Early morbidity associated with fasciotomies for acute compartment syndrome in children.

PURPOSE: Acute compartment syndrome (ACS) requires urgent fasciotomy to decompress the relevant muscle compartment/s prior to onset of irreversible myonecrosis and nerve injury. A fasciotomy is not a benign procedure. This study aims to describe and quantify early morbidity directly associated with fasciotomies for ACS in children. METHODS: Clinical charts of 104 children who underwent 112 fasciotomies over a 13-year period at a tertiary children's hospital were reviewed. The following were analyzed: ACS aetiology, fasciotomy site, number of subsequent procedures, method of wound closure, short-term complications and length of hospital stay. RESULTS: Short-term complications included wound infections (6.7%) and the need for blood transfusion (7.7%). Median number of additional operations for wound closure was two (0 to 10) and median inpatient stay was 12 days (3 to 63; SD 11.7). After three unsuccessful attempts at primary closure, likelihood of needing skin grafting for coverage exceeded 80%. Analyses showed that fasciotomy-wound infections were associated with higher risk for four or more closure procedures. Number of procedures required for wound closure correlated with longer inpatient stay as did ACS associated with non-orthopaedic causes. CONCLUSION: Fasciotomy is associated with significant early morbidity, the need for multiple closure operations, and prolonged hospital stay. The decision for fasciotomy needs careful consideration to avoid unnecessary fasciotomies, without increasing the risk of permanent injury from missed or delayed diagnosis. Skin grafting should be considered after three unsuccessful closure attempts. Less invasive tests or continuous monitoring (for high-risk patients) for compartment syndrome may help reduce unnecessary fasciotomies. LEVEL OF EVIDENCE: Level IV, Case series.

Predictors of Non-adherence to Immunosuppressive Therapy in Asian Liver Transplant Recipients.

BACKGROUND: Adherence to immunosuppressive medications has been shown to affect post-transplant outcomes. We aimed to determine the level of adherence to immunosuppressive therapy in liver transplant (LT) recipients and to elucidate factors associated with it, as well as patient preferences on the dosing schedule. METHODS: LT recipients were recruited during transplant clinic follow-up. A validated Morisky 8-item questionnaire was completed by patients to assess their adherence to immunosuppressive therapy. Adherence was determined by the sum of the responses to the questionnaire. Low, medium, and high adherence were defined by a Morisky score of >2, 1 to 2, and 0, respectively. Data on the patient's socio-economic and clinical background, dosing schedule of immunosuppressant medications, and patient preferences were included in the questionnaire. RESULTS: A total of 107 LT recipients were approached and 75 completed the questionnaire. The majority of patients (48/74, 64.9%) preferred a once-daily medication regimen. The proportion of high adherence was 24/75 (32.0%), medium adherence was 51/75 (42.7%), and low adherence was 19/75 (25.3%). Multivariate analysis showed younger age and post-transplant duration >5 years as independent predictors for low adherence. Among low-adherence patients, 16/19 (84.2%) patients were on a twice-daily regimen, and, of these, 14/16 (87.5%) preferred their medications to be reduced to once daily. CONCLUSIONS: A significant proportion (68%) of LT recipients had low to moderate adherence to medications, with younger age and longer post-transplant duration of >5 years as independent predictors. Early identification of at-risk patients is essential to allow implementation of measures to improve adherence. Simplifying medication regimens to once daily is a potential way to improve adherence.

Supracondylar humeral fractures in children: beware the medial spike.

Supracondylar humeral fractures are common in children, but there are no classification systems or radiological parameters that predict the likelihood of having to perform an open reduction. In a retrospective case-control study we evaluated the use of the medial spike angle and fracture tip-skin distance to predict the mode of reduction (closed or open) and the operating time in fractures with posterolateral displacement. A total of 21 patients (4.35%) with a small medial spike angle (< 45°) were identified from a total of 494 patients, and 42 patients with a medial spike angle of > 45° were randomly selected as controls. The medial spike group had significantly smaller fracture tip-skin distances (p < 0.001), longer operating times (p = 0.004) and more complications (p = 0.033) than the control group. There was no significant difference in the mode of reduction and a composite outcome measure. After adjustments for age and gender, only fracture tip-skin distance remained significantly associated with the operating time (ß = -0.724, p = 0.042) and composite outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold for open reduction when treating patients with a small medial spike angle and a small fracture tip-skin distance.

First Report of Pyricularia grisea Causing Gray Leaf Spot on Lily in Korea.

