The management of brachymetatarsia.

We treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm. The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis.

Hypertrophic non-union of the first rib causing thoracic outlet syndrome: a case report.

We experienced a rare case of thoracic outlet syndrome caused by hypertrophic nonunion of the first rib. A diagnosis was made mainly upon provocative tests and imaging studies. Pain and tingling could be reproduced and the radial pulse obliterated by the hyperabduction test. Abundant callus formation on the posterior aspect of the first rib with fracture line was visible on plain radiograph. Two-dimensional computed tomography showed right thoracic outlet narrowing mainly caused by the mass-effect of the callus. Dynamic arteriographic studies revealed an external compression of the right subclavian artery and duplex ultrasonography demonstrated a reduction in right subclavian artery blood flow when the shoulder is in 90 degrees of abduction. Surgery was performed after the conservative management for three months which failed to relieve the patient of his complaints. Resection of the first rib via transaxillary approach was undergone uneventfully in combination with the myotomy of the scalenus anticus muscle. At postoperative one year follow up, the patient was free of symptoms, and had a full range of motion of the right shoulder with no evidence of arterial insufficiency.

Typing and antimicrobial susceptibilities of methicillin resistant Staphylococcus aureus (MRSA) strains isolated in a hospital in Korea.

Methicillin-resistant Staphylococcus aureus (MRSA) strains may cause serious nosocomial infections, including pneumonia and septicemia. The rate of methicillin-resistance among S. aureus isolates in Korea is over 50%. In this study, 90 MRSA isolates from Kyung Hee University Hospital were characterized employing bacteriophage typing, pulsed-field gel electrophoresis (PFGE), and antimicrobial susceptibility testing. Eighty percent of the strains could be phage-typed. The largest group or 40% of the strains belonged to lyso group III, followed by 32% of the isolates which produced a reaction with regional additional phages. Phage type 83A was most frequently encountered, followed by phage type D11. PFGE patterns confirmed the presence of two major clusters, which comprise the isolates belonging to lyso group III and the strains that were typable with regional additional phages. The latter group also contained a number of strains that were nontypable with bacteriophages. The resistance rates to ciprofloxacin, erythromycin, tetracycline, gentamicin and clindamycin were over 94%. Strains with intermediate resistance to vancomycin strains or resistance to mupirocin were not found. In conclusion, this study demonstrates that the results of phage typing are confirmed and supplemented by PFGE data.

Unicompartmental knee arthroplasty in middle-aged patients: a 2- to 6-year follow-up evaluation.

Twenty-eight unicompartmental knee arthroplasties performed as an alternative to high tibial osteotomy or tricompartmental knee arthroplasty in patients under 60 years of age were reviewed after 2 to 6 years of follow-up. The patient's age at the time of operation averaged 52 years. Using the Knee Society Score, 90% were rated good or excellent results in terms of function and pain relief. The average flexion angle obtained was 124 degrees, and the average postoperative alignment was 4 degrees of anatomic valgus for varus deformities and 8 degrees for valgus deformities. The average activity level according to the Tegner and Lysholm score slightly improved (preoperative, 2.3; follow-up, 2.7 points). Of the 28 knees, 9 (32%) presented radiolucent lines about the tibial component and two had incomplete radiolucent lines at the bone-cement interface on the femoral side. There was no correlation between activity level and tibial radiolucent lines. Two revisions were performed because of loosening of the femoral component at the prosthesis-cement interface. One was converted to another unicompartmental arthroplasty and the other to a tricompartmental arthroplasty. One tibial component exhibited an asymptomatic slowly progressive radiolucency. Unicompartmental knee arthroplasty in middle-aged patients yields 2- to 6-year results competitive with osteotomy but inferior to tricompartmental arthroplasty in terms of revision. The specific prosthetic design used in this series appeared to be vulnerable to femoral component loosening possibly because of constrained tibial topography and smooth tapered femoral fixation lugs.

Patient self-reporting of compliance does not correspond with electronic monitoring: an evaluation using isosorbide dinitrate as a model drug.

