Arthroscopic treatment for ulnar-sided TFCC-tears.

OBJECTIVE: Ruptures of ulnar-sided triangular fibrocartilaginous complex (TFCC) often occur in cases of trauma. Golden standard for diagnosis is the arthroscopy of the wrist. TFCC lesions are classified according to their location if traumatic in origin or if degenerative according to their severity. MATERIALS AND METHODS: Recent literature has focused on the ruptures of ulnar-sided triangular fibrocartilaginous complex. This article describes conservative, operative and arthroscopic surgical techniques to reconstruct the triangular fibrocartilaginous complex and restore distal radioulnar joint stability. RESULTS: The main therapeutic goal should be the stabilization of the DRUJ by reattachment of the torn ligaments in ulnar-sided ruptures to the deep fibers in the fovea. This reinsertion can be performed by transosseous suture, a suture anchor or open. CONCLUSION: Central TFCC tears are typically located close to the sigmoid notch of the radius and are either traumatic or degenerative in origin. While central TFCC lesions are usually treated by arthroscopic debridement using small joint punches or a bipolar high frequency system, the ulnar TFCC avulsions can also be refixed arthroscopically in different techniques.

Rapid health impact assessment of policies to reduce vehicle miles traveled in Oregon.

OBJECTIVE: Health impact assessments (HIAs) enable decisions-makers to assess proposed policies, projects and programmes with respect to their potential health impact. The purpose of this rapid HIA was to inform the debate within a state legislature about the value of state policy and provide information for local planning agencies to better incorporate health considerations into planning activities. STUDY DESIGN: Rapid HIA. METHODS: Literature review was used to evaluate three types of policies to reduce vehicle miles traveled: improving the built environment, increasing the costs of individual driving, and strengthening public transit. RESULTS: Select features of the built environment were found to be associated with increased physical activity, reduced collisions, and decreased air pollution. Increasing the cost of driving was not consistently found to reduce air pollution, increase physical activity, or reduce collisions. Strengthening public transit was associated with increased levels of physical activity. CONCLUSIONS: This rapid HIA provides a framework and focus for future HIAs in this topic area.

Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men.

OBJECTIVES: There is evidence that methamphetamine and sildenafil (Viagra) use are associated with sexual risk behaviour among men who have sex with men (MSM). We investigated the association of methamphetamine, sildenafil, and other substance use with unprotected receptive and insertive anal sex among MSM by conducting an encounter specific analysis. METHODS: Data were from a cross sectional, community based survey of MSM in San Francisco regarding behaviour during their most recent anal sex encounter. Mulitvariate regression analysed independent associations of specific substance use and demographic variables with unprotected anal sex behaviours. RESULTS: The sample (n = 388) was diverse in race/ethnicity, age, income, education, HIV status, and homosexual/bisexual identification. More than half (53%) reported unprotected anal sex, including insertive (29%) and receptive (37%) during their most recent anal sex encounter; 12% reported unprotected insertive and 17% reported unprotected receptive anal sex with an HIV discordant or unknown partner. Methamphetamine was used by 15% and sildenafil was used by 6% of the men before or during the encounter; 2% used both drugs. In multivariate analysis controlling for demographic factors and other substance use, methamphetamine use was associated with unprotected receptive (odds ratio (OR), 2.03; 95% confidence interval (CI), 1.09 to 3.76) and sildenafil use was associated with unprotected insertive (OR, 6.51; CI, 2.46 to 17.24) anal sex. Effects were stronger with HIV discordant or unknown sex partners specifically. CONCLUSION: Encounter specific associations of methamphetamine and sildenafil use with unprotected receptive and insertive anal sex, respectively, indicate the importance of assessment specificity and tailoring risk reduction efforts to address certain drugs and sexual behavioural roles among MSM.

Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison.

