Quantitation of intrathecal measles virus IgG antibody synthesis rate: subacute sclerosing panencephalitis and multiple sclerosis.

A method for quantitating specific anti-viral antibodies in serum and cerebrospinal fluid (CSF) is established using enzyme-linked immunosorbent assay (ELISA). Quantitated antibody levels are used to determine intrathecal specific IgG synthesis rate for the particular antibody. Measles virus was used as a model for validating this quantitative technique: a mutated form of measles virus is a cause of subacute sclerosing panencephalitis (SSPE) and there is a possibility that measles virus is related to the cause of multiple sclerosis (MS). Matched serum and CSF samples were assayed. Concentration of anti-measles IgG was determined and intrathecal measles-specific IgG synthesis rate was calculated. For the SSPE samples, measles-specific IgG synthesis rate was elevated and comprised > 20% of the total intrathecal IgG synthesis rate; these results are consistent with the literature. The ELISA method can be performed routinely, providing a quick, simple, reproducible means of quantitating specific antibody concentrations, with sensitivity greater than 1 nanogram per milliliter. With this method, quantitation of IgG antibodies to any other viral antigen can be reliably and precisely determined.

The posterior fat pad sign in association with occult fracture of the elbow in children.

BACKGROUND: An elevated posterior fat pad visible on a lateral radiograph of a child's elbow following trauma is generally considered to be suggestive of an intracapsular fracture about the elbow. However, in previous studies, the prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture has ranged from only 6 percent (two of thirty-one) to 29 percent (nine of thirty-one). We are not aware of any prospective studies, limited to children, on the value of an elevated posterior fat pad as an indicator of an occult fracture about the elbow. While it is common practice to manage children who have radiographic evidence of an elevated posterior fat pad as if they have a fracture, scientific evidence for this approach is lacking. METHODS: Forty-five consecutive children who had an average age of four and a half years, a history of trauma to the elbow, and an elevated posterior fat pad without other radiographic evidence of a fracture were enrolled in the study. At an average of three weeks after the injury, anteroposterior, lateral, and two oblique radiographs were made and evaluated for evidence of fracture-healing. If there was evidence of new-bone formation on any of these four radiographs, it was considered to indicate a fracture of the elbow. RESULTS: Thirty-four (76 percent) of the forty-five patients had evidence of a fracture. Eighteen (53 percent) of the thirty-four had a supracondylar fracture of the humerus; nine (26 percent), a fracture of the proximal part of the ulna; four (12 percent), a fracture of the lateral condyle; and three (9 percent), a fracture of the radial neck. CONCLUSIONS: This prospective study demonstrated that the posterior fat pad sign was predictive of an occult fracture of the elbow following trauma in thirty-four (76 percent) of forty-five children who had no other evidence of fracture on anteroposterior, lateral, and oblique radiographs after the injury. This finding is in contrast to those of previous studies, in which the highest prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture was 29 percent (nine of thirty-one elbows). Our results support the practice of managing children who have a history of trauma to the elbow, an elevated posterior fat pad, and no other radiographic evidence of fracture as if they have a nondisplaced fracture about the elbow.

Management of chronic deep infection following rotator cuff repair.

BACKGROUND: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. METHODS: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. RESULTS: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. CONCLUSIONS: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity.

Seven adult males with rigid, severe equinovarus deformities underwent single-stage corrective surgery. The procedure included extensive soft tissue release, talectomy and tibiocalcaneal, calcaneocuboid, and tibionavicular fusion. All seven patients fused successfully at an average of 3.5 months with a plantigrade foot. All feet were stiff and had an average of 3.5 cm limb length discrepancy. All of the patients were satisfied with the surgery and would choose to have the procedure again. This small series represents one method of achieving a plantigrade foot in patients with severe, rigid equinovarus deformities.

Skewfoot in patients with osteogenesis imperfecta.

We report skewfoot deformities in two patients who have osteogenesis imperfecta. A discussion will follow proposing etiologies of skewfoot, speculating that the ligamentous laxity often present in children who have osteogenesis imperfecta may predispose the development of skewfoot.

High-pressure injection injuries to the hand.

High-pressure injection injuries of the hand can lead to devastating outcomes. Amputation rates as high as 48% have been reported. The authors review the history of high-pressure injection injuries, with attention to the materials injected, the clinical presentation of these injuries, emergency room and subsequent definitive surgical management of these injuries, the bacteriology and recommendations for antibiotic use in these injuries, and postoperative management.

Culture results and amputation rates in high-pressure paint gun injuries of the hand.

High-pressure paint gun injuries have been well described in the literature, and the use of antibiotics is recommended as part of their management. However, there is no scientific evidence to support the use of antibiotics. In addition, the type of paint injected (water- versus oil-based) has never been investigated to determine the extent of morbidity resulting from these injuries. This study examines the organisms cultured in wounds resulting from these injuries and whether the type of paint injected had an influence on amputation rates. Charts of 35 patients with high-pressure paint gun injuries to their hands were reviewed. The amputation rate was 50% with oil-based paints and 0% with water-based paints. Forty-seven percent of wound cultures were positive, with gram-negative bacteria found in 58% of isolates. Our findings support the use of antibiotics, which should cover both gram-positive and gram-negative organisms.