Lily is an economically important ornamental crop in Korea. In August 2008, severe leaf spot symptoms were observed on an oriental Lily 'Action' in a plant nursery in Daegu, Korea. Disease incidence was 20 to 30%. Initial symptoms were olive green-to-brown lesions on the leaf that developed into tan, elliptical, necrotic lesions. On severely infected leaves, lesions coalesced and killed the entire leaf blade. Infected leaves were surface disinfested with 70% ethanol for 30 s and 2% chlorox for 15 min before plating 1 cm2 sections onto potato dextrose agar. Hyphae appeared 5 days after inoculation and pure culture. Conidia were hyaline, transversely septate with one to three septa; most had two. Conidia were obpyriform and measured 29 to 46 µm long and 7 to 17 µm wide. Mycelia morphology and conidia production were consistent with that described previously for Pyricularia grisea (1). Koch's postulates were fulfilled by spraying five, healthy, vegetative-stage plants with 2 × 105 conidia per ml of sterile distilled water plus 0.05% Tween 20. As a control, five similar plants were sprayed with sterile water plus 0.05% Tween 20 only. Plants were placed inside plastic bags to maintain high relative humidity and incubated in a growth chamber at 25°C under fluorescent light for 14 h and at 20°C in darkness for 10 h. After 3 days, the plastic bags were removed and plants were maintained under the same conditions. Initial symptoms were observed 7 days after inoculation. Ten days after inoculation, disease symptoms on inoculated plants were similar to those previously described in the nursery. Control plants did not show any symptoms. Fungi isolated from these lesions had the same morphological characteristics as the ones isolated previously from plants in the nursery. To our knowledge, this is the first report of gray leaf spot on lily caused by P. grisea in Korea. References: (1) M. B. Ellis. Dematiaceous Hyphomycetes. CMI, Kew, Surrey, UK, 1971.

Traction and spica casting for closed femoral shaft fractures in children.

PURPOSE: To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children. METHODS: Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks. RESULTS: Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait. CONCLUSION: Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.

Comparison between high and low molecular weight hyaluronates in knee osteoarthritis patients: open-label, randomized, multicentre clinical trial.

Efficacy and safety of high and low molecular weight hyaluronates in knee osteoarthritis patients were compared in a randomized, open-label trial. Patients in the high molecular weight hyaluronate group were treated once weekly for 3 weeks and in the low molecular weight group once weekly for 5 weeks. We evaluated weight-bearing pain, degree of flexion, swelling and knee tenderness; frequency and amount of rescue medication; patient and investigator global assessment of pain, and safety over 12 weeks after final injection of study medication. Significant improvements in pain and WOMAC-Likert scores were observed in both groups, but not between groups. Knee joint pain improvement was noted in both groups by patients and investigators during follow-up. Close correlation was observed between patient- and investigator-reported data. There was no significant difference in side-effects between the groups. In conclusion, the efficacy and safety of high and low molecular weight hyaluronate are similar.

Heelys injuries in children.

INTRODUCTION: Heelys, a type of shoes with stealth wheels, are extremely popular among children in Singapore. The widespread availability of cheap imitations has led to a proliferation of young users. Coupled with a total lack of safety equipment and instructions, these shoes can lead to significant injuries. The purpose of this study was to examine the incidence and type of injuries sustained by children using Heelys. METHODS: During a seven-month period from February to August 2004, all children treated at the Paediatric Orthopaedic Department of the KK Women's and Children's Hospital, were asked if the injury was sustained while "heeling". All the patients were reviewed by the authors. A total of 37 patients with significant injuries sustained while "heeling" were identified. Their radiographs and clinical charts were reviewed. The patients and/or their parents were also interviewed to obtain additional information. RESULTS: Upper limb injuries were by far the most common. Distal radius fractures and elbow injuries predominated. None of the children used safety gear. CONCLUSION: "Heeling" can lead to serious injuries despite the relatively low velocity involved. Children and their parents need to be educated on the use of safety gear.

Validity and reliability of the SF-36: the Malaysian context.

Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.

Atypical presentations of emphysematous cystitis.

Emphysematous cystitis is an uncommon infection of the bladder with the formation of carbon dioxide either within the bladder or within its wall. It is commonly seen in women and those with poorly controlled diabetes mellitus, in association with some form of urinary stasis and obstruction. The clinical features are very varied and the outcome is often unpredictable. Radiography may reveal a radiolucent line around the bladder wall or gas within the bladder. Occasionally, computed tomography scans are required to help in the diagnosis due to their atypical presentation with acute abdominal pain. Herein, we report three patients with such a condition who were treated with favourable outcomes. Of the three patients, two had to undergo exploratory laparotomy due to their initial presentations with acute abdomens.

