A comprehensive functional and clinical analysis of ABCC2 and its impact on treatment response to carbamazepine.

At the blood-brain barrier, overexpression of the drug efflux transporter ABCC2 (also known as MRP2) has been proposed as a mechanism for impaired carbamazepine (CBZ) treatment response in epilepsy. However, investigation of the impact of ABCC2 polymorphisms on CBZ treatment efficacy has produced conflicting and inconclusive results. A series of in vitro cell efflux and plasma membrane vesicle uptake assays were undertaken to investigate whether CBZ was an ABCC2 substrate. In addition, the effect of three common ABCC2 polymorphisms, -24C>T, c.1249G>A and c.3972C>T, on the efficacy of CBZ in epilepsy (assessed using the clinical end points time to first seizure and time to 12-month remission from the SANAD (Standard and New Antiepileptic Drugs) trial) was determined. CBZ was found not to be a substrate for human ABCC2 in vitro. Clinically, no significant association was observed for the ABCC2 genetic variants and CBZ treatment outcomes. This comprehensive analysis does not support a role for ABCC2 in CBZ treatment efficacy.

Efficacy of four systemic insecticides for reducing Nantucket pine tip moth (Rhyaciona frustrana) (Lepidoptera: Tortricidae) infestation levels and improving growth metrics in loblolly pines.

The Nantucket pine tip moth (NPTM) (Rhyacionia frustrana Comstock) is a native, regeneration pest of young loblolly pines (Pinus taeda L.), causing shoot dieback, tree deformity, and growth and volume declines. Soil applications of systemic insecticides may be an effective strategy to suppress NPTM populations. The study objective was to assess the efficacy of four systemic insecticide treatments (chlorantraniliprole, dinotefuran, fipronil, and imidacloprid) for two growing seasons in outplanted bareroot and containerized seedling trials. Response variables included NPTM infestation rates, along with tree height, groundline diameter, volume index, and stem form. Infestation rates significantly decreased for each systemic insecticide treatment during the first year compared to controls, although dinotefuran and imidacloprid provided season-long control in one trial. Chlorantraniliprole reduced NPTM infestation rates for two growing seasons in both trials. While imidacloprid treatments did not alter growth metrics except for one comparison, fipronil and dinotefuran treatments improved several growth metrics. Chlorantraniliprole consistently improved growth metrics throughout the study.

Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip.

BACKGROUND: When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule. METHODS: The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast. RESULTS: At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures. CONCLUSIONS: We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.

The assessment of prognosis in Perthes' disease.

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side.

Correction of coxa vara in childhood. The use of Pauwels' Y-shaped osteotomy.

The long-term results following the correction of coxa vara by Pauwels' Y-shaped intertrochanteric osteotomy have been evaluated in 14 children. Ten of the children had unilateral hip disease and were otherwise normal while four had bilateral hip disease due to generalised skeletal dysplasias. In each case, the growth plate was vertical, the femoral head was displaced inferiorly and there were abnormalities in the metaphysis of the femoral neck. The results indicate that this osteotomy provides lasting correction of the deformity, regardless of the cause, as long as the inclination of the growth plate is corrected to 40 degrees or less and adequate support is provided for the metaphyseal defect and the displaced femoral head.

Medial physeal stapling for primary and secondary genu valgum in late childhood and adolescence.

We report the results of medial physeal stapling in 16 knees with primary genu valgum and 27 with secondary genu valgum. In the primary group, stapling was undertaken at a mean chronological age of 12 years in girls and 13 years in boys. The medial femoral physis was stapled in ten knees and the medial femoral and tibial physes in six knees. At skeletal maturity, all patients had excellent or good leg alignment. Secondary genu valgum is due to skeletal dysplasia, haematological or endocrine disorders, or to juvenile chronic arthritis. Stapling was at a mean chronological age of 11 years in girls and 14 years in boys. The medial femoral physis was stapled in 13 knees, the medial tibial physis in three and both in 11 knees. At skeletal maturity, 85% had excellent or good leg alignment, and correction had occurred within one year. Two of the poor results were due to staple extrusion from osteoporotic bone, and two to overcorrection. Rebound growth was minimal and unpredictable after the removal of staples. Medial physeal stapling is a suitable method of treatment for both primary and secondary genu valgum in late childhood and in adolescence. At least one year of knee growth is required to achieve correction, and care is needed to avoid overcorrection of the secondary genu valgum.

Resection for symptomatic talocalcaneal coalition.