STUDY OBJECTIVE: To assess the accuracy of patient-kept diaries relative to electronic monitoring of compliance with isosorbide dinitrate prescribed 3 times/day for ischemic heart disease. DESIGN: Unblinded, prospective, three-phase study. METHODS: Patients with coronary artery disease prescribed isosorbide dinitrate 3 times/day were asked to record the time of administration of each dose in a pocket diary while being monitored for compliance with a computerized Medication-Event Monitoring System (MEMS-4) vial that electronically recorded the date and time the vial was opened. RESULTS: Sixty-eight stable outpatients with documented coronary artery disease who were prescribed isosorbide dinitrate 3 times/day were evaluated. Based on a prospectively chosen definition including a nitrate-free period, the mean (+/-SD) overall compliance rates were 71% (+/-30) versus 55% (+/-32) for the patient-kept diaries and the MEMS vials respectively (p = 0.001). The concordance between patient-kept diaries and MEMS data indicate that 67% of patients overestimate their compliance when using a self-recording tool. An average of 30% of diary entries were in error compared with the MEMS vial recordings. CONCLUSIONS: Patient-kept diaries statistically overestimate actual compliance relative to that determined by MEMS devices. Given the prevalence of the use of diaries as the predominant tool on which researchers depend to document compliance with study drugs, our findings suggest that this practice should be reevaluated specifically when the time of the dose and documentation of administration are critical to qualifying the outcome of drug therapy. Such is the case with isosorbide dinitrate use in patients with ischemic heart disease. Furthermore, the overall poor compliance documented in this study suggests that the utility of isosorbide dinitrate prescribed 3 times/day be reevaluated as a clinically effective antianginal drug.

Magnitude and nature of noncompliance with treatment using isosorbide dinitrate in patients with ischemic heart disease.

Isosorbide dinitrate is one of the most commonly prescribed medications for the treatment of ischemic heart disease. It has been demonstrated to be ineffective relative to placebo when taken inappropriately. This study objectively documents the magnitude and nature of compliance in 68 ambulatory patients who were prescribed isosorbide dinitrate three times a day. Each patient received a 9-week supply of medication in a vial equipped with a computerized monitor (MEMS-4 cap; APREX Corporation, Fremont, CA) and were informed as to the purpose of the study. Of the patients, 74% were classified into the low and 16% into the high compliance category, defined as compliant < 70% and > or = 85% of study days, respectively. The mean (+/- SD) percent days in which isosorbide dinitrate was taken three times was 66% (+/- 29), and the mean number of days in which it was taken three times with a 10-hour "nitrate free period" was 53% (+/- 31). It is concluded that the magnitude of noncompliance in patients prescribed isosorbide dinitrate three times daily is substantial (74%). The nature of this noncompliance is often due to failure to observe a 10- to 12-hour nitrate free period. Given the need to take isosorbide dinitrate appropriately and given the demonstrated magnitude of noncompliance, physicians should take these factors into consideration when selecting this agent for the management of coronary artery disease relative to other pharmacologic options.

Bone marrow findings before and after treatment with recombinant human erythropoietin in chronic hemodialyzed patients.

The stimulating effect of rHuEPO on erythropoiesis has been shown in several studies, using bone marrow cell culture or animal models. To investigate the effect of rHuEPO on bone marrow findings in vivo, we studied the bone marrow cellularity, the myeloid: erythroid (M:E) ratio, an estimate of the number of megakaryocytes, any cytomorphologic or maturation abnormalities, and an estimate of the storage iron before and after 3 months of treatment with rHuEPO in 10 chronic hemodialyzed patients. Nine patients showed a slight or moderate decrease of erythropoiesis in bone marrow in comparison to normal bone marrow before rHuEPO treatment. The bone marrow cellularity was a mean of 28.5% and decreased in 8 out of 10 patients compared to normal values. However, megakaryopoiesis and granulopoiesis were normal. Three months of treatment with rHuEPO had increased erythropoiesis in all 10 patients, including one patient whose bone marrow proved to be normal erythropoiesis on baseline examination. The M:E ratio was significantly decreased from 4.0 +/- 1.2:1 to 2.4 +/- 1.1:1 (p < 0.005). The bone marrow cellularity was also increased in 9 patients, except in 1 patient whose specimen was inadequate for diagnosis, after 3 months of treatment with rHuEPO. On baseline examination of bone marrow, iron staining was undetectable in one, low in one, normal in 2 and high in 5 sections. According to grading, iron staining had decreased from 3.1 +/- 1.7 to 2.1 +/- 0.9 (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Avascular necrosis after fracture-separation of the distal end of the humerus in children.

