[Comparison of treatment results of idiopathic and non-idiopathic congenital clubfoot : prospective evaluation of the Ponseti therapy]. / Vergleich der Behandlungsergebnisse bei kongenitalen idiopathischen und nichtidiopathischen Klumpfüßen : Prospektive Evaluation der Ponseti-Therapie.

BACKGROUND: Clubfoot deformity is one of the most common congenital musculoskeletal deformities and occurs in newborns with different neuromuscular diseases. To date the Ponseti method is the gold standard for the treatment of idiopathic clubfeet but not for non-idiopathic clubfeet which are associated with neuromuscular diseases. The results of the treatment for congenital idiopathic and non-idiopathic clubfeet according to Ponseti performed in our department since 2004 were compared concerning results and relapse surgery with particular reference to the compliance of the parents concerning the use of an abduction splint. PATIENTS AND METHODS: A total of 101 children (28 female and 73 male) with 159 clubfeet were treated with the Ponseti method and included in this prospective non-randomized cohort study. Of these children 27 with 48 affected feet suffered from neuromuscular diseases which are associated with clubfoot deformity, such as myelomeningocele (n=4), arthrogryposis (n=9) and various other syndromes (n=14). The degree of the deformity was evaluated with the Pirani score initially, after casting and at follow-up. Parents were asked at follow-up to state subjectively how compliant they were with the abduction splint treatment. The necessity of surgical treatment of relapses was recorded. Statistical analysis was performed applying χ(2) and Kruskal-Wallis tests for the comparison of idiopathic and non-idiopathic clubfeet. RESULTS: The average period of follow-up was 36 month (range 6-75 months) and non-idiopathic clubfeet were initially significantly more severely deformed according to the Pirani-score (p=0.013). Treatment of non-idiopathic clubfeet was started significantly later than that of idiopathic clubfeet (p=0.003) and took significantly longer (p <0.001). A correlation between the initiation of casting and the duration of casting was not found (p=0.399). At the end of the casting period no significant differences were found between correction of idiopathic and non-idiopathic clubfeet with respect to the Pirani score (p=0.8). The mean score after casting was 0.1 in both groups. At mid-term follow-up the score increased in both groups but stayed below 0.5 with non-idiopathic clubfeet showing a significantly higher score than idiopathic clubfeet (p=0.014). Relapse surgery was necessary in 11% of the patients. No significant difference in the revision rate was found between the two groups (p=0.331) and peritalar release was not necessary in either group. The rate of revisions correlated with the compliance concerning the use of the abduction splint (p <0.001). Only 61% of the parents stated that they adhered strictly to the abduction splint treatment recommendations with no significant difference between the groups (p=0.398). CONCLUSION: This study shows good initial results after Ponseti treatment for idiopathic as well as non-idiopathic clubfeet. Based on the good functional results all clubfeet should initially be treated with the Ponseti method regardless of the etiology.

Blockade of parathyroid hormone-related protein prevents joint destruction and granuloma formation in streptococcal cell wall-induced arthritis.

OBJECTIVE: To determine whether parathyroid hormone-related protein (PTHrP), an interleukin-1beta-inducible, bone-resorbing peptide that is produced in increasing amounts by the synovium in rheumatoid arthritis (RA), may play a role in the pathophysiology of joint destruction in RA. METHODS: PTHrP expression and the effect of PTHrP 1-34 neutralizing antibody on disease progression were tested in streptococcal cell wall (SCW)-induced arthritis, an animal model of RA. RESULTS: As has been reported in RA, while serum levels of PTHrP did not change during SCW-induced arthritis, PTHrP expression dramatically increased in the arthritic synovium. Treatment with PTHrP neutralizing antibody (versus control antibody) did not affect joint swelling in SCW-treated animals. However, PTHrP antibody significantly inhibited SCW-induced joint destruction, as measured by its ability to block increases in serum pyridinoline (a marker of cartilage and bone destruction), erosion of articular cartilage, decreases in femoral bone mineral density, and increases in the numbers of osteoclasts in eroded bone. Unexpectedly, granuloma formation at sites of SCW deposition in the liver and spleen was also inhibited by PTHrP antibody, an effect associated with significant decreases in the tissue influx of PTH/PTHrP receptor-positive neutrophils and in SCW-induced neutrophilia. In vitro, neutrophil chemotaxis was stimulated by PTHrP 1-34. CONCLUSION: These findings suggest that PTHrP, consistent with its previously described osteolytic effects in metastatic bone disease, can also be an important mediator of joint destruction in inflammatory bone disorders, such as RA. Moreover, this study reveals heretofore unknown effects of PTHrP peptides on neutrophil function that could have important implications in the pathogenesis of inflammatory granulomatous disorders.

