Prevention of deep vein thrombosis after elective hip surgery. A randomized trial comparing low molecular weight heparin with standard unfractionated heparin.

OBJECTIVE: To determine the relative efficacy and safety of low molecular weight (LMW) heparin (Enoxaparin) compared with standard calcium heparin for the prevention of postoperative deep vein thrombosis in patients undergoing elective hip surgery. DESIGN: A double-blind, randomized, controlled trial. PATIENTS: Six hundred sixty-five consecutive patients undergoing hip replacement at five participating hospitals. INTERVENTIONS: Patients received either fixed-dose LMW heparin, 30 mg subcutaneously twice daily, or fixed-dose standard calcium heparin, 7500 units subcutaneously twice daily; both regimens were started 12 to 24 hours after surgery and continued for 14 days or until discharge if sooner. MEASUREMENTS: All patients had postoperative I-125-fibrinogen leg scanning and impedance plethysmography. If results of one or both tests were positive, then venography was done. Otherwise, venography was done between day 10 and day 14, or sooner if the patient was ready for discharge. RESULTS: Evaluable venograms were obtained in 258 of the 333 patients randomly assigned to receive LMW heparin and in 263 of the 332 patients assigned to receive calcium heparin. For patients with evaluable venograms, thrombosis was detected in 50 patients (19.4%) who received LMW heparin compared with 61 patients (23.2%) who received standard heparin (difference, -3.8%; 95% CI, -11.1% to 3.6%) (P greater than 0.2). Proximal deep vein thrombosis was detected in 5.4% of the patients receiving LMW heparin and in 6.5% of the patients receiving standard heparin (difference, -1.1%; CI, - 5.2% to 3.3%) (P greater than 0.2). For the entire group of 665 patients, venous thrombosis occurred in 17.1% given LMW heparin and in 19.0% given standard heparin. Hemorrhagic complications occurred in 31 patients (9.3%) given standard heparin and in 17 patients (5.1%) given LMW heparin (difference, 4.2%; CI, 0.3% to 8.2%) (P = 0.035). The relative risk reduction was 45%. The rate of major bleeding in the standard heparin group was 5.7% compared with 3.3% in the LMW heparin group (difference, 2.4%; CI, -1.0% to 5.4%) (P = 0.13). The relative risk reduction was 42%. CONCLUSION: Low molecular weight heparin is significantly less hemorrhagic than standard unfractionated heparin; the difference in the rate of deep vein thrombosis, although not statistically significant (P greater than 0.2), favors the use of LMW heparin.     

Local induction of an insulin-like growth factor binding protein-3 degrading protease activity in the course of wound healing

Proteases that reduce insulin-like growth factor binding protein-3 affinity for insulin-like growth factor-I have been found in various biological fluids from human beings and rats. The aim of this study was to assess the local and systemic role of insulin-like growth factor binding protein-3 proteases in the course of wound healing. Six rats had polyvinyl alcohol sponges implanted subcutaneously. Wound fluid and serum were collected 3 days after wounding. Gel filtration experiments showed that insulin-like growth factor-I was present as a 150 kDa complex in both serum and wound fluid. However, insulin-like growth factor binding protein-3 measured by Western ligand blotting was virtually absent in wound fluid. Co-incubation of serum and wound fluid resulted in an ethylenediamine tetraacetic acid-inhibitable degradation of serum insulin-like growth factor binding protein-3, suggesting the presence of an insulin-like growth factor binding protein-3 degrading activity in wound fluid. Incubation of ((125)I)-labeled insulin-like growth factor binding protein-3 in wound fluid and serum showed a rapid and time-dependent proteolysis of insulin-like growth factor binding protein-3 in wound fluid with metabolites similar to those generated by human term pregnant serum. No sign of insulin-like growth factor binding protein-3 degrading activity was observed in rat-serum. In conclusion, there is an insulin-like growth factor binding protein-3 proteolytic activity in wound fluid, and it is hypothesized that this activity results in a localized increase in insulin-like growth factor-I bioactivity.     

A Randomized Pilot Study of Behavioral Treatment to Increase Calorie Intake in Toddlers With Cystic Fibrosis

This pilot study examined a behavioral treatment to increase calorie intake in toddlers with cystic fibrosis. Eight toddlers were randomly assigned to behavioral plus nutrition (BEH) or nutrition intervention (NTR) conditions. Calorie intake and weight were measured at pre- and posttreatment. The BEH group showed a trend for changes in calorie intake pre- to posttreatment (p = .07; 40% increase). Results for the BEH and NTR groups did not differ significantly. Most participants achieved weight gains consistent with normal growth. Seventy-five percent had not shown this pattern during the year prior to intervention. These results support the feasibility and potential for behavioral interventions in this age group.     

