TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care?

OBJECTIVE: The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). METHODS: Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions. RESULTS: The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001). CONCLUSIONS: Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

OBJECTIVE: The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS: We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS: Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS: Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care.

OBJECTIVE: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus. METHODS: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes. RESULTS: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs. CONCLUSIONS: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

Multisegment Foot Kinematic and Kinetic Compensations in Level and Uphill Walking Following Tibiotalar Arthrodesis.

BACKGROUND: Foot and ankle movement alterations following ankle arthrodesis are still not well understood, particularly those that might contribute to the documented increase in adjacent joint arthritis. Generalized tarsal hypermobility has long been postulated, but not confirmed in gait or functional movements. The purpose of this study was to more thoroughly evaluate compensation mechanisms used by arthrodesis patients during level and uphill gait through a variety of measurement modalities and a detailed breakdown of gait phases. METHODS: Level ground and uphill gait of 14 unilateral tibiotalar arthrodesis patients and 14 matched controls was analyzed using motion capture, force, and pressure measurements in conjunction with a kinetic multisegment foot model. RESULTS: The affected limb exhibited several marked differences compared to the controls and to the unaffected limb. In loading response, ankle eversion was reduced but without a reduction in tibial rotation. During the second rocker, ankle dorsiflexion was reduced, yet was still considerable, suggesting compensatory talar articulation (subtalar and talonavicular) motion since no differences were seen at the midtarsal joint. Also during the second rocker, subjects abnormally internally rotated the tibia while moving their center of pressure laterally. Third rocker plantarflexion motion, moments, and powers were substantially reduced on the affected side and to a lesser extent on the unaffected side. CONCLUSION: Sagittal plane hypermobility is probable during the second rocker in the talar articulations following tibiotalar fusion, but is unlikely in other midfoot joints. The normal coupling between frontal plane hindfoot motion and tibial rotation in early and mid stance was also clearly disrupted. These alterations reflect a complex compensatory movement pattern that undoubtedly affects the function of arthrodesis patients, likely alters the arthrokinematics of the talar joints (which may be a mechanism for arthritis development), and should be considered in future arthrodesis as well as arthroplasty research. LEVEL OF EVIDENCE: Level III, comparative study.

Biomechanical comparison of double grasping repair versus cross-locked cruciate flexor tendon repair.

PURPOSE: This study was conducted to compare the in vitro biomechanical properties of tensile strength and gap resistance of a double grasping loop (DGL) flexor tendon repair with the established four-strand cross-locked cruciate (CLC) flexor tendon repair, both with an interlocking horizontal mattress (IHM) epitendinous suture. The hypothesis is that the DGL-IHM method which utilizes two looped core sutures, grasping and locking loops, and a single intralesional knot will have greater strength and increased gap resistance than the CLC-IHM method. METHODS: Forty porcine tendons were evenly assigned to either the DGL-IHM or CLC-IHM group. The tendon repair strength, 2-mm gap force and load to failure, was measured under a constant rate of distraction. The stiffness of tendon repair was calculated and the method of repair failure was analyzed. RESULTS: The CLC-IHM group exhibited a statistically significant greater resistance to gapping, a statistically significant higher load to 2-mm gapping (62.0 N), and load to failure (99.7 N) than the DGL-IHM group (37.1 N and 75.1 N, respectively). Ninety percent of CLC-IHM failures were a result of knot failure whereas 30 % of the DGL-IHM group exhibited knot failure. CONCLUSIONS: This study demonstrates that the CLC-IHM flexor tendon repair method better resists gapping and has a greater tensile strength compared to the experimental DGL-IHM method. The authors believe that while the DGL-IHM provides double the number of sutures at the repair site per needle pass, this configuration does not adequately secure the loop suture to the tendon, resulting in a high percentage of suture pullout and inability to tolerate loads as high as those of the CLC-IHM group.

TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms?

