Prednisone pretreatment leads to histaminic airway hyporeactivity soon after resolution of the immediate allergic response.

We assessed the effect of prednisone pretreatment (50 mg/day for three days) on the development of the early increase in histamine reactivity that occurs soon after resolution of the immediate response in allergic humans. Four allergic subjects who were known to develop only isolated immediate responses upon Kentucky bluegrass inhalation, as well as four mild allergic asthmatic subjects known to develop typical dual phase responses, were evaluated. All testing was done more than nine weeks after the grass pollen season had ended. Allergen inhalation produced an immediate response in all subjects. However, upon resolution of the immediate response to allergen in these pretreated subjects, the PC200His in all dual responding asthmatics and in three of the four isolated immediate responders had substantially increased above baseline values. We conclude that prednisone pretreatment leads to histaminic hyporeactivity soon after resolution of the immediate allergic response in both dual responding asthmatics and isolated immediate responders. It would seem that this prednisone effect is independent of its potential influence on the influx of inflammatory cells into diseased airways.

Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome.

BACKGROUND: The Internet has become a popular source of medical information for patients. Authors of health-related web pages are not required to adhere to any standard for medical content or accuracy. The goal of the present study was to assess the type, quality, and reliability of information about carpal tunnel syndrome that is available on the Internet. METHODS: The search phrase "carpal tunnel syndrome" was entered into five commonly used World Wide Web search engines. The search results then were given as an ordered list of universal resource locators, or web-site addresses. The top (first) fifty web sites from each of the five searches were combined to create a master roster of 250 web-site addresses. These web sites then were evaluated for authorship and content, and an informational value score ranging from 0 to 100 points was assigned to each. RESULTS: Thirty-three percent of the sites sold commercial products for the evaluation or treatment of carpal tunnel syndrome. An additional 30 percent were commercial web sites that did not sell products. Only 23 percent of the sites were authored by a physician or an academic organization. Fewer than half of the sites offered conventional information. Twenty-three percent of the sites offered unconventional or misleading information. The mean informational value of the web sites was 28.4 of a possible 100 points. CONCLUSIONS: The information about carpal tunnel syndrome on the Internet is of limited quality and poor informational value. The public and the medical communities need to be aware of these limitations so that the quality of medical information available on the World Wide Web can be improved.

Treatment of castration-induced osteoporosis by a capacitively coupled electrical signal in rat vertebrae.

Castrated male Sprague Dawley rats were subjected to various capacitively coupled electrical fields for six and eight weeks at two and 4.5 months after castration, respectively, with pairs of electrodes that were located paraspinally on the surface of the skin dorsally at the eleventh thoracic and fourth lumbar levels. When the animals were killed, dry and ash weights per unit of volume (apparent density), elastic modulus, ultimate stress, work to failure, trabecular area fraction, and mean trabecular width were determined for selected vertebrae. The results indicated that a sixty-kilohertz, 100-microampere signal (a calculated current density of five microamperes root-mean-square per square centimeter and a field of twelve millivolts root-mean-square per centimeter) significantly reversed the castration-induced osteoporosis in the lumbar vertebrae and restored bone mass per unit of volume in rats that had been stimulated for eight weeks after castration.

A quantitative system for staging avascular necrosis.

Much of the current confusion and contradiction on the treatment of avascular necrosis of the femoral head is caused by the lack of an agreed efficient, quantitative system for evaluation and staging. We have used a new system to evaluate over 1000 hips with avascular necrosis during a period of 12 years; it has proved to be very valuable. The system is based on the sequence of pathological events known to take place. It allows accurate quantification in both early and later stages, does not use older, invasive diagnostic procedures, and incorporates the newer techniques of bone scanning and MRI. Clinical records of pain and reduced function are not a specific part of the system, although they help to determine treatment and outcome. Hips are first placed into one of seven stages from 0 to VI, based upon the type of radiological change. The extent of involvement is then measured. This allows more accurate evaluation of progression or resolution and better comparison of different methods of management. The system also helps to provide a prognosis and to decide on the best available method of treatment.

Fractures of the proximal interphalangeal joint.

