doses for 6 days) were compared retrospectively to a matched comparison group who received neither Minidex nor standard-dose dexamethasone. RESULTS: 50 babies who received Minidex were compared to a comparison group of 26 babies. Babies treated with Minidex extubated significantly faster than controls, Cox regression hazard ratio 6.24 (95% CI 2.34 to 16.63). By day 4, 34% of babies treated with Minidex had extubated but no controls had. Babies who received Minidex showed significant improvements in both ventilatory index and oxygen requirements, had no increased rate of clinical hypertension (OR 1.16 (95% CI 0.42 to 3.21)) or hyperglycaemia (OR 1.55 (95% CI 0.44 to 5.45)) and had a similar rate of chronic lung disease at 36 weeks' corrected age (OR 1.61 (95% CI 0.62 to 4.22)). No baby developed gastrointestinal perforation or haemorrhage. CONCLUSION: Minidex therapy facilitates extubation and is not associated with clinically significant short-term side effects. A randomised controlled trial is required to further assess efficacy and long-term outcomes.

Does routine assessment and real-time feedback improve cancer patients' psychosocial well-being?

This study examined the effectiveness of giving medical oncologists immediate feedback about cancer patients' self-reported psychosocial well-being in reducing those patients' levels of anxiety, depression, perceived needs and physical symptoms. Cancer patients attending one cancer centre for their first visit were allocated to intervention (n = 42) or control (n = 38) groups. All patients completed a computerized survey assessing their psychosocial well-being while waiting to see the oncologist. Intervention patients' responses were immediately scored and summary reports were placed in each patient's file for follow-up. A total of 48 participants (25 intervention and 23 control) completed the survey four times. Intervention patients who reported a debilitating physical symptom at visit 2 were significantly less likely to report a debilitating physical symptom at visit 3 compared with control patients (OR = 2.8, P = 0.04). Reductions in levels of anxiety, depression and perceived needs among intervention patients were not significantly different to control patients. Repeated collection and immediate feedback of patient-reported health information to oncologists has potential to improve patients' symptom control, but has little impact upon emotional well-being, including those at high risk. Future research should consider providing the feedback to other health professionals and patients, and monitor the impact on the process of individual patient care.

Survey of paediatric complementary and alternative medicine use in health and chronic illness.

Groups of 25 children with cerebral palsy (CP), inflammatory bowel disease (IBD), and cancer were compared to 25 healthy children to establish use of complementary or alternative medicine (CAM). Children with chronic disease were greater than three times more likely to use CAM, usually without paediatricians' knowledge.

Effects of transfusion in anemia of prematurity.

The authors aimed to test the hypothesis that blood transfusions depress hematopoiesis in healthy infants with anemia of prematurity (AOP). They also set out to find markers that predict recovery from AOP. Thirty-nine premature babies underwent weekly and post-transfusion measurements of hemoglobin concentrations, reticulocyte counts (RCC), and erythropoietin levels (EPO). RCC and EPO dropped significantly 7 days after a blood transfusion but had normalized after 14 days. Elevated RCC or EPO levels were not predictive of an increase in hemoglobin. Postnatal HbFg/dL was higher in babies who had received transfusions. The authors conclude that blood transfusions depress erythropoiesis in infants with AOP and stimulate HbF synthesis but this effect is not sustained. Reticulocyte counts and erythropoietin levels are unhelpful in predicting recovery from AOP.

Regulation of Staphylococcus aureus type 5 and type 8 capsular polysaccharides by CO(2).

Staphylococcus aureus expression of capsular polysaccharide type 5 (CP5) has been shown to be downregulated by CO(2). Here we show that CO(2) reduces CP5 expression at the transcriptional level and that CO(2) regulates CP8 expression depending on the genetic background of the strains. Growth in the presence of air supplemented with 5% CO(2) caused a significant decrease in CP8 expression in four S. aureus strains, a marginal effect in four strains, and higher CP8 expression in strain Becker. Absolute CP8 expression in the nine S. aureus strains differed largely from strain to strain. Four groups of strains were established due to sequence variations in the promoter region of cap5 and cap8. To test whether these sequence variations are responsible for the different responses to CO(2), promoter regions from selected strains were fused to the reporter gene xylE in pLC4, and the plasmids were electrotransformed into strains Becker and Newman. XylE activity was negatively regulated by CO(2) in all derivatives of strain Newman and was always positively regulated by CO(2) in all derivatives of strain Becker. Differences in promoter sequences did not influence the pattern of CP8 expression. Therefore, the genetic background of the strains rather than differences in the promoter sequence determines the CO(2) response. trans-acting regulatory molecules may be differentially expressed in strain Becker versus strain Newman. The strain dependency of the CP8 expression established in vitro was also seen in lung tissue sections of patients with cystic fibrosis infected with CP8-positive S. aureus strains.