CONTEXT: HIV risk behavior among urban gay/bisexual men has recently increased. High-risk sexual activity and drug use may be particularly high during circuit party (CP) weekends, during which gay/bisexual men congregate for social activities and dancing. OBJECTIVES: To compare prevalence of risk behaviors during CP weekends with those during non-CP weekends. DESIGN: Cross-sectional study. PARTICIPANTS: 295 gay/bisexual men from the San Francisco Bay Area. MAIN OUTCOME MEASURES: Drug use and sexual risk behavior during a San Francisco CP weekend, a CP weekend held in another geographic area (distant weekends), and two non-CP weekends. RESULTS: During their most recent distant CP weekend, 80% of participants used methylenedioxymethamphetamine (ecstasy), 66% ketamine, 43% crystal methamphetamines, 29% gamma-hydroxybutyrate or gamma-butyrolactone (GHB/GBL), 14% sildenafil (Viagra), and 12% amyl nitrites (poppers); 53% used four or more drugs. Drug use prevalence was greater during CP than non-CP weekends ( p <.001). Unprotected anal sex with partners of unknown or opposite HIV serostatus was most prevalent during distant CP weekends, reported by 21% of HIV-positive and 9% of HIV-negative participants. In multivariate analysis, predictors of unprotected anal sex with opposite or unknown HIV serostatus partners included being HIV-positive (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4-7.5), and weekend use of crystal methamphetamines (OR 2.4; 95% CI, 1.1-4.9), sildenafil (OR, 3.8; 95% CI, 2.0-7.3), and amyl nitrites (OR, 2.2; 95% CI, 1.3-4.0). CONCLUSIONS: Prevalence of high-risk activity during these weekends suggests significant potential for HIV transmission in this population. Public health programs in communities hosting CPs should aim to reduce rates of drug use and sexual risk behavior among CP participants, especially HIV-positive men.

The Circuit Party Men's Health Survey: findings and implications for gay and bisexual men.

OBJECTIVES: This study examined characteristics of gay and bisexual men who attend circuit parties, frequency of and motivations for attending parties, drug use and sexual behavior during circuit party weekends, and use of risk reduction materials available at parties. METHODS: A cross-sectional survey was conducted among 295 gay and bisexual men from the San Francisco Bay Area who had attended a circuit party in the previous year. RESULTS: One fourth of the men reported a drug "overuse" incident in the previous year. Nearly all respondents reported use of drugs during circuit party weekends, including ecstasy (75%), ketamine (58%), crystal methamphetamine (36%), gamma hydroxybutyrate or gamma butyrolactone (25%), and Viagra (12%). Two thirds of the men reported having sex (oral or anal), 49% reported having anal sex, and 28% reported having unprotected anal sex during the 3-day period. An association was found between use of drugs and sexual risk behavior. Prevention materials were observed at party events by some men; however, relatively few men used the materials. Common motivations for attending the parties were "to listen to music and dance" and "to be with friends." CONCLUSIONS: Intensive, targeted health promotion efforts are needed for gay and bisexual men who attend circuit parties.

Preferences about the characteristics of future HIV prevention products among men who have sex with men.

This study of men who have sex with men (MSM) examined preferences about the characteristics of a potential product for preventing sexual transmission of HIV, such as a rectal microbicide. MSM were recruited in West Hollywood, California. They self-administered a questionnaire and rated 48 product characteristics representing seven dimensions. Overall, the ratings were highest for effectiveness in preventing HIV and other sexually transmitted diseases, followed by characteristics reflecting the physical or secondary effects of the product and logistics of use. Physical attributes, convenience/accessibility, and psychological aspects had intermediate ratings; interpersonal dynamics had the lowest rating. Men with negative attitudes about using condoms to prevent HIV infection were more likely than their counterparts to prefer a product that does not reduce sexual sensation or pleasure, does not break the mood, and can be used after a sexual encounter ends. A similar pattern was observed when participants were stratified by whether or not they had engaged in unprotected anal intercourse in the past 12 months. The findings inform the development, testing, and marketing of a future HIV prevention product for MSM.

Improving the thromboresistivity of chemical sensors via nitric oxide release: fabrication and in vivo evaluation of NO-releasing oxygen-sensing catheters.

The development and in vivo analytical performance of a nitric oxide (NO)-releasing amperometric oxygen sensor with greatly enhanced thromboresistivity are reported. Gas permeable coatings formulated with cross-linked silicone rubber (SR) containing NO-generating compounds (diazeniumdiolates) are shown to release NO for extended periods of time (> 20 h) while reducing platelet adhesion and activation. Oxygen-sensing catheters prepared by dip-coating the NO-releasing films over the outer SR tubes of the implantable devices display similar analytical response properties in vitro (sensitivity, selectivity, response times) when compared to analogous sensors prepared without the NO release coatings. Superior analytical accuracy (relative to blood PO2 values measured in vitro) and greatly reduced thrombus formation on the outer surface of the sensors are observed in vivo (in canine model) with the NO release PO2 sensors compared to control sensors (without NO release) implanted simultaneously within the same animals. Based on these preliminary studies, the use of NO release polymers to fabricate catheter-style chemical sensors may be a potential solution to lingering biocompatibility and concomitant performance problems encountered when attempting to employ such devices for continuous intravascular measurements of blood gases and electrolytes.

Re-epithelialization of porcine skin by the sweat apparatus.

