[Acquired flat foot of the adult by posterior tibial dysfunction. Options for surgical treatment]. / Pie plano adquirido del adulto por disfunción del tibial posterior. Opciones para el tratamiento quirúrgico.

We present the possible etiopatogenic causes of posterior tibial dysfunction or painful flat foot of the adult and the cause-and-effect relationship that may exist. We also expose the gradation of the lesion and the different therapeutic options for the surgical treatment of the deformity. Since 1939, multiple articles have been published, which have been endorsed by clinical, experimental, electromyographic and biomechanical studies; publications that have been consulted and evaluated for the development of this review. In our opinion: the dysfunction of the posterior tibial is caused in principle by a failure of the plantar navicular calcaneus ligament (spring ligament), the main passive stabilizer of the internal plantar arch. This failure would, in time, mean an increase in work of the posterior tibial tendon, in itself "insufficient", which would go into fatigue, until it reached a partial or total rupture. Published work on soft-part procedures acting on the posterior tibial tendon in stage II has not had the expected result in the natural history of deformity. Arthrodesis, on the other hand, has been effective in other stages, but is associated with a loss of movement dynamics in the back foot and increased pressure on adjacent joints.

Presentamos la posible causa etiopatogénica de la disfunción del tibial posterior o pie plano doloroso del adulto y la relación causa-efecto que puede existir. También exponemos la clasificación de la lesión y las diferentes opciones para el tratamiento quirúrgico de la deformidad. Desde 1939, múltiples artículos han sido publicados, avalados por la clínica, así como por estudios experimentales, electromiográficos y biomecánicos; publicaciones consultadas y evaluadas para el desarrollo de esta revisión, según nuestro criterio: el primum movens de la disfunción del tibial posterior es ocasionado por un fallo del ligamento en hamaca o calcáneo navicular plantar (spring ligament), principal estabilizador pasivo del arco plantar interno. Este fallo supondría en el tiempo un aumento de trabajo del tendón tibial posterior, de por sí "insuficiente", que entraría en fatiga hasta llegar a la rotura parcial o total. Los trabajos publicados en relación con los procedimientos de partes blandas que actúan sobre el tendón tibial posterior en el estadio II no han tenido el resultado esperado en la historia natural de la deformidad. La artrodesis por el contrario, ha sido efectiva en otros estadios, pero está asociada a una pérdida de la dinámica del movimiento en el retropié y a un aumento de la presión en las articulaciones adyacentes.

Culture-specific programs for children and adults from minority groups who have asthma.

BACKGROUND: People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered. OBJECTIVES: To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups. SEARCH STRATEGY: We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in March 2007. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma. DATA COLLECTION AND ANALYSIS: Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required. MAIN RESULTS: Three studies were eligible for inclusion in the review. A total of 396 patients, aged from 7 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41) and asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53). There was no significant difference between groups in occurrence of asthma exacerbations, but the width of the confidence interval means that effects on exacerbation rates cannot be ruled out, rate ratio 0.93 (95% CI 0.80 to 1.10). AUTHORS' CONCLUSIONS: Culture-specific programmes for adults and children from minority groups with asthma, have been found to be more effective than generic programmes in improving some (Quality of Life and asthma knowledge) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.

Clinical pathways for chronic cough in children.

BACKGROUND: Chronic cough (a cough lasting longer than 4 weeks) is a common symptom presenting to primary care in Australia and internationally. Chronic cough costs the community, is distressing to parents, and ignoring cough may lead to delayed diagnosis and illness progression of serious underlying respiratory disease. Clinical guidelines have been shown to provide more efficient and effective patient care and can clarify clinical decision making. Cough guidelines have been designed to facilitate management of chronic cough, however treatment recommendations vary and specific clinical pathways for the treatment of chronic cough in children are important, as the cause and treatments for cough in a child vary significantly adults. Therefore, it would be beneficial to clinical practice to systematically evaluate the use of clinical pathways for the treatment of chronic cough in children. OBJECTIVES: To evaluate the effectiveness of using a clinical pathway in the management of children with chronic cough. SEARCH STRATEGY: The Cochrane Register of controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in May 2007. SELECTION CRITERIA: All randomised controlled trials with parallel group design comparing use vs non-use of a clinical pathway for treatment of chronic cough in children. DATA COLLECTION AND ANALYSIS: Results of searches were reviewed against the pre-determined criteria for inclusion. Two reviewers independently selected the studies and it was planned that data extraction would have been done in duplicate. MAIN RESULTS: The search identified 471 potentially relevant titles but no studies met criteria for inclusion in the review. AUTHORS' CONCLUSIONS: Without further available evidence, recommendations for the use of clinical pathways for the treatment of chronic cough in children cannot be made. Until further evidence is available, the decision for further investigation and treatment for the child presenting with chronic cough should be made on an individual basis (i.e. dependent on symptoms and signs) with consideration for existing data from other Cochrane reviews on specific treatments for cough. Trials are required to provide evidence on the effectiveness of clinical pathways for the treatment of chronic cough in children.