Prediction of Remission of Acute Posttraumatic Stress Disorder in Motor Vehicle Accident Victims

One hundred forty five individuals who sought medical attention as a result of a motor vehicle accident (MVA), and who were initially assessed 1 to 4 months post-MVA, were followed up prospectively for 6 months to determine how many of the 55 with posttraumatic stress disorder (PTSD) and the 43 with sub-syndromal PTSD would remit and what variables would predict remission. Thirty (55%) of those with initial PTSD had remitted at least in part by 6 months while 67% of those with sub-syndromal PTSD had remitted (and 5% had worsened). Four variables, including severity of initial symptoms, degree of initial physical injury, relative degree of physical recovery by 4 months and whether a close family member suffered a trauma during the follow-up interval, combined to classify 6-month clinical status of 84% of those with initial PTSD secondary to MVAs.     

Quantitative Magnetic Resonance Imaging of Human Brain Development: Ages 4-18

Brain magnetic resonance images (MRI) of 104 healthy childrenand adolescents, aged 4–18, showed significant effectsof age and gender on brain morphometry. Males had larger cerebral(9%) and cerebellar (8%) volumes (P < 0.0001 and P = 0.008.respectively), which remained significant even after correctionfor height and weight After adjusting for cerebral size, theputamen and globus pallidus remained larger in males, whilerelative caudate size was larger in females. Neither cerebralnor cerebellar volume changed significantly across this agerange. Lateral ventricular volume increased significantly inmales (trend for females), with males showing an increase inslope after age 11. In males only, caudate and putamen decreasedwith age (P = 0.007 and 0.05, respectively). The left lateralventricles and putamen were significantly greater than the rightP = 0.01 and 0.0001, respectively). In contrast, the cerebralhemispheres and caudate showed a highly consistent right greater-than-leftasymmetry (P < 0.0001 for both). All volumes demonstrateda high degree of variability. These findings highlight gender-specificmaturational changes of the developing brain and the need forlarge gender-matched samples in pediatric neuropsychiatric studies.     

Orthopedic office management. The need for planning and goals

The purpose of this article is to provide physicians in private practice with a methodology for shaping their own destinies and to ensure they will be able to cope successfully with the current changes, as well as those yet to come, that will impact on their practices. It attempts to highlight those core techniques employed in long-term and strategic planning, enabling them to understand what the planning process is all about.     

Comparison of chemical, histomorphometric, and absorptiometric analyses of bones of growing rats subjected to dietary calcium stress

Absorptiometric, histomorphometric, and chemical analyses of bones from growing rats fed diets with low (0.2%, w/w), marginal (0.4%, w/w), or adequate (0.8%, w/w) calcium (Ca) content with or without phytate were compared. Phytate was added to each diet in a molar ratio of 19:1 to calcium. Male weanling Sprague-Dawley rats were fed one of the six diets for 8 weeks. At the end of 8 weeks, rats were killed, and mandibles, femurs, and tibias were removed. Bone density profiles were determined on the mandibles and femurs using single photon absorptiometry. Femurs were also used for calcium and phosphorus analyses. Tibias were used for histomorphometric analyses. Bone density of the femurs and mandibles increased as dietary Ca increased. The only effect of phytate addition measured was in the 0.8% calcium diet, where density was lower in rats fed the phytate-containing 0.8% calcium diet. Femur calcium concentration also increased as dietary Ca increased and was unaffected by addition of phytate. Femur phosphorus concentration was unaffected by dietary Ca levels but was increased by 10% when phytate was added to the diet. Bone density values were highly correlated with bone calcium and phosphorus levels (r = 0.94). Rats fed the 0.2% calcium diets had 20% lower mineralized bone area and 20% larger medullary cavity area than rats fed the other diets. Bone densitometry appears to be useful for determining changes in bone occurring in growing rats fed low, marginal, and adequate levels of dietary Ca. Bone density values also correlated well with chemically determined calcium and phosphorus concentrations and with histomorphometric data.     

Finishing techniques for amalgam restorations: Clinical assessment at three years

Use of the optimum finishing technique for an amalgam restoration may enhance the marginal integrity of the restoration and discourage its unnecessary early replacement. Two hundred and twenty-eight high copper amalgam restorations in 56 patients were evaluated, using clinical assessment criteria, up to three years after placement. Each patient had received at least one carved-only amalgam, at least one immediately finished restoration, and at least one amalgam that was polished at a subsequent appointment. Regardless of the finishing technique, the restorations exhibited similar marginal integrity up to three years after placement. Polished restorations were found to have substantially superior surface texture and less likelihood of surface discoloration. No evidence was found to support the use of immediate finishing techniques. The clinical significance of these findings, with respect to the need to polish amalgam restorations, is discussed.