The behavior of the keratinocyte during the initial stages of cutaneous wound repair has been the subject of intense investigation. Most of these studies have focused on the lateral edges of wounds as the source of activated keratinocytes. Less attention has been directed towards elucidating the role of the appendageal structures as sources of keratinocytes for re-epithelialization, particularly the sweat apparatus. Surgical wounds of specific depths were created in pig skin, above and below hair follicles, and wound healing was allowed to take place in a setting in which lateral ingrowth of keratinocytes by migration was prevented. In this manner, all re-epithelialization occurred from residual appendageal structures. In those wounds where only sweat gland elements remained, an epithelium formed that had clinical, morphologic, and protein electrophoretic features closer to palmar/plantar or mucosal-like epithelia. In contrast, wounds that retained elements of the hair follicle healed faster and the resultant epithelium clinically, morphologically, and biochemically resembled the surrounding nonwounded epidermis. These findings establish that the sweat apparatus is capable of re-epithelializing the skin surface after a major cutaneous wound, but may not be capable of mimicking the epidermis.

The Sensory Stimulation Assessment Measure (SSAM): a tool for early evaluation of severely brain-injured patients.

There has been little definitive research ono the efficacy of sensory stimulation, yet many brain-injury rehabilitation programmes offer some form of it as treatment for severely injured patients. In general, however, sensory stimulation programmes and outcome studies alike lack precise definitions of terms, consistent criteria of patient selection, and valid and reliable measures of response to treatment. The Sensory Stimulation Assessment Measure (SSAM) was developed as a neuropsychological approach that provides a reliable and valid measure of responsiveness in patients who can neither communicate nor consistently follow commands. Patient responses are divided into three six-point behavioural scales (Eye Opening, Motor, and Vocalization) that require little evaluator subjectivity or inference. The measure may be used in treatment planning and is designed to address the rigorous demands of scientific research. Validity, reliability, and normative data are presented.

Management of the frail and deconditioned patient.

Deconditioning brought on by inactivity or bed rest affects important body systems and results in reduced functional capacity. Elderly individuals are particularly vulnerable to becoming deconditioned. Risk factors for deconditioning include illness, disability, chronic disease, medications, and psychosocial circumstances. Deconditioned individuals present multiple physical and psychosocial signs and symptoms. Prevention of deconditioning requires a multifaceted approach that includes walking, turning and positioning, nutrition, medical management, and psychologic support. Because reconditioning is a long process that may be overwhelming to the patient and caregivers, a specific treatment plan must be established to meet the unique needs of each individual. Management of the frail and deconditioned patient relies on a commitment to maintaining or restoring functional independence through a coordinated effort in all aspects of care.

Chlorpromazine-induced psychosis after brain injury.

Antipsychotic agents, most often used for treatment of schizophrenia, are sometimes prescribed for the agitated patient with an organic brain disorder. We report the case of a brain-injured patient who was prescribed chlorpromazine for agitation and who developed a delusional state while taking this antipsychotic agent. The emergence of this delusional state coincided with the exacerbation of certain cognitive deficits. Possible mechanisms for this phenomenon are discussed. Caution is advised when prescribing neuroleptics for patients with traumatic brain injury, especially those agents with significant cognitive side-effects or with a significant potential to precipitate seizures.

Whose child is this? Assessment and treatment of children in foster care.

Clinicians who treat children in foster care must continually balance the development and therapeutic needs of the foster child with the expectations of a complex network of caretakers and professionals with whom the child interacts. A model that integrates individual and systemic issues in the assessment and treatment of children in foster care is proposed.

Inflammatory pseudotumor of spleen.

The case of a 66-year-old man with pseudotumor of the spleen is presented. This rare entity can mimic malignant lymphoma clinically and radiographically. Splenectomy is diagnostic and curative. The etiology of pseudolymphoma is unknown, although a review of the literature suggests an association with prior systemic bacterial infection, as in the present case.

Heterogeneity of the Ro/SSA antigen and autoanti-Ro/SSA response: evidence of the four antigenically distinct forms.

Precipitating antibodies to the Ro/SSA antigen occur in the sera of 40% of patients with systemic lupus erythematosus (SLE) and in 40-70% of the sera of patients with primary Sjögren's syndrome. Previous work has shown that lymphocyte extracts contain two Ro/SSA antigens with protein moieties of 60 kD and 52 kD and that erythrocyte haemolysate contain two analogous but antigenically distinct Ro/SSA molecules of 60 kD and 54 kD. Frequency analysis of the various specificities in 43 sera with precipitating anti-Ro/SSA and studies with affinity-eluted antibodies suggest that the lymphocyte 60 kD and erythrocyte 60 kD Ro/SSA molecules are related as are the lymphocyte 52 kD and erythrocyte 54 kD Ro/SSA proteins. Anti-Ro/SSA sera when accompanied by other precipitins (anti-La/SSB and anti-U1RNP) react preferentially with certain Ro/SSA isoforms. Evidence is also presented for a 45 kD form of Ro/SSA. These data suggest that the antigenic heterogeneity of the Ro/SSA antigen is immunologically relevant and that there are two families of Ro/SSA antigens; one comprising of the two 60-kD proteins in the erythrocyte and lymphocyte and the other the erythrocyte 54 kD and lymphocyte 52 kD Ro/SSA proteins, respectively.