Using cultural beliefs and patterns to improve mammography utilization among African-American women: the Witness Project.

Breast cancer and early detection of the disease is a significant issue for all women. Moreover, the sociocultural implications in the differential mortality rates increased interest in possible barriers to screening practices. Recently, a number of studies have investigated African Americans' cultural beliefs associated with breast cancer. This study is based upon qualitative focus group data gathered from 1989 to 1991 and 1996. This article provides focus group data that informed a culturally competent community-based cancer education program for African-American women--the Witness Project. Analysis of the qualitative data along with the quantitative outcome data revealed a direct relationship between cultural beliefs and patterns with mammography utilization. The once perceived cultural barriers can actually be applied as a cultural intervention strategy to improve breast cancer screening initiatives designed specifically for African-American women.

Hemochromatosis of the foot and ankle. Report of three cases and review of the literature.

Genetic hemochromatosis is a disorder of iron metabolism that results in deposition of massive amounts of iron in the tissues. Arthropathy is one of numerous clinical manifestations associated with this disease. Characteristic radiographic features have been reported in the hand and wrist, and the hip; however, there is no mention in the literature of joint manifestations in the foot and ankle. In this report, the authors present three patients with hemochromatosis arthropathy of the foot and ankle. Two patients presented primarily with foot pain and were treated initially with orthoses. One of these patients went on to have to midfoot arthrodesis performed. The third patient presented with ankle joint symptoms, and was treated successfully with an ankle foot orthosis. The arthritis of hemochromatosis has classic radiographic findings. However, the arthritis of hemochromatosis may be difficult to differentiate from several other joint diseases. Characteristic features of this disease in the foot and ankle are discussed.

Macrodystrophia lipomatosa of the foot: a report of three cases and literature review.

Macrodystrophia lipomatosa is a distinct clinical entity often misdiagnosed as other forms of macrodactyly. The most specific finding is an overabundance of fibrofatty tissue on the plantar aspect of the foot. Three cases, with the diagnoses made from tissue specimens, are presented in this article. The clinical, pathologic, and roentgenographic findings are discussed and a review of the literature is provided.

Intraarticular calcaneus fractures: a biomechanical comparison or two fixation methods.

OBJECTIVE: To compare the strength of fixation obtained using two unicortical 4.0 mm diameter cancellous screws versus two bicortical 3.5 mm diameter cortical screws in the fixation of intra-articular calcaneus fractures. DESIGN: In eight paired fresh frozen cadaver feet, the subtalar joint complex, consisting of the talus, interosseous ligaments, and calcaneus was removed as a unit. An oblique osteotomy of the calcaneus was then created in the sagittal plane. The two fragments were reduced and stabilized using either two unicortical 4.0 mm diameter cancellous screws or two bicortical 3.5 mm diameter cortical screws. A force was then applied to the medial calcaneal tuberosity until failure occurred. In all specimens testing was discontinued due to ligamentous failure, without causing bony disruption. RESULTS: In all specimens the forced applied to the calcaneus created a disruption of the interosseous ligaments across the subtalar joint and rotation of the calcaneus on the talus. Thus in each specimen, testing was discontinued due to interosseous ligamentous failure, without causing bony disruption. There was no statistically significant difference in force to failure between the specimens fixed with 3.5 mm diameter cortical screws as compared to those fixed with 4.0 mm diameter cancellous screws. CONCLUSIONS: The lack of a statistically significant difference in force to failure of the intra-articular calcaneus fractures fixed using 3.5 mm diameter cortical screws as compared to those fixed using 4.0 mm diameter cancellous screws and, the fact that the mode of failure was a disruption of ligaments rather than bony disruption suggest that either method of screw fixation is biomechanically adequate.

The health-care system and African Americans in Indianapolis.

In order to critically assess the health-care system in Indianapolis, it is important to analyze this African-American population from two major perspectives. First, the local African-American population must be viewed in the context of the local health-care system in its present and historical setting. Second, the local African-American population must be viewed in conjunction with other urban African-American populations. These two perspectives will show how the region's economic, social, cultural, and political climate have affected the health-care status of African Americans in Indianapolis.

Synthesis and structure-activity relationships in a series of antiinflammatory corticosteroid analogues, halomethyl androstane-17 beta-carbothioates and -17 beta-carboselenoates.