Fractures of the proximal interphalangeal joint constitute a broad spectrum of injuries. An understanding of the anatomy, the potential for joint instability, and the treatment options is essential to management of these fractures. Commonly observed fracture patterns involve one or both condyles of the proximal phalanx or the base of the middle phalanx. Fractures of the middle phalanx may involve the palmar lip or the dorsal lip or may be a "pilon" type of injury involving both the palmar and the dorsal lip with extensive intra-articular comminution. Intra-articular injuries may lead to joint subluxation or dislocation and must be identified in a timely manner to limit loss of motion, degenerative changes, and impaired function. These injuries range from those requiring minimal intervention to obtain an excellent outcome to those that are challenging to the most experienced surgeon. The treatment options include extension-block splinting, percutaneous pinning, traction, external fixation, open reduction and internal fixation, and volar-plate arthroplasty. Prompt recognition of the complexity of the injury and appropriate management are essential for an optimal functional outcome.

Acute flexor tendon injuries.

Current surgical techniques and controlled postoperative mobilization have significantly decreased the amount of intertendinous adhesions that plagued earlier attempts at repair. Nevertheless, the ability to recover normal function after flexor tendon injury remains a challenging and often elusive goal. In the civilian population, good to excellent results may be expected in 69% to 90% of patients. A thorough understanding of tendon anatomy and physiology, attention to atraumatic surgical technique, and a well-designed postoperative therapy regimen will ensure satisfactory results in the majority of cases. Further improvements can be expected as we continue to make advances in the areas of suturing technique, rehabilitation, and pharmacologic intervention.

Early results in the treatment of avascular necrosis of the femoral head with electrical stimulation.

Our goal in the treatment of avascular necrosis is to retard or reverse the progressive changes that normally take place and thus preserve rather than replace the femoral head. "Conservative" or nonoperative management has generally proved unsuccessful, and results with established surgical procedures have been inconsistent and frequently disappointing. A new approach has been described that uses direct-current stimulation in conjunction with bone grafting and decompression. Results were determined clinically and radiographically using a new method of staging and evaluation. The majority of patients who underwent surgery showed significant clinical improvement, especially in regard to pain relief. Some degree of radiologic progression, however, was detected in most cases, even in many with clinical improvement. Electrical stimulation, as used in this study, did not appear to alter the results obtained with decompression and grafting alone. It must be emphasized that this is a preliminary report. More data and longer follow-up will be required before definitive conclusions can be drawn, and we must continue our efforts to improve the management of avascular necrosis.

Electrical stimulation in the treatment of osteonecrosis of the femoral head--a 1-year follow-up.

To date, there is no completely satisfactory method for the treatment of osteonecrosis of the femoral head. "Conservative" management leads to a high failure rate, and surgical results have been inconsistent and disappointing. The study described in this article seeks to evaluate the role of electrical stimulation in conjunction with decompression and bone grafting. A total of 82 hips have been included to date, of which 42 with a minimum follow-up of 1 year have been evaluated. Pain relief and improved function have been noted in the majority of hips operated on, both with and without electrical stimulation. Careful radiologic assessment using a comprehensive new method of evaluation has shown some degree of progression in the majority of cases, however. No effects of electrical stimulation per se have been demonstrated to date. It must be emphasized that this is a preliminary report with a minimum follow-up of 1 year. Final conclusions await the completion of the study, when all patients have been followed for a minimum of 3 years.

Consequences of knuckle cracking: a report of two acute injuries.

A question commonly asked of physicians focuses on the possible deleterious effects of knuckle cracking. Patients are usually concerned that the risk of arthritis is increased by the habit; however, reports addressing the potential long-term consequence are controversial. We present two cases in which acute injuries were suffered while the patients were attempting to crack their knuckles. Both injuries responded well to conservative treatment. Our investigation shows that acute injuries can result from the forceful manipulation needed to achieve the audible pop of cracking knuckles and that patients should be counseled accordingly.

Utility of obtaining radiographs in patients with trigger finger.

We performed a combined retrospective and prospective study on the utility of obtaining radiographs in patients with trigger finger. Ninety-three patients with a total of 110 involved fingers were reviewed. The average age of the patients was 52 years, and 61% had involvement of their dominant hand. There were 54 women and 39 men. Eighty-four percent of the radiographs were reviewed retrospectively, and 16% of the radiographs were reviewed prospectively. There were no abnormal findings in 62% of the radiographs [corrected]. Thirty-one percent had radiographic abnormalities that were not currently clinically significant. Four percent had radiographic findings that correlated with other clinical problems. No radiographic finding changed our management. Patients with stenosing flexor tenosynovitis without a history of injury or inflammatory arthritis do not need routine radiographs.