Fracture-separation of the distal end of the humerus in children has been reported infrequently, and may be misdiagnosed as a fracture of the condyle or a traumatic dislocation of the elbow. We discuss eight cases of a seldom reported complication following fracture-separation of the distal end of the humerus. This complication consists of dissolution of the trochlea within three to six weeks postinjury and a defect of the medial or central part of the condyle that develops later. The fractures were severely displaced fracture-separation of the distal end of the humerus with large medial or lateral metaphyseal fragment, but initially misdiagnosed as a fracture of the medial, lateral condyle or a traumatic dislocation of the elbow in six of eight cases. We performed open reduction in six cases because of initial misdiagnosis or because of difficulty in satisfactory closed reduction. We speculated that this complication is due to avascular necrosis of the distal end of the humerus, and that fracture-separation of the distal end of the humerus is more common than reported.

Angiotensin converting enzyme inhibitors. 10. Aryl sulfonamide substituted N-[1-carboxy-3-phenylpropyl]-L-alanyl-L-proline derivatives as novel antihypertensives.

Compounds 1a-g consisting of enalaprilat covalently bonded to aryl sulfonamides, including several known thiazide diuretics, were synthesized and tested for ACE inhibitory and diuretic and overall antihypertensive effects. All compounds were potent ACE inhibitors in vitro, with IC50 = 6.5-85 nM. At 10 mg/kg iv or ip in the rat, 1a-g inhibited the AI pressor response by 76-100%; inhibition declined significantly upon oral dosing. Compounds 1a and 1f at 100 mg/kg ip in the sodium-depleted, spontaneously hypertensive rats reduced blood pressure 28-35% and 41-42%, respectively. Compounds 1a and 1f elicited natriuresis and kaliuresis without accompanying volume increases in the rat; 1c at 25 mg/kg iv induced delayed diuresis. Compound 1f has been chosen for further development.

Differential effects of a series of hydroxamic acid derivatives on 5-lipoxygenase and cyclooxygenase from neutrophils and 12-lipoxygenase from platelets and their in vivo effects on inflammation and anaphylaxis.

The synthesis of a series of novel substituted hydroxamates has been described along with their profile of inhibitory activity against 5-lipoxygenase, 12-lipoxygenase, and cyclooxygenase enzymes. The structure--activity relationship suggests that future molecules could be designed to specifically inhibit one or more of these enzymes since there were definite differences in structure--activity relationships for these different enzymes. A representative number of these compounds have been tested in vivo and found to possess potent oral activity in a systemic anaphylaxis model mediated by leukotrienes and topical activity in an arachidonic acid induced inflammation model. One of these molecules, compound 20, demonstrated that a leukotriene antagonist pharmacophore can be modified such that it contains both antagonist activity and 5-lipoxygenase inhibitory activity.

Angiotensin-converting enzyme inhibitors: new orally active 1,4-thiazepine-2,5-diones, 1,4-thiazine-2,5-diones, and 1,4-benzothiazepine-2,5-diones possessing antihypertensive activity.