Quantitative hepatobiliary scintigraphy in normal cats and in cats with experimental cholangiohepatitis.

Quantitative hepatobiliary scintigraphy using 99mTc-mebrofenin was performed on eight normal cats and on the same cats after induction of experimental cholangiohepatitis by infection with the liver fluke Platynosomum concinnum. Hepatobiliary scintigraphy was performed 3 times at 10 weeks, 4 months and 6 months after infection. In addition, routine biochemical tests, hepatic ultrasound and ultrasound guided hepatic biopsy samples were obtained at the same time points, and the results compared with hepatobiliary scintigraphy. The normal hepatic extraction fraction was determined to be 85%, and the normal hepatic excretion half time (T 1/2) was 14 minutes. There was no significant change in scintigraphic parameters compared to pre-infection values at any time following infection with the liver fluke. No correlation between scintigraphic parameters and histologic scores was found; however, significant correlation was identified between parasite burden and histologic scores 6 months following infection. Despite the presence of severe multifocal histologic abnormalities, minimal clinical, biochemical and scintigraphic derangements were identified using this model of cholangiohepatitis. Based on this study, hepatobiliary scintigraphy appears to be an insensitive test for structural hepatobiliary abnormalities. The role of hepatobiliary scintigraphy in functional hepatobiliary abnormalities of the feline liver has not been determined.

The effect of mercury and PCBs on organisms from lower trophic levels of a Georgia salt marsh.

We examined several indicators of salt marsh function, focusing on primary producers, microbes, and grass shrimp, at a Superfund site (LCP) contaminated with mercury and polychlorinated biphenyls (PCBs) and a reference site (Cross-River) in Georgia. Primary production of Spartina alterniflora was assessed by measuring peroxidase activity (POD), glutathione concentration (tGSH), photosynthesis (A(net)), and transpiration (E). Microbial populations were assessed by measuring living-fungal standing crop (as ergosterol) and Microtox(R). Grass shrimp (Palaemonetes pugio) reproductive potential was determined by measuring individual egg mass, average egg area, brood size, and brood mass of gravid females. Comparison of the sites suggested that P. pugio reproduction was affected at the LCP site, but we were unable to document clear negative effects on other organisms we investigated. Due to natural environmental gradients, the Cross-River site may not have been a perfect control for the LCP site. Therefore, data from just the LCP site were reanalyzed using multiple regression. Fungal biomass was related to methylmercury concentrations, but the direction of the relationship differed between wholly dead shoots (positive) and partially dead shoots (negative). S. alterniflora POD was positively related to methylmercury concentrations. S. alterniflora A(net) and E were negatively related to elevation and salinity, respectively. Despite high levels of contamination at the LCP site, our results provided only suggestive evidence for impacts on organisms at lower trophic levels.

Definition and determination of acetabular component orientation in cemented total hip arthroplasty.

OBJECTIVE: To describe the spatial orientation of the cemented acetabular component in cemented total hip arthroplasty, based on a ventrodorsal and lateral radiographic projection of the pelvis. METHODS: Equations were derived by using trigonometric relationships that describe the radiographic rotation about the longitudinal pelvic axis (alpha), transverse pelvic axis (beta), acetabular inclination (phi), acetabular inclination corrected for longitudinal pelvic rotation, version (phiC), acetabular version (theta), acetabular version corrected for longitudinal pelvic rotation (thetaC), acetabular inclination corrected for transverse pelvic rotation (phi(beta)), and acetabular version corrected for transverse pelvic rotation (theta(beta)) RESULTS: Alpha was calculated by using the equation alpha = sin(-1) (x/y) where x is the transverse distance between the dorsal spinous processes and the center of the pubis on a ventrodorsal radiograph and y is the distance from the pubis to the dorsal aspect of the first coccygeal vertebra perpendicular to the long axis of the pelvis on a lateral radiograph. Phi was calculated from the long axis (LA) and short axis (SA) of the ellipse formed by the radiopaque acetabular marker ring by using the equation phi = sin(-1) (SA/LA). phiC was calculated by using the equation phiC = phi +/- (alpha - tan(-1) (tan alpha cos thetaC)). Theta was determined as previously described. ThetaC was calculated by using the equation thetaC = tan(-1) (tan theta cos alpha). Theta(beta) and theta(beta) were calculated with the equations phi(beta) = tan(-1) (tan theta cos beta) and theta(beta) = theta - tan(-1) (sin beta), respectively. Beta could not be accurately determined from ventrodorsal and lateral pelvic radiographs. CONCLUSIONS AND CLINICAL RELEVANCE: These techniques allow for more accurate postoperative radiographic assessment of acetabular component positioning. This information can then be used in retrospective or prospective analyses examining that effects of implant positioning on clinical outcome.