Is the blind spot enlarged in early glaucoma?

PURPOSE: We investigated whether the blind spot is larger in early "preperimetric" glaucoma with already deeply excavated optic discs than in normal persons. METHODS: We examined eight eyes of five patients with definite glaucomatous optic disc cupping but normal visual fields. Ten eyes of five normal healthy volunteers, with normal central excavation, served as controls. With SLO-perimetry we measured the differential light sensitivity 0.5-1.0 degrees outside the disc margins, "within" the center (Goldmann V stimulus) and along the horizontal meridian of the optic discs. Optic disc topography was documented with the Heidelberg Retina Tomograph (HRT). RESULTS: Differential light sensitivities adjacent to the optic discs did not differ in the two groups (normal 8.3dB, early glaucoma 8.4dB). Goldmann IV stimuli presented on the horizontal meridian of optic discs with glaucomatous cupping were seen up to 0.7 degrees centrally (i.e., towards the center) of the disc margin. In the control group this distance was significantly greater (1.3 degrees). The light differential thresholds with stimulus presentation in the disc center (Goldmann V) were significantly higher in the glaucoma group (0+/-2.8dB) than in the normal controls (6.6+/-1.3dB), though disc size was the same in both groups. CONCLUSIONS: Blind spots of normal discs seem to be smaller than those of deeply excavated discs in eyes with early glaucoma, possibly because there is more light scattering by the normal disc surface towards the adjacent functioning retina.

[Band-like keratopathy after treatment of postoperative fibrin reaction with tissue plasminogen activator]. / Bandförmige Keratopathie nach Behandlung der postoperativen Fibrinreaktion mit Gewebeplasminogenaktivator.

BACKGROUND: In recent years TPA (tissue-plasminogen activator) has been increasingly and successfully used for the treatment of severe, postoperative fibrin reaction in the anterior chamber. So far no serious side effects of this treatment have been reported. PATIENTS AND METHODS: Altogether, 32 patients received 0.2 ml solution with 20 micrograms TPA intracamerally. In 2 cases a dense corneal opacity was observed 12-24 hours after the injection of TPA which was resistant to treatment with local dexamethasone and lubricants. Therefore it was removed by superficial keratectomy. In one case the keratectomy specimen could be examined by light- and electronmicroscopy. RESULTS: In the keratectomy specimen a selective, fine-granular calcification of Bowman's membrane could be demonstrated. CONCLUSIONS: The intracameral TPA treatment for postoperative fibrin reaction can cause a rapid band keratopathy. Therefore the application of TPA should be restricted to severe therapy-resistant cases of intracameral fibrin reaction. In cases with the development of a band keratopathy EDTA-treatment is recommended.

Pattern electroretinogram and computerized optic nerve-head analysis in ocular hypertension--interim results after 2.5 years.

Evidence exists that both the pattern electroretinogram (PERG) as a parameter of ganglion-cell function and computerized morphometric disc analysis (ONHA) predict subsequent glaucomatous visual field defects in ocular hypertensive eyes. Since November 1991 we have conducted a prospective longitudinal study to evaluate the suitability of PERG and ONHA for detecting incipient glaucoma damage. Inclusion criteria were: an intraocular pressure of > or = 25 mmHG (at least two measurements taken on different days) or, in eyes with additional risk factors, > or = 23 mmHG; a normal Octopus visual field (mean defect < or = 2 dB, no local defect); and no definite glaucomatous disc cupping. After a mean follow-up period of 14.6 +/- 8.8 (range 1-33) months and with a mean intraocular pressure of 24.4 (range 18-42) mmHg, none of the 66 patients (115 eyes) converted to glaucoma. Furthermore, PERG and ONHA do not agree in their estimation of the glaucoma risk at this stage.

Dietary supplementation with very long-chain n-3 fatty acids in patients with atopic dermatitis. A double-blind, multicentre study.

The purpose of this study was to investigate whether fish oil and/or corn oil had a beneficial effect on the clinical state of atopic dermatitis, and to evaluate the dietary intake of nutrients in this group of patients. In a double-blind, multicentre study lasting 4 months, during wintertime, 145 patients with moderate to severe atopic dermatitis were randomly assigned to receive either 6 g/day of concentrated n-3 fatty acids, or an isoenergetic amount of corn oil. As local treatment, only an emollient cream or hydrocortisone cream was allowed. The fatty acid pattern in serum phospholipids, and the dietary intake of nutrients were monitored in a subgroup of patients, and the results were compared with a group of patients with psoriasis. The overall clinical score, as evaluated by the physicians, improved during the trial by 30% in the fish oil (P < 0.001) and 24% in the corn oil group (P < 0.001). This was also consistent with the results from a selected skin area, and it was further confirmed by the total subjective clinical score reported by the patients. There were no significant differences in the clinical scores between the two groups at baseline, and at the end of the study. In the fish oil group, the amount of n-3 fatty acids in serum phospholipids was significantly increased at the end of the trial, compared with pretreatment values (P < 0.001), whereas the level of n-6 fatty acids was decreased (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of dietary supplementation with very-long-chain n-3 fatty acids in patients with psoriasis.