The preparation of a series of 1,4-thiazepine-2,5-diones, 1,4-thiazine-2,5-diones, and 1,4-benzothiazepine-2,5-diones and their ability in inhibiting the activity of angiotensin-converting enzyme (ACE) in vitro and in vivo were examined. These compounds are assumed to act as prodrugs since they undergo rapid ring-opening reactions to give the corresponding biologically active free SH compounds when incubated with rat plasma or when treated with aqueous 0.1 N HCl or phosphate buffer (pH 7.4). The thiazepines 23-25 and 30 are potent inhibitors of ACE when administered po to rats and are comparable in potency to captopril (1). The most active thiazines in rats, po, were 42 and 45. Of the benzothiazepines studied, 22a was the most active in inhibiting ACE in the conscious normotensive rat, ID50 = 0.15 mg/kg, po. The acute antihypertensive effects of oral administration of a number of these compounds on mean arterial pressure and heart rate were studied in spontaneously hypertensive rats (SHR) maintained on a sodium-deficient diet.

Angiotensin converting enzyme inhibitors. (Mercaptoaroyl)amino acids.

A series of (mercaptoaroyl)amino acids and related compounds was synthesized and tested for ability to inhibit angiotensin converting enzyme (ACE). The most active compound was N-(3-chloro-2-mercaptobenzoyl)-N-cyclopentylglycine, having an in vitro I50 = 0.28 microM. Substitution of the aromatic 3-position by small polar groups enhanced ACE inhibitory activity, whereas bulky groups diminished it. Alteration of the beta relationship between the mercaptan and amide carbonyl or masking of the thiol by acylation reduced activity. Replacement of the thiol by nitro, hydroxy, or carboxy gave compounds lacking ACE inhibitory activity.

Angiotensin-converting enzyme inhibitors. New orally active antihypertensive (mercaptoalkanoyl)- and [(acylthio)alkanoyl]glycine derivatives.

A variety of N-substituted (mercaptoalkanoyl)- and [(acylthio)alkanoyl]glycine derivatives was synthesized and their ability in inhibiting the activity of angiotensin-converting enzyme (ACE) was examined in vitro and in vivo. The acylthio derivatives prepared are assumed to act as prodrugs since they are much less active than the corresponding free SH compounds in vitro and can be expected to act in vivo only after conversion to the free sulfhydryl compounds. A number of these compounds are potent ACE inhibitors that lowered blood pressure in Na-deficient, conscious spontaneously hypertensive rats (SHR), a high renin model. One of the most active members of the series was (S)-N-cyclopentyl-N-[3-[(2,2-dimethyl-1-oxopropyl)thio]-2-methyl-1 -oxopropyl]glycine (REV 3659-(S), pivopril). Structure-activity relationships are discussed.

Angiotensin-converting enzyme inhibitory and antihypertensive activities of pivalopril (RHC 3659-(S)).

Pivalopril (RHC 3659-(S); (S)-N-cyclopentyl-N-(2-methyl-3-pivaloylthiopropionyl) glycine) is a new compound with a hindered sulfur group that has been compared to captopril for oral angiotensin-converting enzyme (ACE) inhibition in rats and dogs and antihypertensive activity in rats. In separate groups of conscious normotensive rats, pivalopril (0.03-1.0 mg/kg, orally [p.o.]) produced a dose-related antagonism of angiotensin I (AngI)-induced pressor effects. The ED50 for pivalopril and captopril was 0.1 mg/kg. In conscious normotensive dogs, pivalopril (incremental doses of 0.01-1.0 mg/kg, p.o.) produced a dose-related antagonism of AngI pressor effects. The ED50 was 0.17 mg/kg for pivalopril and 0.06 mg/kg for captopril. At equieffective doses the two compounds had similar durations of action. In sodium-deficient, conscious spontaneously hypertensive rats (SHR), pivalopril (1-100 mg/kg, p.o.) produced a dose-related reduction in mean arterial pressure. The potency and duration were similar to those of captopril. In the sodium-replete SHR, 5 days of oral dosing with pivalopril, 100 mg/(kg . day), decreased mean arterial pressure more effectively than captopril, 100 mg/(kg . day). No tolerance developed to the antihypertensive effect of either drug. It is concluded that pivalopril is a potent, orally effective ACE inhibitor and antihypertensive agent.