Acetabular component orientation as an indicator of implant luxation in cemented total hip arthroplasty.

OBJECTIVE: To determine the sensitivity and specificity with which acetabular component angles of inclination and version could be used, alone or in combination, to predict luxation of cemented total hip arthroplasties (THA). STUDY DESIGN: Comparison of retrospectively selected cases and controls SAMPLE POPULATION: All THA performed at the University of Florida between 1991 and 1998 with the BioMedtrix system and for which at least 2 months of radiographic follow-up were available. All THA performed at the University of Georgia with the BioMedtrix system which subsequently luxated. METHODS: Acetabular component inclination angle (IA) and acetabular version angle (VA) were determined for each THA. Data were grouped according to outcome - luxation or no luxation - with the luxated cases from the 2 institutions pooled. Receiver operator characteristic (ROC) analysis was used to evaluate decision rules for using IA and VA as tests for detecting postoperative luxation. Sensitivity and specificity for luxation and 95% confidence bounds were computed with selected values of IA and VA as cut-points. RESULTS: The nonluxation group consisted of 68 THA with a median follow-up time of 5 months (range, 2-60 months). The luxation group consisted of 12 THA with a mean time to luxation of 36 days. The nonluxation group had a mean +/- standard deviation (SD) IA and VA of 40.3 degrees +/- 8.9 degrees and 71.1 +/- 13.6 degrees, respectively, whereas the luxation group had a mean +/- SD IA and VA of 34.7 degrees +/- 12.6 degrees and 72.9 degrees +/- 16.6 degrees, respectively. An IA cut-point of 37.8 degrees achieved 58.3% sensitivity and 57.4% specificity. A VA cut-point of 73 degrees achieved 75.0% sensitivity and 51.5% specificity. IA and VA considered simultaneously achieved a 50.0% sensitivity and 88.2% specificity. CONCLUSIONS AND CLINICAL RELEVANCE: ROC analysis indicated that both IA and VA considered individually or simultaneously were poor indicators of luxation. Although extreme values of IA may predict luxation with high specificity, the potential for luxation cannot be excluded based on apparently appropriate values of IA and VA. The results of this study also indicate that a successful outcome is possible with a wide range of acetabular component positions.

Accuracy of patients' recall of Pap and cholesterol screening.

OBJECTIVES: This study was undertaken in mid-1994 and assessed how accurately patients recall the recency and result of their most recent cholesterol and Papanicolaou (Pap) tests. METHODS: A cross-sectional, door-to-door community survey was used to gather self-report and, subsequently, pathology laboratory data for 195 individuals. RESULTS: In regard to cholesterol screening, 30% of individuals who reported being adequately screened were actually inadequately screened, 45% who reported normal cholesterol levels actually had elevated levels, and 21% of inadequately screened individuals and 56% of individuals with elevated levels were not identified by self-report. In terms of Pap screening, 28% of women who reported being adequately screened were actually inadequately screened, 11% of patients who reported a normal Pap test actually had abnormal or inadequate results, and 55% of inadequately screened individuals and 53% of individuals with abnormal or inadequate results were not identified by self-report. CONCLUSIONS: This study revealed self-report to be a less-than-adequate measure of individuals' recall of cholesterol and Pap screening. Relying exclusively on self-report surveys as indicators of screening coverage is likely to result in significant underestimations of the proportion of people who are inadequately screened or whose results indicate a need for intervention.

Use of a circular external skeletal fixator for stifle arthrodesis in a dog.

Arthrodesis of the right stifle was performed in a 21 kg German shepherd dog that had sustained a comminuted fracture of the lateral femoral condyle as a result of a gunshot wound. The arthrodesis was stabilised with a circular external skeletal fixator. A simplified technique to facilitate creation of the osteotomies of the femur and tibia, and positioning of the stifle at the desired angle, is described. Compression of the subchondral bone surfaces of the distal femur and proximal tibia was achieved using tensioned coiled transarticular Kirschner wires. Arthrodesis of the stifle was confirmed radiographically 21 weeks following surgery, and the fixator was removed. After union of the arthrodesis and removal of the fixator, the dog was fully weightbearing when standing or walking, and intermittently weightbearing or non-weightbearing at faster gaits.