BACKGROUND: In several studies dietary fish oil has been found to have beneficial effect on psoriasis, but the results are contradictory and based mainly on open studies or studies of small numbers of patients. METHODS: In a four-month double-blind, multicenter trial, we randomly assigned 145 patients with moderate-to-severe psoriasis to receive in their diet either highly purified ethyl esters of n-3 fatty acids ("fish oil"; 6 g of oil per day, containing 5 g of eicosapentaenoic and docosahexaenoic acid) or an isoenergetic amount of corn oil containing mainly n-6 fatty acids. All the patients were advised to reduce their intake of saturated fatty acids. A 48-hour dietary recall was performed, and the fatty-acid pattern in the serum phospholipids was monitored in a subgroup of patients. RESULTS: In the fish-oil group, n-3 fatty acids were increased in serum phospholipids (P < 0.001), the ratio of arachidonic acid to eicosapentaenoic acid decreased (P < 0.001), and the level of n-6 fatty acids decreased (P < 0.001). In the corn-oil group, only docosahexaenoic acid increased significantly (P < 0.05). The ratio of polyunsaturated to saturated fatty acids increased in both groups. Plasma concentrations of triacylglycerol decreased from base line in the fish-oil group (P < 0.05). The score on the Psoriasis Area and Severity Index, as evaluated by the physicians, did not change significantly during the trial in either group. This was also true of a total subjective score reported by the patients, but a selected area of skin in the corn-oil group showed a significant reduction in the clinical signs (P < 0.05). Scaling was reduced from base line in both groups (P < 0.01). The fish-oil group had less cellular infiltration (P < 0.01), and the corn-oil group had improvement in desquamation and redness (P < 0.05). There was no significant difference in clinical manifestations between the groups. Among the patients in the fish-oil group, an increase in the concentration of n-3 fatty acids in serum phospholipids was not accompanied by clinical improvement, whereas in the corn-oil group there was a significant correlation between clinical improvement and an increase in eicosapentaenoic acid and total n-3 fatty acids. CONCLUSIONS: Dietary supplementation with very-long-chain n-3 fatty acids was no better than corn-oil supplementation in treating psoriasis. Clinical improvement was not correlated with an increase in the concentration of n-3 fatty acids in serum phospholipids among the patients in the fish-oil group, whereas there was a significant correlation between clinical improvement and an increase in eicosapentaenoic acid and total n-3 fatty acids in the corn-oil group.

Increase of neuroretinal rim area after surgical intraocular pressure reduction.

The Optic Nerve Head Analyzer was used to measure the optic disc structure of 18 eyes (13 adult glaucoma patients) before and after surgical intraocular pressure reduction. Neuroretinal rim area markedly increased (from +0.15 mm2 to +0.45 mm2) in eight eyes, but changed either very little (less than +/- 0.1 mm2) or not at all in the remaining 10 eyes. The mean increase was from 0.75 +/- 0.26 mm2 to 0.92 +/- 0.36 mm2. The increased neuroretinal rim area found at this time remained in all eyes reexamined 1 to 3 years after surgery. Our data support previous findings that glaucomatous disc cupping may be reversed even in adult eyes, perhaps as the result of adequate pressure reduction.

Assessing the predictive validity of developmental milestones.

Parental report of development milestones influences the physician's decision to refer for developmental evaluation and early education. The predictive validity of commonly reported milestones was evaluated by collecting data from records in a comprehensive care clinic. Multivariate analyses determined the relationships among age of milestone achievement and Wechsler intelligence Scale for Children-Revised (WISC-R) intelligence quotient (IQ) scores. Other routinely collected medical and demographic information was then added, and stepwise regressions determined the best combinations of predictors of WISC-R IQ scores. Milestones alone predicted 24 to 42% of the variance in WISC-R IQ scores, suggesting that there are meaningful relationships between the age of attainment of milestones and later intellectual functioning. However, when other medical and demographic information was added to the prediction equation, the predictive power of milestones was overshadowed by that of the new variables. Milestones are validated as one criterion for referral for specialized early development services, but adding other objective data, including standardized developmental screening, is recommended for optimal decision making.