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety. OBJECTIVES: The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions. METHODS: Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%). RESULTS: Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation. CONCLUSIONS: Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) documents are medical orders intended to honor patient choice in the hospital and prehospital settings. We hypothesized that prehospital personnel will find these forms confusing. OBJECTIVES: The aim of this study was to determine whether POLST documents accord consensus in determining code status and treatment decisions among emergency medical services providers on the basis of an Internet survey. Consensus in this context reflects content clarity. METHODS: A statewide survey of Pennsylvania emergency medical technicians and paramedics was conducted from October 2013 to January 2014. Respondents supplied code status and treatment decisions for scenarios involving critically ill patients who present with POLST documents and then develop cardiac arrest. The gamut of combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and treatment (full, limited, comfort measures) was represented. Subgroup analysis was done using the Fisher exact test with a Bonferroni-corrected P = 0.017 as significant. We defined consensus as a supermajority of 95%. RESULTS: Response to the survey was 18.4% (1069/5800). For scenarios specifying DNR and full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. With DNR and comfort measures specified, approximately 85% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Respondent age significantly affected response rates (P ≤ 0.004); prior POLST education had no impact. For most scenarios, responses failed to attain consensus, suggesting confusion in interpretation of the form. CONCLUSIONS: In the Pennsylvania prehospital setting, POLST documents can be confusing, presenting a risk to patient safety. Additional research, standardized education, training, and/or safeguards are required to facilitate patient choice and protect safety.

Effects of interleukin-6 ablation on fracture healing in mice.

This study examined the impact of an interleukin-6 (IL-6) knockout on fracture healing in terms of histological and biomechanical responses. Following IACUC approval, tibial fractures were produced in 4- to 6-week-old IL-6 knockouts (n = 35) and wild-type mice (n = 36) and harvested along with contralateral limbs at 2 and 6 weeks postsurgery. Histology quantified stage of healing, lymphocyte infiltration, TRAP+ cells, and osteocalcin deposition. Bend testing established maximum load and stiffness. Based on normality assessments, Mann-Whitney U or independent t-tests were used for data analysis using a p-value threshold of 0.05. Stage of healing, lymphocyte infiltration, and osteocalcin deposition were similar for all time points (p ≥ 0.243). TRAP+ cell counts were reduced approximately 10-fold in the knockout at 2 weeks (p = 0.015) but were similar at 6 weeks (p = 0.689). Force-to-failure in knockouts was approximately 40% that of wild-type mice at 2 weeks (p = 0.040) but similar at 6 weeks (p = 0.735). Knockout bone was about 25% less stiff at 2 weeks but approximately 60% stiffer at 6 weeks (p ≥ 0.110). The absence of IL-6 during early fracture healing significantly reduced osteoclastogenesis and impaired callus strength. By 6 weeks, most histological and biomechanical parameters were similar to fractures in wild-type bone.

Locking plates have increased torsional stiffness compared to standard plates in a segmental defect model of clavicle fracture.

OBJECTIVE: To evaluate the effect of locked plate technology to resist torsion in a clavicle fracture model of segmental bone loss. METHODS: Forty-four synthetic clavicles were repaired with either 3.5 mm locked compression plate (LCP) or 3.5 mm low-contact dynamic compression plate (LCDCP). They were divided into two groups of 22 specimens. Each group was tested to evaluate torsional stiffness, load at failure, deflection at failure, and unconstrained plate motion. RESULTS: LCP group showed significantly greater stiffness in torsion compared to the LCDCP group (p < 0.001). Average difference was 20.9%. Load at failure was not significantly different (p < 0.07). Deflection at failure was significantly less for the LCP group (p < 0.03). Unconstrained motion or plate 'looseness' was significantly less for the LCP group (p < 0.017). CONCLUSIONS: In a simulated model of segmental clavicle fracture, a LCP provided more stiffness and less deflection than a low-contact dynamic compression plate.

Detection of RXFP1 receptors in skin biopsies from children with congenital adrenal hyperplasia: a preliminary report.

OBJECTIVE: Relaxin may potentiate the effect of topical estrogen treatment to eradicate post-incisional scarring in congenital adrenal hyperplasia (CAH) patients undergoing genitoplasty. The aim of this study was to determine whether CAH skin is capable of responding to relaxin. PATIENTS AND METHODS: Skin biopsies were obtained from four female CAH patients (aged 2-9 years; Prader 4-5, salt-wasting, 21-hydroxylase deficiency, Caucasian) during routine genitoplasty surgery and screened for relaxin receptors. All received corticosteroid and mineralocorticoid replacement therapy. Specimens were sectioned, mounted and screened for the presence of the putative H2 relaxin receptor using conventional two-antibody immunohistochemistry. Tissue controls were processed concurrently. RESULTS: Tissue controls evidenced appropriate staining. Biopsies from CAH patients stained positively for RXFP1 expression while some variation between specimens was evident. Staining occurred adjacent to the basement membrane of the epithelium, localized to germinative basal keratinocytes. CONCLUSION: Based on a limited patient sample, germinative keratinocytes in CAH patients appear competent to respond to relaxin perhaps topically applied. Given that relaxin downregulates collagen accretion and upregulates collagenases, its use may potentiate the effects of estradiol and abrogate post-incisional wound scarring. More research is needed to confirm or refute this thesis.