Ultrasonographic features of canine gastrointestinal pythiosis.

Pythiosis is a chronic pyogranulomatous infection of the gastrointestinal tract or skin caused by the water borne pathogen Pythium insidiosum. The ultrasonographic features of nine dogs with gastrointestinal pythiosis are reported. The stomach, duodenum, jejunum or colon were affected. All dogs had thickening of the gastrointestinal wall and areas with obliteration of the normal layered appearance. In one dog an eccentric mass was found arising from the serosal surface of the wall of the colon with mild diffuse wall thickening. Regional lymph node enlargement was seen in seven of the nine dogs. One dog had invasion of the pancreas and signs compatible with extrahepatic biliary obstruction. When compared to previous reports of gastrointestinal neoplasia, the features of wall thickening, loss of layering and regional lymphadenopathy are not considered specific for gastrointestinal pythiosis. Histological examination of tissue specimens is required for diagnosis.

Can compliance with nonpharmacologic treatments for cardiovascular disease be improved?

OBJECTIVE: To critically review the literature regarding the effectiveness of interventions aimed at improving cardiovascular patient compliance with nonpharmacologic treatments. METHODS: We searched Medline, Healthplan, and Psychlit from 1985 to 1996; searched the bibliographies of located studies; contacted Australian government departments and nongovernment organizations; and two experts examined the resulting study list. We selected 27 studies, which randomly allocated patients to groups and were published in English, and we evaluated interventions aimed at increasing compliance with nonpharmacologic treatments for cardiovascular disease. These trials were critically appraised against eight methodologic criteria and, subsequently, classified as of good, fair, or poor quality. Information about target groups, samples, trial intervention strategies and their effectiveness were extracted from the 18 good- and fair-quality trials. Interrater reliability was high on the 20% of references that were double-coded. The 18 studies reviewed described the effectiveness of 27 intervention strategies at improving compliance with dietary, smoking-cessation, exercise, weight-loss, stress-reduction, general lifestyle, relaxation, and blood pressure screening programs. RESULTS: Tentative recommendations were made for or against most trial strategies: partner-focused and structural strategies showed the most consistent benefits, physician-focused strategies were unanimously unsuccessful, and patient-focused strategies were of mixed benefit. CONCLUSIONS: The methodologic quality of many of the located trials was less than optimal. Therefore, further good-quality, randomized trials are necessary to clarify the effectiveness of those strategies identified as potentially useful in this review.

Australian oncologists' self-reported knowledge and attitudes about non-traditional therapies used by cancer patients.

OBJECTIVE: To assess Australian radiation and medical oncologists' self-reported knowledge about and attitudes towards a range of non-traditional therapies used by people with cancer. DESIGN: Postal survey during May and June 1997 of all 265 radiation and medical oncologists practising in Australia. PARTICIPANTS: 161 oncologists returned surveys (61% response rate). MAIN OUTCOME MEASURES: Oncologists' own level of knowledge, and, for each known therapy, their perceptions of its likely harm or benefit in patients being treated curatively and palliatively, and of the prevalence of use among their patients. RESULTS: Oncologists reported knowing most about acupuncture, antioxidant therapy and meditation and least about cellular therapy, magnetotherapy and psychic surgery. The therapies most likely to be considered helpful were meditation, acupuncture and hypnotherapy. Those most likely to be considered harmful were coffee enemas, psychic surgery, Iscador therapy and diet therapies. Perceptions of patients' use of most therapies varied widely, with herbal therapies, antioxidant therapy and meditation considered the most commonly used. CONCLUSIONS: These results indicate self-identified gaps in oncologists' knowledge about non-traditional therapies their patients may use; they suggest a need to consider including education about these therapies in oncologists' training.

Solitary rectal ulcer syndrome in children.

Solitary rectal ulcer syndrome (SRUS) is rare in children. Few reported cases have undergone detailed investigations, treatments have been extremely varied and outcome poorly documented. We report two cases of SRUS in children, each with a different macroscopic pathology. The diagnosis was delayed in both cases. The importance of appropriate investigation and the need to tailor treatment to the type of lesion are emphasised. One case of SRUS was associated with a complete, full thickness rectal prolapse and symptoms improved after an abdominal sutured rectopexy. The other patient responded well to endoanal excision of polypoid lesions. The diagnosis and management of this condition in children deserves wider recognition.