Over a nine-year period, 20 feet with persistently symptomatic talocalcaneal coalition were treated by resection of the bar. The 17 patients were all under 16 years of age. Excellent or good long-term results were achieved in the ten feet in which preoperative coronal CT had shown that the area of coalition measured 50% or less of the area of the posterior facet of the calcaneum. In these feet heel valgus was less than 16 degrees and there were no radiographic signs of arthritis of the posterior talocalcaneal joint. Talar beaking was present in 70% of these feet but it did not impair the clinical result. Fair or poor results were observed in the ten feet in which preoperative CT had shown the area of relative coalition to be greater than 50%. In these feet, heel valgus was greater than 16 degrees and most had narrowing of the posterior talocalcaneal joint and impingement of the lateral process of the talus on the calcaneum.

Surgical treatment of double major scoliosis. Improvement of the lumbar curve after fusion of the thoracic curve.

We have evaluated two methods of surgical treatment of adolescent idiopathic double major scoliosis in 59 patients. In group 1, 31 patients were treated by fusion of the upper curve only. In group 2, 28 patients had lumbar fusions also including most of the lower curve. The magnitude of the lower curve and the correction obtained in traction were good indicators of the correction achieved postoperatively. Forty-four patients were reviewed at a minimum of 10 years after operation. Those in group 1 showed sustained improvement of the lower curve with minimal stiffness and pain. Group 2 patients had lumbar curves of similar severity at review, but had significantly more low back pain and stiffness. The number of lumbar segments which remained mobile appeared to be a critical factor in determining the outcome. Selective fusion of the upper curve in double major scoliosis produces satisfactory results if the lumbar curve is less than 50 degrees. It may also be appropriate for flexible lumbar curves of larger angle.

Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity.

We reviewed 13 children with partial growth plate arrest who had been treated by epiphyseolysis. Eight were followed to skeletal maturity and five for at least four years. In three cases the affected limb was restored to normal and in five the operation was successful in improving angular deformity and leg length discrepancy such that further surgery was not necessary. In the five failures, angular deformity had progressed or limb length discrepancy had increased. There were no significant complications and the procedure did not prevent subsequent osteotomy or limb length equalisation. Epiphyseolysis was most effective for small bars and those affecting only the central area of the plate.

Torticollis due to a combination of sternomastoid contracture and congenital vertebral anomalies.

We report four children with sternomastoid contracture combined with torticolis secondary to congenital vertebral anomalies. Two had features of Klippel-Feil syndrome and a proximal release of the contracted sternomastoid produced good cosmetic correction initially. Progression of the deformity occurred subsequently without recurrence of sternomastoid contracture. One child had such mild deformity that it was merely observed. The fourth child was born with torticollis without sternomastoid tightness and a vertebral anomaly was later recognised. He slowly developed a sternomastoid contracture and his condition was considerably improved by sternomastoid release. This combination of causes of torticollis has not, as far as we know, been previously reported. The clinician should be aware of it and should also realise that radiographs of the very immature spine may not disclose the bony anomalies.

Chest wall deformity in patients with repaired esophageal atresia.

Chest wall deformities developed after thoracotomy for esophageal atresia, in 77 of 232 patients (33%) who did not have a congenital vertebral anomaly. Anterior chest wall asymmetry was present in 47, scoliosis in 18 and a combination of both in 12 patients. Scoliosis was convex away from the incision in two thirds of those affected. Anterior chest wall deformity was more common in patients greater than 25 years of age, and scoliosis was more common in patients who had had multiple thoracotomies. Breast surgery to minimize inequality was required in three female patients, and spinal surgery in one patient. Twenty-two of 53 patients with a congenital vertebral anomaly developed scoliosis, eight of whom required surgery. The scoliosis was probably the result of the vertebral anomaly in these patients, who are particularly at risk for progressive deformity.

AIDS and pregnancy. Survey of knowledge, attitudes, beliefs, and self-identification of risk.

A descriptive educational needs assessment was conducted at a southwestern military medical center on knowledge, attitudes, beliefs, and self-identification of risk factors for acquired immunodeficiency syndrome (AIDS). A self-report questionnaire was administered to 700 pregnant women. Misinformation and lack of knowledge about AIDS were identified. A small group of women reported that they were at risk for AIDS. The study findings support a need for AIDS educational programs for childbearing women.

Muscle abnormalities in idiopathic toe-walkers.