The preparation and topical antiinflammatory potencies of a series of halomethyl 17 alpha-(acyloxy)- 11 beta-hydroxy-3-oxoandrosta-1,4-diene-17 beta-carbothioates, carrying combinations of 6 alpha-fluoro, 9 alpha-fluoro, 16-methyl, and 16-methylene substituents, are described. Key synthetic stages were the preparation of carbothioic acids and their reaction with dihalomethanes. The carbothioic acids were formed from 17 beta-carboxylic acids by initial reaction with dimethylthiocarbamoyl chloride followed by aminolysis of the resulting rearranged mixed anhydride with diethylamine, or by carboxyl activation with 1,1'-carbonyldiimidazole (CDI) or 2-fluoro-N-methylpyridinium tosylate (FMPT) and reaction with hydrogen sulfide, the choice of reagent being governed by the 17 alpha-substituent. Carboxyl activation with FMPT and reaction with sodium hydrogen selenide led to the halomethyl 16-methyleneandrostane-17 beta-carboselenoate analogues. Anti-inflammatory potencies were measured in humans using the vasoconstriction assay and in rats and mice by a modification the Tonelli croton oil ear assay. Best activities were shown by fluoromethyl and chloromethyl carbothioates with a 17 alpha-propionyloxy group. S-Fluoromethyl 6 alpha, 9 alpha-difluoro-11 beta-hydroxy-16 alpha-methyl-3-oxo-17 alpha- (propionyloxy)androsta-1,4-diene-17 beta-carbothioate (fluticasone propionate, FP) was selected for clinical study as it showed high topical antiinflammatory activity but caused little hypothalamic-pituitary-adrenal suppression after topical or oral administration to rodents.

The squalestatins: novel inhibitors of squalene synthase. Enzyme inhibitory activities and in vivo evaluation of C1-modified analogues.

Squalestatin analogues modified in the C1 side chain were prepared and evaluated for their ability to inhibit rat liver microsomal and Candida squalene synthase (SQS) in vitro. While maintaining the 4,6-dimethyloctenoate or 4,6-dimethyloctanoate ester groups at C6, a number of modifications to the C1 side chain were well tolerated. However, in the absence of the C6 ester group, similar modifications to the C1 side chain caused substantial loss of activity. Compounds were also evaluated for their ability to inhibit cholesterol biosynthesis in vivo in rats and to reduce serum cholesterol levels in marmosets. These studies revealed that compounds with similar SQS inhibitory activities can possess different in vivo durations of action and lipid-lowering abilities.

Inhibitors of cholesterol biosynthesis. 1. 3,5-Dihydroxy-7-(N-imidazolyl)-6-heptenoates and -heptanoates, a novel series of HMG-CoA reductase inhibitors.

3,5-Dihydroxy-7-(N-imidazolyl)heptanoates 4 and the corresponding heptenoates 5 were synthesized as novel classes of potent HMG-CoA reductase (HMGR) inhibitors in which members of the latter series possess enzyme inhibitory activity greater than that of lovastatin 1 and pravastatin 2. Structure-activity studies show that the 7-(N-imidazolyl)heptenoates 5 are more active than the corresponding heptanoates 4. For both imidazolyl series, the 4-fluorophenyl group is preferred at C-5, and a broad range of aryl substituents which promote widely different lipophilicities is tolerated at C-4. While the CF3 group is preferred at C-2 in the heptanoate series, the 2-(1-methylethyl) substituent is optimal in the heptenoate series. The 2-(1-methylethyl) and 5-(4-fluorophenyl) groups can be interchanged in the latter series as exemplified by 5ab. Enzyme inhibitory activity resides principally in the 3R,5S series. These potent HMGR inhibitory activities by members of the heptenoate series translated well into whole cell activities in HepG2 cells. X-ray crystallographic studies on the active enantiomer 28 reveal noncoplanarity of the heptenoate C-C double bond with the imidazole ring; this finding provides an explanation for the high acid stability of the heptenoate series.

Community health screening programs for African-Americans and the medical anthropologist.

Community health screening programs were originally designed: to stimulate change in family and community knowledge and behavior relating to the prevention of disease; to inform the use of available health resources; and to improve the environmental, economic, and educational factors related to health. Since their inception, however, community health screening programs have primarily used conventional approaches to health improvement for the African-American community. That is, the need is not merely for the provision of more preventative and curative health services or the distribution of services to passive recipients, but for the active involvement of local populations in ways which will preserve or repattern their knowledge, attitudes and motivation concerning major health care issues. Health care professionals such as the clinicians need to expand their biopsychosocial model to include specific sociocultural data concerning African-American health care seeking pattern. Collaborative efforts of this type will therefore enable health care professionals to design future community health screening programs for the African-American community that are practical and culturally-oriented.

An ethnomedical analysis of hypertension among Detroit Afro-Americans.