Consumer participation in the development of psychosocial clinical practice guidelines: opinions of women with breast cancer.

Clinical practice guidelines are playing an increasingly important role in defining quality care and consumers have a considerable interest in participating in the development of guidelines. The objective of this study was to explore consumer's perceptions of guideline items relating to psychosocial care of women with breast cancer, developed by Australia's National Health and Medical Research Council National Breast Cancer Centre. Women diagnosed with breast cancer in the previous 2 years (n = 313) received a letter about the study via their radiation oncologist. Consenting women were contacted by the researchers to complete a telephone survey. The survey asked women to rate the importance of draft guidelines items, including discussing prognosis, providing information and choice, doctor-patient communication, preparation for surgery, providing emotional support, providing social support, dealing with practical and cultural issues and continuity of care. One hundred and forty women (45%) completed the survey. The results indicated that at least 50% of respondents rated 28 of the 52 items as 'essential' components, with respondents identifying providing information and choice, and doctor-patient communication as the most important aspects of psychosocial care. The findings suggest the guidelines adequately reflect consumer opinions and identify priority areas for clinicians to address in providing psychosocial support to women with breast cancer.

The physical and psycho-social experiences of patients attending an outpatient medical oncology department: a cross-sectional study.

The aim of this study was to assess the prevalence and predictors of physical symptoms, anxiety, depression and perceived needs among patients receiving treatment at an outpatient medical oncology department using a cross-sectional survey. It was carried out at the outpatient clinic of an academic medical oncology department, which sees around 150-180 outpatients each week; 201 patients were selected. These patients answered questions to assess their levels of anxiety and depression (Hospital Anxiety and Depression Scale), perceived needs (Cancer Needs Questionnaire) and the frequency and severity of 15 physical symptoms. Fatigue, nausea, appetite loss and vomiting were the most commonly experienced and most debilitating physical symptoms. Approximately 25% of participants had borderline or clinical levels of anxiety and depression. Although relatively low levels of perceived needs were reported, physical and psychological needs were the most common. Levels of each outcome measure tended to be predictive of each other. Medical oncology outpatients experience a wide range of physical and psycho-social problems which appear, to some extent, interrelated.

Magnetic resonance imaging and ultrasonography in the diagnosis of a malignant peripheral nerve sheath tumor in a dog.

A 9-year-old male neutered mixed breed dog had a two-month history of progressive left thoracic limb lameness. There was electromyographic evidence of denervation potentials in all muscles of this limb. In magnetic resonance images a multilobulated, hyperintense mass was visible caudal to the middiaphysis of the left humerus on T-2 weighted images. The mass, which was isointense with surrounding tissue on T1 weighted images, extended proximally towards the brachial plexus. The mass was also visible as a fusiform structure of mixed echogenicity sonographically, although fine-needle aspiration performed at this time was nondiagnostic. A malignant peripheral nerve sheath tumor was diagnosed histopathologically.

The utility of pacemaker evoked T wave amplitude for the noninvasive diagnosis of cardiac allograft rejection.

Previous work suggested that pacemaker evoked T wave amplitude (ETWA) may be a sensitive noninvasive marker of cardiac allograft rejection. A Topaz QT sensing rate responsive pacemaker (Vitatron Medical) was implanted at transplantation using epicardial ventricular leads in 45 recipients (35 males; median age 51 years, range 20-63). The median duration of follow-up was 129 days (range 4-327). The ETWA at a paced rate of 100 beats/min was measured daily during hospitalization and at each outpatient attendance (900 readings). Endomyocardial biopsies were at routine intervals or when otherwise clinically indicated (257 biopsies with concurrent ETWA data). There were 58 episodes of rejection > or = grade 3a in 28 patients. The biopsies were classed as either no rejection (grade < 3a) or rejection requiring treatment (grade > or = 3a). The median normalized ETWA was 100.8% (range 24.6-239.7) without rejection and 89.9% (17.0-189.7) with rejection (Mann-Whitney U Test: P = 0.028). The performance of ETWA monitoring as a diagnostic test for the individual recipient was evaluated with exponentially weighted moving average quality control charts. For the diagnosis of all rejection episodes, ETWA monitoring had a sensitivity of 55%, a specificity of 62%, a positive predictive value of 30%, and negative predictive value of 83%. It is concluded that although analysis of pooled data showed a significant reduction in normalized ETWA with biopsy proven rejection, ETWA monitoring requires further refinement to improve sensitivity before it can be considered a clinically useful technique for the non-invasive diagnosis of cardiac allograft rejection in individual recipients.