Transurethral resection of prostate (TURP) through the decades--a comparison of results over the last thirty years in a single institution in Asia.

INTRODUCTION: This study was conducted to evaluate the results and complications of transurethral resection of prostate (TURP) over the last 30 years in our institution. MATERIALS AND METHODS: This retrospective study encompasses 3 different eras: 168 patients in the late 70s, 175 patients in the late 80s and 283 patients in the late 90s. All the patients had at least 18 months of follow-up. RESULTS: The mean age from the 1970s, the 1980s and 1999 were 68.8 years, 69.2 years and 69.4 years respectively. The proportion of patients operated on for acute retention fell from 78.6% (132) in the 1970s, to 54% (96) in the 1980s, and 43% (122) in 1999. The mean resection time was 44.8 minutes in 1989 and 41.8 minutes in 1999. The mean weight of prostate resected was 22.1 g in the 1970s, 24.2 g in 1989 and 22.2 g in 1999. 44% (74) required blood transfusion in the 1970s, with 11% (19) in 1989 and 4% (11) in 1999. There were 2 deaths (acute myocardial infarction and pneumonia) in the 1970s, 1 (pneumonia) in 1989 and no mortality in 1999. There were 4 patients with TURP syndrome in the 1970s, 3 in 1989 and 1 in 1999. The incidence of postoperative urinary tract infection (UTI) was 25% (42) in the 1970s, 16% (29) in 1989 and 6% (17) in 1999. CONCLUSIONS: As expertise and experience in TURP progress, the complication rates fall, as evidenced by the lower rates of transfusion, TURP syndrome and postoperative UTI in the later series.

Use of 2n gametes for the production of sexual polyploids from sterile Oriental x Asiatic hybrids of lilies (Lilium).

Sixteen Oriental and 12 Asiatic cultivars were crossed in 158 different combinations. A total of 708 F1 hybrids were obtained from 86 of the different combinations of 15 Oriental and 11 Asiatic cultivars. Because the Lilium cultivars (2n=2x=24) used for the production of these hybrids belong to two different taxonomic sections-Archelirion (0) and Sinomartagon (A), respectively-the F1 hybrids (OA) could be obtained only through embryo, embryo sac rescue, ovary slice or ovule culture. Most of the F, hybrids were highly sterile (did not produce viable n gametes) due to the failure of chromosome pairing. However, in a few cases F1 plants were found that produced viable 2n pollen at variable frequencies. These 2n pollen grains were successfully used for the production of backcross progenies. Using genomic in situ hybridization we found intergenomic recombinant chromosomes in the sexual polyploid progenies. These results indicate that there are effective prospects for combining important horticultural traits from the two main groups of cultivars of lilies through sexual polyploidization.

Evaluation of BC2 progenies derived from 3x-2x and 3x-4x crosses of Lilium hybrids: a GISH analysis.

An allotriploid (ALA, 2n=3 x=36) BC(1) plant was obtained by backcrossing a diploid F(1) interspecific hybrid (LA, 2n=2 x=24), derived from a Lilium longiflorum (L genome) and an Asiatic hybrid (A genome), to the latter parent. This allotriploid was backcrossed to a diploid Asiatic hybrid (2n=2 x=24) and to an allotetraploid (LLAA, 2n=4 x=48) LA hybrid. A total of 25 plants of these crosses were examined for ploidy level, and 12 individuals were analyzed for their genome constitution through genomic in situ hybridization (GISH). In most cases the progenies from the triploid-diploid (3 x-2 x) crosses consisted of aneuploids. Further more, there was evidence for the formation of near-haploid (x=12+2) to triploid (3 x=36) gametes in the allotriploid BC(1) plant. The progenies of triploid-tetraploid (3 x-4 x) cross also consisted of mostly aneuploids but in this case the triploid female parent had contributed predominantly near-triploid (2n) gametes for the origin of BC(2) progenies. The different ploidy levels observed between 3 x-2 x and 3 x-4 x crosses are possibly caused by preferential fertilization or survival resulting in a different ratio of chromosome numbers between the embryo and endosperm. Though Lilium has a tetrasporic, eight-nucleate type of embryo sac formation (Fritillaria type), the observed difference between the progeny types in 3 x-2 x and 3 x-4 x crosses is comparable to that of observed in monosporic eight nucleate types (Polygonum type) that predominate in most genera of Angiosperms. An important feature of the genome constitution of the progenies was that the homoeologous recombinant chromosomes were transmitted intact from BC(1) to BC(2) progenies in variable numbers. In addition, there was evidence for the occurrence of new homoeologous recombinations in the triploid BC(1). Of the two euploid BC(2) plants one had originated through the parthenogenetic development of a 2n egg and the other had originated through indeterminate meiotic restitution (IMR).