The cause of toe-walking is unknown. Muscle biopsies were taken from a group of 25 toe-walkers who were treated at this hospital to try to identify the pathological cause of the condition. The most common abnormality noted was an increase in the proportion of type I muscle fibers with type grouping; other less common changes included the presence of angulated atrophic fibers and thickened capillaries and cases in which occasional fibers were undergoing active degeneration and regeneration. The combination of these changes suggests that there may be an underlying neuropathic process in idiopathic toe-walkers.

Idiopathic toe-walking: does treatment alter the natural history?

Outcomes from observation or cast or surgical treatment of idiopathic toe-walking were determined in 136 children. With patient-determined outcomes, for the observation group, gait was normal in 6%, improved in 45%, and unchanged in 49%. Physician-determined outcomes demonstrated normal gait in 12% of children. Outcomes were similar in the cast group. With patient-determined outcomes in the surgical group, 22% walked normally, 50% had improved, 26% were unchanged, and 2% had deteriorated; with physician-determined outcomes, 37% walked normally. The natural history, determined from the observation group, was for idiopathic toe-walking to persist, albeit with improvement in 50%. Cast treatment did not alter the natural history. Surgical treatment may influence the outcome, but indications for surgery need to be clarified.

An anti-smoking project instituted by senior nursing students in a rural community.

The Health Council of Hawkins County, Tennessee, received a State Tobacco Prevention grant to institute an anti-smoking program in the county schools. The program chosen was called TarWars and encompasses a prohealth tobacco-free program curriculum. The goal was to discourage tobacco use among the nation's youth by focusing on tobacco's short-term ill effects. Because the program encourages community involvement, nursing students from East Tennessee State University, Johnson City, identified volunteers from the Hawkins County Retired Teachers Association to develop a teaching program for use in the first year of the program and as well as in subsequent years of the TarWars curriculum. A pretest and posttest were given to the students to assess the program's success. The objectives of the grant were that 80% of the students would be able to name three negative effects associated with tobacco use and three positive effects of not using tobacco. The goal was met when 91% could identify negative effects and 89% could identify three positive effects of not using tobacco.

A new approach to lateral cutaneous nerve of thigh block.

A new approach to the lateral cutaneous nerve of thigh is described. It depends on locating the depth of the canal through which the nerve passes immediately medial to the anterior superior iliac spine. Anatomical dissections show that it lies deep to the attachments of external oblique aponeurosis, the internal oblique muscle, and a deep fascial layer. Two district 'pops' or loss of resistance can be identified during insertion of a short-bevelled needle. Location of the canal by the technique described has been confirmed radiographically.

Bilateral hypoplastic calcanei.

A previously undescribed anomaly of the calcaneus occurred in an otherwise healthy 2-month-old girl. There was marked bilateral hypoplasia of the calcanei, involving approximately the posterior half of each. The child stood at 15 months and walked at 22 months. At age 5 years, the child had a slight in-toed gait that corrected with dorsiflexion. Her only problem has been some difficulty with shoeware. The etiology of this anomaly remains conjectural.

Osteochondritis of the first metatarsal epiphysis.

Two cases of painful osteochondritis of the basal epiphysis of the first metatarsal are described. Complete resolution without deformity was achieved in both patients. We suggest that this condition be considered in the differential diagnosis of transitory foot pain in childhood.

Spinal deformity in patients born with oesophageal atresia and tracheo-oesophageal fistula.

Spinal deformity was present in 58 (19%) of 302 patients born with oesophageal atresia and fistula when examined at review. This was present in 24 (47%) of 51 patients with vertebral anomalies and 34 (14%) of 251 patients with normal vertebrae. Scoliosis was present in 21 patients with vertebral anomalies, torticollis in two, and lordosis in one. Two thirds of the patients with congenital scoliosis have had or are likely to require operation, compared with five patients with non-congenital scoliosis. Scoliosis associated with mixed vertebral anomalies in the lower thoracic spine had the worst prognosis. The medical records of a further 64 patients who had survived operation but who could not be traced were reviewed, and indicated that four had had congenital vertebral anomalies but none had a spinal deformity. We recommend early detection of vertebral anomalies in this group and careful follow up of patients with these abnormalities.

Survival of bacterial enteropathogens in the ice of popular drinks.

We examined the survival of four bacterial enteropathogens frozen in ice and subsequently allowed to melt in various popular drinks. The counts of all the organisms were markedly lowered by freezing alone, and the numbers were further decreased by exposure to some of the drinks. Nevertheless, none of the organisms were completely eliminated as a result of freezing for 24 hours followed by melting in any of the test drinks, even when the drink was 86-proof tequila.