Differences in the fine specificity of anti-Ro (SS-A) in relation to the presence of other precipitating autoantibodies.

In sera from patients with systemic lupus erythematosus or Sjögren's syndrome, we determined the fraction of antibody that remained reactive with human Ro (SS-A) after absorption with bovine spleen extract, and the reactivity with the 60-kd and 54-kd red blood cell Ro (SS-A) bands by Western blot. Of the 3 groups of sera studied, those containing anti-Ro (SS-A) alone had the highest degree of reactivity with human Ro (SS-A) after absorption with bovine spleen extract, followed, in descending order, by sera containing anti-Ro (SS-A) and anti-La (SS-B), and sera containing anti-Ro (SS-A) and anti-nuclear RNP. The groups of sera could be distinguished on this basis. Sera with anti-Ro (SS-A) and anti-nuclear RNP could also be distinguished from the other 2 types of sera by their uniform and preferential reactivity with the 60-kd red blood cell Ro (SS-A), by Western blot analysis. These findings indicate that there are both qualitative and quantitative differences, associated with the presence of other autoantibodies, in the fine specificity of anti-Ro (SS-A) sera.

Fluorouracil and recombinant alfa-2a-interferon: an active regimen against advanced colorectal carcinoma.

Based on in vitro studies that have demonstrated synergy between recombinant alfa-2a-interferon (rIFN alpha-2a) and the fluoropyrimidine, fluorouracil (5FU), against two human colon cancer cell lines, a pilot clinical trial was initiated to determine the effects of the combination of 5FU and rIFN alpha-2a in patients with advanced, unresectable colorectal carcinoma. A total of 30 patients were enrolled; all were evaluable. 5FU was administered as a loading course, 750 mg/m2 daily for 5 days by continuous infusion followed by weekly bolus therapy, rIFN alpha-2a, 9 MU, was administered subcutaneously three times per week. Of 17 previously untreated patients evaluable for response, 13 achieved a response. Three patients had disease progression. No previously treated patients had a major response. There was one death clearly related to therapy, an event preceded by watery diarrhea and neutropenic sepsis. Other toxicities were reversible and responded to dose reduction. With a median follow-up of 16+ months, median survival has not been reached among the previously untreated patient cohort. We conclude that the combination of 5FU and rIFN alpha-2a is an active regimen against disseminated colorectal cancer in previously untreated patients.

Autoimmune response to the Ro/SSA particle is directed to the human antigen.

Autoantibodies to defined cellular antigens in systemic lupus erythematosus (SLE) are usually directed to conserved epitopes on ubiquitous macromolecules including histone, Sm + nRNP (URNP particles), DNA, and La(SSB). We report here that the autoimmune response to the Ro(SSA) RNA protein particle is directed to epitopes on the human antigen which are not conserved in evolution. Ro(SSA) from bovine, rat, and mouse Ro(SSA) particles cross-react with human autoantibodies less effectively than does human Ro(SSA), and antigenically active Ro(SSA) is not detectable in chicken thymus extracts with the assays employed. These data suggest a special role for the Ro(SSA) antigen in the initiation and/or perpetuation of the anti-Ro(SSA) response in autoimmune disease.

Sensory stimulation of severely brain-injured patients.

The research reported here consisted of a series of three studies of the use of a sensory stimulation protocol and assessment scale with brain-injured patients at either Level II or Level III on the Ranchos Los Amigos Cognitive Scale. In the first study, a pilot project with six patients addressed the hypotheses that: (1) immediate changes in responsiveness occur as a result of sensory stimulation; (2) variables such as positioning and level of contact have an effect on responsiveness; and (3) these changes can be measured. The second study established acceptable concurrent validity (n = 20), test-retest (n = 20) reliability and inter-rater reliability (n = 19) values for the procedures. The third study assessed whether change in responsiveness occurs over time secondary to sensory stimulation. General Responsiveness measures for 19 patients were obtained and then remeasured after 3 months. No significant differences in mean General Responsiveness values were found using the t-test for related measures procedure. Relationships were reviewed between General Responsiveness and amount of treatment per day, frequency of family visits, pre-morbid education, age, time since injury and neurological status. No differences were found between those patients who improved and those who did not improve.