Limited magnetic resonance imaging (MRI) and the occult hip fracture.

INTRODUCTION: Diagnosis of hip fracture is normally readily made from clinical evaluation and plain radiographs. Occasionally, clinical suspicion of fracture is not confirmed on plain X-rays. MATERIALS AND METHOD: Between January 2001 and March 2002, 422 patients were admitted to our department for post-traumatic hip pain. The diagnosis of hip fracture was unequivocally made in 365 patients (86%). Fifty-seven (14%) patients had a negative or equivocal radiograph. RESULTS: Limited magnetic resonance imaging (MRI) of the hip in this group of 57 patients confirmed that 8 (14%) sustained a femoral neck fracture, while 5 (9%) had an intertrochanteric fracture. In 19 patients (33%), some other pathology was found, mainly stable fractures of the femoral trochanters and pubic rami. Overall, 32 scans (56%) were positive and 25 (44%) were negative. Limited MRI detected patients with undisplaced hip fractures and identified them as candidates for surgery. CONCLUSION: The use of MRI in this specific and 'limited' way provides orthopaedic surgeons with a rapid, accurate and cost-effective diagnostic tool in this clinical scenario. Definitive diagnosis allows the correct management plan to be implemented early. We recommend that patients, who have significant hip pain following injury but indeterminate plain radiographs, undergo a limited MRI scan as a matter of routine.

Randomised clinical trial of suture compared with adhesive strip for skin closure after HRT implant.

To determine which method of skin closure was associated with less bleeding, 250 women were randomly allocated to have either a suture closure (3-0 Dexon II) or an adhesive strip closure (Steri-Strip) following subcutaneous insertion of hormone (HRT) implants. Data were collected via a tested questionnaire and analysed. Significantly, more women in the adhesive strip group recorded postprocedure bleeding (RR = 2.26; 95% CI 1.42-3.60) and considered the bleeding excessive (RR = 4.17; 95% CI 1.18-14.76) and unacceptable (RR = 12.52; 95% CI 1.63-96.19). Pain scores and symptoms of local infection were similar in both groups. Routine use of adhesive strips for implant skin incision closure is not recommended.

Induction of apoptosis in mammary gland by a pure anti-estrogen ICI 182780.

The antiestrogen, ICI 182780 (ICI) proves to be clinically useful for the treatment of estrogen receptor positive breast tumours. We report the assessment of the in vivo and in vitro effects of ICI on apoptosis of breast epithelial cells. In vivo, administration of rats with ICI for 3 weeks resulted in a reduction in the size of the lobular structures with the rate of mammary epithelial apoptosis equivalent to 10, 35 and 45% on treatment with 1, 1.5 and 2 mg ICI per kg body weight, respectively. Concomitantly, these treatment led to a 2.0-, 2.2- and 2.5-fold increase in Bax. Similar elevations were also observed in Bad levels which increased 1.7-, 2.6- and 2.7-fold respectively in the ICI treatment as compared to controls. This also resulted in a dose dependent decrease in Bcl-2 and Bcl-xL protein expressions. Growth inhibition and induction of apoptosis were also observed in the MCF-7 cells following in vitro treatment with ICI. This is closely associated with [1] the down-regulation of Bcl-2 and Bcl-xL proteins and [2] upregulation of Bax and Bad, whose gene products are known to be involved the regulation of apoptosis in mammalian cells. Stable over-expression of Bcl-2 resulted in protection of MCF-7 cells from apoptosis and growth inhibitory effects of ICI. Conversely, reduction of Bcl-2 by antisense transfection make MCF-7 cells more sensitive to ICI-induced growth inhibition and apoptosis. These findings suggest that modulation of Bax, Bcl-xL, Bcl-2 and Bad proteins by ICI may be, in part, responsible for the anti-proliferative and apoptotic effect of ICI seen clinically and in animal models.

Karyotype analysis of Lilium longiflorum and Lilium rubellum by chromosome banding and fluorescence in situ hybridisation.