Anatomy of the median nerve at the wrist. Open carpal tunnel release--classic.

An understanding of the normal anatomy of the carpal tunnel and a variety of associated anomalies is important for the physician treating carpal tunnel syndrome. There are many strong arguments for open surgical decompression of the median nerve where full visualization of the transverse carpal ligament and contents of the carpal tunnel can be expected. The authors describe their preferred operative technique and post-operative management for carpal tunnel release.

Quadrimembral amputation: indications and contraindications for vascularized composite allotransplantation.

INTRODUCTION: Quadrimembral amputees, as patients who have lost both upper and lower extremities, may benefit greatly from hand transplantation. The objective of this study is to evaluate the indications and contraindications for transplantation in this subset of patients. METHODS: A retrospective review was conducted of five quadrimembral amputees evaluated by our program for transplantation. Information collected included age, sex, level of amputations, time since amputations, etiology, level of dependence, medical stability, psychosocial status, and the ability to tolerate immunosuppression. Indications and contraindications for transplantation were reviewed for each patient. RESULTS: All etiologies were based in extremity ischemia: three from septic shock, one from myocardial infarction, and one from drug overdose. All patients are completely dependent. Of the five patients, two needed further reconstructive surgery and two others had a history of resolved hepatic/renal insufficiency. After thorough evaluation, two patients were selected as potential transplant candidates. They demonstrated strong psychosocial support systems, a thorough understanding of hand transplantation, along with its risks and postoperative requirements. They had also completed a full regimen of rehabilitation along with prosthetic fitting and utilization. CONCLUSIONS: Clearance for transplantation is based on medical stability, absence of infection or systemic diseases, and strong psychosocial support systems. Contraindications for transplantation are drug dependence and noncompliant behavior. Relative contraindications include a history of hepatic/renal insufficiency which if not resolved may preclude the use of postoperative immunosuppression.

The early history of arthroplasty in the United States.

Arthroplasty is defined in the broadest sense as a reconstructive procedure that alters the structure or function of a joint. The first recorded procedures done in the United States in the early nineteenth century and the introduction of modern total joint replacement in the 1970s will be discussed. Although major surgical procedures occasionally were performed in the early 1800s, it was not until the introduction of general anesthesia and antiseptic techniques during the latter half of the nineteenth century that the field of surgery could be developed. Procedures involving the major joints of the upper and lower extremities are described. These procedures include resection and interposition arthroplasties, joint debridement, procedures done to correct complications of hip fractures and developmental dysplasia of the hip, cup arthroplasties, endoprosthetic replacement, hinge arthroplasties, resurfacing procedures, and early total joint replacement.

Decision making in upper extremity problems in the elderly.

As life expectancy continues to increase, orthopaedists must become more knowledgeable about upper extremity problems common to geriatric patients. Alternatives to direct repair of certain soft tissue injuries must be considered, because of their diminished healing ability and the morbidity associated with prolonged immobilization. Osteoporosis present in these patients affects surgical management of difficult fractures. Acquired soft tissue disorders such as nerve compression and Dupuytren's contractures often will require operative intervention to improve hand function. Osteoarthritis and rheumatoid arthritis disproportionately affect this age group. A variety of conservative and operative treatments are available to improve quality of life in these patients.

Progesterone-responsive urticaria and eosinophilia.

A 30-year-old black albino woman was first observed with a 4-year history of monthly urticarial episodes associated with hypereosinophilia. Hives consistently began at the end of menses and lasted for 1 to 2 weeks. A comprehensive evaluation excluded underlying malignancy and infection. There was no evidence of extracutaneous visceral involvement consistent with the primary hypereosinophilic syndrome. A 6-month prospective evaluation was performed, during which daily hive symptoms were recorded and weekly determinations of eosinophils, serum total IgE, progesterone, estradiol, and 24-hour urine histamine were obtained. Eosinophil counts (range, 4002 to 37,350 cells per cubic millimeter) increased in association with the onset of hives and decreased to baseline levels after their resolution. The 24-hour urine histamine peaked at the onset of each urticarial episode. When serum progesterone levels increased, the hives were quiescent and peripheral eosinophils decreased to baseline levels. Progesterone caused in vitro dose-related inhibition of antihuman IgE-induced histamine release from peripheral basophils of this patient. Treatment with oral medroxyprogesterone resulted in remission of urticaria and a decrease in eosinophil counts. This patient represents a unique case of chronic cyclic urticaria and hypereosinophilia that appears to be modulated by the effects of progesterone.