Posteromedial ankle impingement.

We present a case of soft tissue impingement in the posteromedial ankle, which has not been previously reported. When a patient presents with chronic posteromedial ankle pain and swelling, clinicians should be suspicious of soft tissue impingement in the posteromedial ankle. Pertinent history and physical examinations are most helpful in the diagnosis of this lesion. Arthroscopic debridement of the hypertrophic soft tissue is successful in returning the patient to his or her previous activities.

Current review. Functional knee bracing.

Recent surgical advancements in anterior cruciate ligament reconstructions have led to better results in the treatment of knee injuries. Functional knee braces have been prescribed in greater number, leading to an increased production of commercially available braces. The effectiveness of braces remains controversial because of inconsistency in investigations of functional knee braces. This article reviews the historical background, biomechanics, and static and dynamic testing of knee braces and compares custom and off-the-shelf functional knee braces. Factors such as hinge design and soft tissue compliance, which may affect functional knee bracing, are discussed.

A technique to determine proper pin placement of crossed pins in supracondylar fractures of the elbow.

Supracondylar humerus fractures are the most common elbow injury in children. Stable fractures can be closed, reduced, and casted, whereas unstable fractures require percutaneous pinning. Studies have shown that there is a biomechanical advantage of crossed pin fixation as opposed to two lateral pin fixation. However, medial pin placement has the risk of injuring the ulnar nerve. This modification of technique was used on 46 patients, aged 12 months to 14 years (median age, 3.6 years). Two patients had an ulnar sensory and motor neurapraxia, and two patients had cubitus varus deformities postoperatively. Thus, a safe, easy, and reproducible technique of crossed pin fixation is described here.

Ganglion cysts of the anterior cruciate ligament: a case report and review of the literature.

Ganglion cysts on the anterior cruciate ligament (ACL) should be suspected in any patient having pain and clicking sensation during terminal knee extension. Previous investigators have reported incidental findings of ganglion cysts on the ACL. However, we report a symptomatic case of a ganglion cyst on the ACL that was treated successfully with arthroscopic debridement.

Cocaine-induced thrombosis of common iliac and popliteal arteries.

Cocaine-induced thrombosis has been reported in the literature; however, its mechanism is not fully understood. Most cases are of small caliber vessels, such as the coronaries and cerebral vasculature. We report a case of a 36-year-old man with signs and symptoms of acute arterial insufficiency in his right lower extremity. At angiography, the right common iliac artery and the popliteal artery were occluded. The patient was successfully treated with thrombolytic therapy. Cocaine-induced thrombosis should be suspected in a patient with history of cocaine abuse who presents with acute arterial insufficiency in an extremity, without an identifiable source.

Urethral carcinoma metastatic to bone: a case report and literature review.

Distant urethral carcinoma metastasis is a very rare event. The following discussion presents a unique case of urethral carcinoma (adenocarcinoma) metastatic to bone and reviews the literature regarding this condition.

Luminal glucose concentrations in the gut under normal conditions.

Luminal glucose (Glc) concentrations in the small intestine (SI) are widely assumed to be 50-500 mM. These values have posed problems for interpreting SI luminal osmolality and absorptive capacity, Glc transporter Michaelis-Menten constants (Km), and the physiological role of active Glc transport and its regulation. Hence we measured luminal contents, osmolality, and Glc, Na+, and K+ concentrations in normally feeding rats, rabbits, and dogs. Measured Glc concentrations were compatible with the portion of measured osmolality not accounted for by Na+ and K+ salts, amino acids, and peptides. Mean SI luminal osmolalities were less than or equal to 100 mosmol/kg hypertonic. For animals on the most nearly physiological diets, SI Glc concentrations averaged 0.4-24 mM and ranged with time and SI region from 0.2 to a maximum of 48 mM. The older published very high values are artifacts of direct infusion of concentrated Glc solutions into the gut, nonspecific Glc assays, and failure to test for quantitative recovery or to centrifuge samples in the cold. By storing food after meals and releasing it between meals, rat stomach greatly damps diurnal fluctuations in quantity and osmolality of food reaching the SI and hence also damps fluctuations in absorption rates. These new values for luminal Glc have five important physiological implications: the problem of accounting for apparently very hypertonic SI contents in the face of high osmotic water permeability disappears; the effective Km of the SI Glc transporter is now comparable to prevailing Glc concentrations; the SI no longer appears to have enormous excess absorptive capacity for Glc; regulation of Glc transport by dietary intake now makes functional sense; and the claim that high luminal Glc concentrations permit solvent drag to become the major mode of Glc absorption under normal conditions is undermined.