Adequacy of sanitization and storage of catheters for intermittent use after washing and microwave sterilization.

PURPOSE: Clean intermittent catheterization is used to treat neurogenic bladders and it can be adequate to maintain sterile urine. Typically polyvinylchloride, individually packaged catheters are used but they are not intended for repeat use by the manufacturer. Antibacterial soap alone or combined with microwave heating was advocated to decrease pathogens and bacterial residue, which could inoculate the bladder from a colonized catheter. We assessed the efficacy of catheter sanitizing and storage for reuse. MATERIALS AND METHODS: Catheters were inoculated with a 24-hour broth culture of Escherichia coli and washed in antibacterial soap, washed and microwaved or immediately packaged (positive controls) and stored for 1, 3 and 7 days, respectively. Common packaging was used, including paper towels, sealable plastic bags or sealable rigid plastic containers. Each condition was assessed in triplicate via culture of the entire catheter contents, yielding a total of 27 catheters per sanitization method. RESULTS: Antibacterial wash alone failed to sanitize 67% of catheters (6 of 9 with 2 of 3 positive per container) on day 1, 22% (2 of 9 with all positive catheters in a paper towel) on day 3 and 44% (4 of 9 with 1 in a paper towel and 3 in a plastic container) on day 7. For combined antibacterial wash and microwave heating the positive rate was 0% (0 of 9 catheters) on day 1, 22% (2 of 9 in a plastic container) on day 3 and 56% (5 of 9 with 3 in a paper towel, 1 in a plastic bag and 1 in a plastic container) on day 7. Positive untreated controls showed viable organisms throughout the test period. CONCLUSIONS: Overall 44% of catheters (12 of 27) washed with antibacterial soap yielded E. coli vs 26% (7 of 27) with combined antibacterial soap-microwave treatment. The latter is a more effective but not an absolute way to sanitize catheters for intermittent use. Longer storage time increased the risk of E. coli growth on the catheters.

Relaxin's involvement in extracellular matrix homeostasis.

Burgeoning evidence suggests that the hormone relaxin modulates collagen in the extracellular matrix of diverse tissues. In separate lines of study, we provide further substantiation of this hypothesis. Immunofluorescence was used to probe isolated fibroblasts derived from volar oblique ligament explant culture for vimentin, actin, RXFP1, and estrogen receptor beta. Ligaments were obtained as surgical waste from thumb reconstruction patients. Four specimens have been examined to date. Cells derived from these patients expressed vimentin and actin, consistent with fibroblast morphology. Putative fibroblasts derived from two of three female patients expressed RXFP1 receptors; the solitary male was negative. Given the small sample, however, the data are considered preliminary. Immunohistochemistry was used on frozen sections from 26 skin biopsies obtained from children undergoing genitoplasty. A subset of samples was also probed for transforming growth factor (TGF-beta1) and TGF-beta3. Appropriate controls were used. Finally, a subset of patient blood was assayed for relaxin by using an enzyme-linked immunosorbent assay-based method. The results showed RXFP1 receptor expression in the cells that populate the basement membrane in 96% of patients, regardless of gender. Most tissue expressed TGF-beta. Finally, serology suggested that relaxin was detectable in these children. Our two lines of research provide additional evidence for the diverse tissue tropism of relaxin. In particular, connective tissues as diverse as ligaments and basal lamina keratinocytes express RXFP1. These data lend support to our contention that relaxin affects ligament integrity and wound healing.

Fate of mu receptors during rat skeletogenesis.