Cockroach sensitization in laboratory workers.

Six laboratory workers who were exposed to American cockroaches (AC) and German cockroaches (GC) while they were performing immunologic experiments were evaluated for cockroach hypersensitivity. Prick skin testing and RAST were performed with whole body extracts (1:20 wt/vol) of AC, brown-banded (BB), and GC species as well as hemolymph and fecal (F) extracts of AC. Three of six workers reported work-related nasal and ocular symptoms associated with xenografting and bleeding of cockroaches. All three symptomatic workers exhibited cutaneous reactivity to at least one cockroach antigen. Elevated RAST binding was observed in one of the three symptomatic workers. A nasal provocation to AC was positive in the most symptomatic worker at a provocative dose of 3.2 X 10(-3) mg causing a 50% decrease of nasal flow rate from baseline. After pretreatment with nasal cromolyn, the provocative dose causing a 50% decrease from baseline increased to 2.6 X 10(-1) mg. Nasal provocation with the same concentrations of AC were negative in two skin test negative subjects. RAST-inhibition studies demonstrated cross inhibition of the serum-specific IgE binding to AC-hemolymph by AC, GC, and BB whole body extracts. However, specific IgE binding to AC-F was inhibited by AC-F and AC but not by GC or BB whole body extracts, suggesting there was greater specificity of the F allergens. This study demonstrated that cockroach allergens elicit IgE-dependent upper respiratory sensitization in the workplace.

Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment?

The purpose of this study is to determine whether the addition of computed tomography (CT) results in changes in the evaluation and treatment of intra-articular distal radius fractures. Fifteen intra-articular distal radius fractures were evaluated independently by 4 hand surgeons. Plain x-rays were reviewed initially followed by the corresponding CT scans for comparison of articular step-off and gapping, comminution, and treatment. Kappa coefficients (kappa) of intraobserver and interobserver reliability for treatment plans were generated. Computed tomography scans improved the sensitivity of measurement of articular surface gapping, improved the accuracy of detection of comminution and distal radioulnar joint involvement, and altered proposed treatment plans within observers (intraobserver agreement: kappa =.54, moderate) and improved agreement of proposed treatment plans between observers (kappa =.34 to kappa =.44, fair to moderate). Computed tomography scanning influenced observers to change treatment plans and resulted in increased interobserver reliability in the proposed management of these injuries.

The significance of the three volar spaces in forearm compartment syndrome: a clinical and cadaveric correlation.

The goal of this study was to assess the importance of the 3 volar spaces in forearm compartment syndrome in a prospective manner. A cadaveric model was developed to correlate with our clinical experience. All but 1 of 21 volar compartments (superficial volar, deep volar, and pronator quadratus spaces) in 7 patients in our clinical series decompressed adequately after release of the superficial volar fascia. One patient needed further release of the pronator quadratus compartment; he had suffered a combined crush and vascular injury. All volar compartments in our cadaveric model decompressed with superficial fasciotomy. Prefasciotomy and postfasciotomy pressures should be obtained from all 3 compartments of the volar forearm. Superficial fasciotomy usually adequately decompresses the entire volar forearm; however, in the event that deep compartment pressures remain high after superficial fasciotomy, release of the affected space is indicated.

The utility of portable nerve conduction testing for patients with carpal tunnel syndrome: a prospective clinical study.

The usefulness and accuracy of a portable instrument, the electroneurometer, for measuring distal motor latencies was determined in a prospective study of 28 patients (51 hands) with carpal tunnel syndrome and 10 controls (18 hands). There was a close correlation of distal motor latencies from the electroneurometer with those from formal electrodiagnostic testing. The average distal motor latency of controls was 3.3 +/- 0.4 msec, compared with a mean value of 5.2 +/- 1.8 msec in symptomatic hands. The sensitivity of the neurometer test alone was 69% (9 false-negatives); when combined with quantitative sensibility testing, sensitivity increased to 84%. Specificity of the neurometer test alone was 100% (no false-positives). The portable electroneurometer is a convenient, painless, inexpensive device for screening patients with carpal tunnel syndrome. Formal electrodiagnostic testing is indicated for differentiation of lesions present at different levels, for detection of subtle sensory changes, and for use in those patients in whom surface electrode usage is ineffective.