To analyze Afro-American ethnomedical beliefs and practices concerning disease and health care, the author investigated the health-care-seeking behavior among 285 Afro-Americans and 178 Euro-Americans in the Detroit metropolitan area with respect to hypertension. Hypertension was chosen because more than 60 million individuals in the United States have elevated blood pressure (140/90 mmHg or greater).QUANTITATIVE AND QUALITATIVE DATA REVEALED FIVE THEMES ASSOCIATED WITH HYPERTENSION: (1) degree of activity and responsibility, (2) individual and familial moral strength, (3) naturalistic causation, (4) family, folk, or personal care, and (5) physical and spiritual balance. In addition to these ethnohealth and ethnocaring modes, the decisive sociocultural factors in the utilization of the health screening were (1) the health beliefs of the extended lay network, (2) the type of health facility, (3) the lifestyle and behavioral patterns of Detroiters from 1910 to the present, and (4) the adherence to traditional Afro-American cultural beliefs. Once health care professionals recognize the multitude of factors that affect health-care-seeking behavior among Afro-Americans, many health care issues can be resolved.

Sociocultural factors and health care-seeking behavior among black Americans.

This study investigates the health care-seeking behavior of black Americans in the Detroit Metropolitan area. Analyses of 176 semistructured interviews and 27 life history profiles obtained from participants, nonparticipants, clinic coordinators, community leaders, and health care professionals at local screening clinics suggest that black Americans follow a culturally specific health care-seeking pattern, and that such behavior is significantly influenced by sociocultural factors. This information should be particularly useful for health care professionals and educators, because it can help them plan and implement special intervention strategies for the black community.

Comparison of the activity of antibiotic combinations in vitro with clinical outcome and resistance emergence in serious infection by Pseudomonas aeruginosa in non-neutropenic patients.

Techniques for demonstrating synergy in vitro were compared in testing different beta-lactam-aminoglycoside combinations against 30 isolates of Pseudomonas aeruginosa. Poor concordance was noted among the results from chequerboard and 6 h and 24 h time-kill methods. Comparison of in-vitro synergy results with clinical outcome in 14 patients with pseudomonas infection showed that antagonism in the 24 h time-kill method was the most reliable prognostic indicator of clinical and bacteriological outcome. Although more than 70% of patients were cured clinically with cefsulodin or ticarcillin with tobramycin or amikacin, pseudomonas resistant to the beta-lactam emerged in 7 of 14 patients (50%); of those seven, three had poor clinical outcome. The rationale of adding aminoglycoside to beta-lactams against P. aeruginosa to prevent emergence of resistance needs closer examination.

A decade's experience with an individualized clomiphene treatment regimen including its effect on the postcoital test.

During a 10-year period, 428 women received clomiphene citrate according to a graduated therapeutic regimen in which the dose of clomiphene and the laboratory studies were individualized according to each patient's history, examination and response. Of the 428 patients, 85.3% ovulated and 42.8% conceived. The great majority of those who conceived did so during the first three ovulatory cycles. There was no evidence that clomiphene therapy was associated with the induction of another cause of infertility. Overall, 88.2% of those with no other causes for infertility who ovulated also conceived. However, only 7.8% of those who had one or more factors in addition to anovulation became pregnant. There was no evidence that clomiphene adversely affected the postcoital test, as only 15% of the patients had poor cervical mucus. The low rate of complications of this treatment, 5.1% cyst formation as well as the 14% abortion rate and the 2.6% congenital anomaly rate and the excellent gestational outcome in those who conceived support the use of this treatment regimen.

Interferon in biopsy and autopsy specimens of brain. Its presence in herpes simplex virus encephalitis.

Quantitative virus and interferon titers were assayed in temporal lobe brain biopsy specimens (six patients); in various regions of the brain at autopsy (five of the six patients); and in serums and CSF during courses of herpes simplex virus, type 1 (HSV-1) encephalitis. Until the tenth day of neurologic disease, interferon (geometric mean titer, 25 units/mL) was present in each virus-positive brain biopsy specimen. The geometric mean HSV-1 titer at brain biopsy was 328 tissue culture dose (TCD)50/g. On the sixth day of disease, CSF from the sole survivor contained 160 units/mL, but five other samples of CSF contained no detectable interferon. No serums from any of the six patients contained interferon. At autopsies performed on the sixth to 19th day of neurologic disease, 13 of 35 of the regional areas of the brain retained HSV, but only a single specimen from a temporal lobe had measurable interferon. Early in the course of HSV-1 encephalitis, substantial interferon titers are present in areas of virus multiplication. This local brain interferon is insufficient alone to inhibit progression of a disease but could possibly be important in combination with antiviral chemotherapy.