Studies have intimated a role for endogenous opioids in skeletal ontogeny. We hypothesized that this role may be confined to the perinatal period. We, therefore, examined both fetal and postnatal rat long bones to determine the pattern, if any, of mu receptor expression. Perfused long bones and brains were harvested from 3 to 4 each of near-term fetuses, 3- to 4-week-old neonates, and 6-week-old juveniles. Tissues were decalcified, embedded, sectioned, quenched of peroxidase, and then blocked. Sections were incubated overnight with either rabbit antirat mu receptor IgG or naïve rabbit IgG (control) at 4 degrees C. The next day, sections were washed, blocked again, and incubated with biotin-labeled secondary antibody, streptavidin-peroxidase conjugate, and a chromogen substrate with intervening wash steps. Slides were counterstained with hematoxylin and coverslipped. Digital photomicrographs were then imported into an image analysis program and the percent area of stained cortical and trabecular bone quantified. Mu receptor expression decreased significantly with age. Approximately 25% of the area of fetal long bones stained positively, including the endosteum, periosteum, and the growth plate. Little or no nonspecific staining occurred. Staining in neonatal tissue was diminished to <11% of the area and involved areas of apparent remodeling; chondrocytes in the growth plates failed to stain. Finally, juvenile bone evidenced staining approaching background levels produced by control slides (approximately 2%). Mu receptors are abundant in developing rat long bones during fetal development but become progressively less abundant postnatally. This infers a role for endogenous opioids during skeletal ontogeny.

Maturity assessment and curve progression in girls with idiopathic scoliosis.

BACKGROUND: Scoliosis progression during adolescence is closely related to patient maturity. Maturity has various indicators, including chronological age, height and weight changes, and skeletal and sexual maturation. It is not certain which of these indicators correlates most strongly with scoliosis progression. The purpose of the present study was to evaluate various maturity measurements and how they relate to scoliosis progression. METHODS: Physically immature girls with idiopathic scoliosis were evaluated every six months through their growth spurt with serial spinal radiographs; hand skeletal ages; Oxford pelvic scores; Risser sign determinations; height; weight; sexual staging; and serologic studies of the levels of selected growth factors, estradiol, bone-specific alkaline phosphatase, and osteocalcin. These measurements were then correlated with the curve-acceleration phase. RESULTS: The period and pattern of curve acceleration began during Risser stage 0 for all patients. Skeletal maturation scores derived with the use of the Tanner-Whitehouse-III RUS method, particularly those for the metacarpals and phalanges, were superior to all other indicators of maturity. Regression of the scores provided good estimates of maturity relative to the period of curve progression (Pearson r = 0.93). The initiation of this period occurred simultaneously with digital changes from Tanner-Whitehouse-III stage F to G. At this stage, curves also separated into rapid, moderate, and low-acceleration patterns, with specific curve types in the rapid and moderate-acceleration groups. The low-acceleration group was not confined to a specific curve type. CONCLUSIONS: The curve-acceleration phase separates curves into various types of curve progression. The Tanner-Whitehouse-III RUS scores are highly correlated with timing relative to the curve-acceleration phase and provide better maturity determination and prognosis determination during adolescence than the other parameters tested. Accurate skeletal maturity determination should be used as the primary maturity measurement in girls with idiopathic scoliosis.

Femoral remodeling may influence patient outcomes in slipped capital femoral epiphysis.

Clinical studies of patients treated for slipped capital femoral epiphysis have found limited functional impairment and femoral neck deformity causing eventual coxarthrosis. Since patient-focused assessments minimize bias and reflect health-related quality of life status, we coupled their use to a clinical examination to obtain a more patient-centered picture of slipped capital femoral epiphyseal outcomes. The impact of residual deformity on outcomes also was examined. Of 78 patients treated for slipped capital femoral epiphyses between 1972 and 1998, 29 (38 hips) were evaluated at a mean followup of 7.6 years (range, 1.4-26 years). The average patient age was 21.8 years (range, 14.6-39 years), 55% were female, and the average body mass index was 28.7 (range, 16.1-50.2). Most slips were stable (92%, 35 of 38) and mild or moderate in severity (98%, 36 of 37). Followup examinations revealed slight deficits in range of motion, strength, and limb length. Radiographs showed slight improvements in head-shaft angle and reduced but persistent femoral neck deformity. Osteoarthritic changes were absent or negligible in 84% (32 of 38) of the hips. The average Iowa hip score was 90.5 (range, 51-100). Patient outcome scores for the AAOS Hip/Knee Questionnaire fell slightly below 50th percentile norms. Neither slip stability, severity, nor body mass index impacted outcome. Femoral neck deformity correlated with function, pain, and Boyer grade. Overall, patients had minor functional deficits and pain that may have been related to femoral neck deformity, but longer followup is warranted.