Detailed karyotypes of Lilium longiflorum and L. rubellum were constructed on the basis of chromosome arm lengths, C-banding, AgNO3 staining, and PI-DAPI banding, together with fluorescence in situ hybridisation (FISH) with the 5S and 45S rDNA sequences as probes. The C-banding patterns that were obtained with the standard BSG technique revealed only few minor bands on heterologous positions of the L. longiflorum and L. rubellum chromosomes. FISH of the 5S and 45S rDNA probes on L. longiflorum metaphase complements showed overlapping signals at proximal positions of the short arms of chromosomes 4 and 7, a single 5S rDNA signal on the secondary constriction of chromosome 3, and one 45S rDNA signal adjacent to the 5S rDNA signal on the subdistal part of the long arm of chromosome 3. In L. rubellum, we observed co-localisation of the 5S and 45S rDNA sequences on the short arm of chromosomes 2 and 4 and on the long arms of chromosomes 2 and 3, and two adjacent bands on chromosome 12. Silver staining (Ag-NOR) of the nucleoli and NORs in L. longiflorum and L. rubellum yielded a highly variable number of signals in interphase nuclei and only a few faint silver deposits on the NORs of mitotic metaphase chromosomes. In preparations stained with PI and DAPI, we observed both red- and blue-fluorescing bands at different positions on the L. longiflorum and L. rubellum chromosomes. The red-fluorescing or so-called reverse PI-DAPI bands always coincided with rDNA sites, whereas the blue-fluorescing DAPI bands corresponded to C-bands. Based on these techniques, we could identify most of chromosomes of the L. longiflorum and L. rubellum karyotypes.

Cloning and characterization of a novel pregnancy-induced growth inhibitor in mammary gland.

Growth factors and growth inhibitors play crucial roles in the growth regulation and differentiation of mammary epithelial cells. Studies have shown that during pregnancy, with the onset of terminal differentiation, there is a dramatic decrease in the proliferation of the mammary epithelial cells. Here we report the cloning and characterization of a novel pregnancy-induced cDNA, OKL38, from a human ovarian cDNA library. This cDNA encodes for a protein of approximately 34.5 kDa. Tissue distribution studies through Northern analyses revealed the ubiquitous nature of OKL38 transcripts in most tissues, with the highest levels observed in the ovary, kidney, and liver. The onset and advancement of pregnancy also gave rise to a concomitant increase in OKL38 gene expression. In situ hybridization revealed that OKL38 mRNA was further detected in mammary secretory epithelial cells. However, low levels of OKL38 transcripts were observed in the various human breast cancer cell lines studied and were barely detectable in all dimethylbenz(A)anthracene-induced mammary tumors examined. Transfection studies with OKL38 cDNA with MCF-7 cells resulted in growth inhibition in vitro and reduction in tumor formation in vivo. These observations led to speculation that OKL38 may play a vital role in the growth regulation and differentiation of breast epithelial cells during pregnancy and its implications in tumorigenesis.

Induction of UO-44 gene expression by tamoxifen in the rat uterus and ovary.

A complementary DNA, uterine-ovarian-specific gene 44 (UO-44), has been isolated from tamoxifen-induced rat uterine complementary DNA library using differential display techniques. UO-44 transcripts are found to be abundant in the uterus and ovary. UO-44 gene expression in the uterus is strictly regulated by estrogens, tamoxifen, and GH, whereas the pure antiestrogen ICI 182780 is inhibitory. Treatment of ovariectomized rats and hypophysectomized rats with tamoxifen and GH, respectively, resulted in up-regulation of UO-44 expression in a dose-dependent manner. In situ hybridization revealed that UO-44 gene expression was restricted to the luminal and glandular epithelial cells of the uterus and to granulosa cells of medium-size ovarian follicles. Transfection studies showed that UO-44 was a membrane-associated protein. Because estrogens, tamoxifen, and GH are stimulators of uterine luminal epithelial cell growth in vivo, UO-44 protein may serve as a mediator of the effect of these compounds in inducing epithelial proliferation and differentiation in these tissues.

STR data for the AmpFlSTR Profiler loci from the three main ethnic population groups (Malay, Chinese and Indian) in Malaysia.

Allele frequencies for the nine STRs genetic loci included in the AmpFlSTR Profiler kit were obtained from samples of unrelated individuals comprising 139-156 Malays, 149-153 Chinese and 132-135 Indians, residing in Malaysia.