Correlates of the peak height velocity in girls with idiopathic scoliosis.

STUDY DESIGN: Prospective longitudinal. OBJECTIVE: Determine correlates of the peak height velocity (PHV) in girls with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Only identifiable retrospectively, the PHV is the most useful known maturity marker in idiopathic scoliosis. Clinically useful correlates are needed to make PHV timing helpful. METHODS: A total of 24 immature girls with idiopathic scoliosis were followed with serial heights, sexual staging, skeletal ages, spinal radiographs, insulin-like growth factor (IGF)-1, IGF binding protein-3, dehydroepiandrosterone sulfate, estradiol, bone-specific alkaline phosphatase, and osteocalcin levels. These markers were correlated to PHV timing. RESULTS: There were 14 girls who had identifiable growth peaks that averaged 10.5 +/- 1.8 cm/y at age 11.7 +/- 1 years. At the PHV, all girls were Risser 0 with open triradiate cartilages. On a skeletal age radiograph, digital uncapped phalangeal epiphyses were indicative of pre-PHV and fused epiphyses of post-PHV. Capped but unfused epiphyses were indeterminate. Tanner stage 1 for breast strongly indicates pre-PHV. Stage 3 for breast and pubic hair occurred at or after the PHV, and stage 4 always occurred after PHV. Higher IGF-1 and estradiol levels after PHV are potentially discriminatory. CONCLUSIONS: The PHV occurs during Risser 0 with open triradiate cartilages. If triradiate cartilages are open, then Tanner stages, IGF-1, estradiol levels, and the appearance of the epiphyses on a skeletal age radiograph are useful in determining status before or after PHV.

Immunohistological detection of relaxin binding to anterior cruciate ligaments.

Relaxin, a member of the insulin-like growth factor family, alters collagen metabolism in fibroblasts. It was hypothesized that relaxin interacts with the anterior cruciate ligament (ACL), contributing to its elasticity. Twelve ACL specimens were collected from reconstruction surgeries, sectioned, rinsed, and exposed to rh-relaxin overnight. Polyclonal antirelaxin antibodies, in conjunction with HRP-AEC, localized areas of tissue binding. Controls were used to infer binding specificity. Staining was present in the positive control and all 12 ACL specimens; little or no staining occurred in the negative controls. These data suggest that relaxin binding to the ACL is specific, indicative of a receptor-mediated event.

Takeoff forces transmitted to the upper extremity during water-skiing.

As data were unavailable, this study quantified the forces acting on the upper extremities during water-skiing takeoff in 10 male volunteers (mean age: 28 years). Body weight ranged between 141 and 195 lbs. Low, medium, and full-power takeoffs were used to propel each skier out of the water. Although low-power takeoffs produced significantly less peak force (P < or = .0004), they yielded a trend toward greater time under load (P = .097). As the data suggest that forces assume roughly one and one-half times body weight, individuals with pre-existing shoulder morbidity may risk exacerbation of their condition.

Effect of Timolol vs. a postural orthotic on hand tremor during microsurgery.

The efficacy of beta blockers to control hand tremor remains equivocal. This study evaluated the effectiveness of Timolol, as well as a postural orthotic, in reducing movement deviation during a laboratory exercise. Eleven volunteers completed three randomized trials involving administration of Timolol, a placebo, or a postural orthotic. Drug administration was blinded. Each trial consisted of a simulated 2-hr clinical procedure, punctuated by video recordings of the subject's hand motion during a standardized pattern of instrument movement. ECRL EMG activity and digital oxygen perfusion were also measured. Recordings were converted into estimates of linear variance at baseline and 1 and 2 hr. A repeated-measures ANOVA, or the Friedman test, were used to assess significant differences. Movement deviation, EMG activity, and oxygen perfusion were unaffected by the duration of exercise or treatment (P > or = 0.454). We conclude that none of the treatments accorded a significant benefit in allaying hand tremor.