Accuracy of passive ankle joint positioning during quiet stance in young and elderly subjects

Age-related postural deficits elicit compensatory mechanisms such as ankle dorsiflexion in the elderly. To gain further insight into this problem, the ability to match an ankle angle during quiet stance was studied in 12 elderly and 12 young subjects. Following an initial single limb angular perturbation presented in the ±4° range, a subject had to return a tilt platform to level, as determined by the nonperturbed limb. Elderly subjects exhibited significant positive (0.9°) over-shoot of the level position, in contrast to young subjects who matched ankle angle with a mean error of −0.1°. The elderly group also exhibited an increase in positioning error for angular displacements in the range between −1 and +1°. The results document age-related postural changes in ankle positioning which might affect postural stability in older adults.     

Multiple myeloma: evaluation by CT

Although patients who have multiple myeloma usually have straightforward clinical symptoms and corroborative radiographs, in some instances, these patients will present atypically, with symptoms suggesting active disease but radiographs that are normal or nonspecific. We reviewed the records of 32 patients who had documented multiple myeloma and had undergone CT examinations, assessing the value of those examinations. Although CT is not indicated in all patients who have multiple myeloma, it is especially useful in patients who have bone pain and normal or nonspecific radiographs. CT provided confirmatory information in all cases in which lesions were seen on radiographs. CT also frequently demonstrated a greater extent of disease than could be appreciated on the radiographs.     

Advance Directives in the Emergency Department: Too Few, Too Late

Objective: To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.
Methods: A cross-sectional, observational survey of a convenience sample of high-risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.
Results: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).
Conclusion: The majority of high-risk patients presenting to this ED do not have ADs. Among those high-risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high-risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.     

Supraacetabular insufficiency fractures

Insufficiency fractures in the supraacetabular region were identified in five women, aged 55-83 years. Factors contributing to the diminished resistance of their bones included postmenopausal osteoporosis, steroid therapy, radiation therapy, and rheumatoid arthritis. The supraacetabular fractures were seen on routine radiographs as hazy bands of sclerosis located immediately above and parallel to the acetabular roof. All five patients had additional fractures in the spine or pelvis. Supraacetabular insufficiency fractures may be an unsuspected cause of hip pain, especially in older women.     

Capsular and vascular invasion: important prognostic factors in Wilms' tumor.

The influence of capsular and vascular invasion on prognosis was determined retrospectively in 52 children with Wilms' tumor. Local recurrence was more prevalent (0.26) in patients with rupture or capsular invasion than in any other group. Inadequate postnephrectomy irradiation or infiltration of the liver by nephroblastoma cells appeared to be predisposing factors in the development of these reccurrences. Of the 26 patients with gross or microscopic vascular invasion, 13 developed metastasis. This proportion was significantly higher than in patients without vascular involvement (p less than 0.05). These observations emphasize the importance of microscopic detection of capsular and vascular invasion in staging of Wilm's tumor.     

A rat model of preeclampsia

Preeclampsia/eclampsia is a disorder of human pregnancy that continues to exact significant maternal morbidity and mortality and fetal wastage. Therapy of these disorders has not changed in over 50 years and there are no proven preventive measures. We describe a model of the development of a syndrome in the pregnant rat that resembles preeclampsia, which results from the imposition of excessive volume expansion early in gestation. We administered desoxycorticosterone acetate (DOCA) to pregnant animals whose drinking water had been replaced with saline. We compared the results obtained in these animals with those resulting from the study of control, virgin animals, virgin animals receiving DOCA and saline, and normal pregnant (NP) animals. The virgin animals given DOCA and saline did not become hypertensive. The experimental paradigm in the DOCA plus saline pregnant (PDS) animals provides many of the phenotypic characteristics of the human disorder including the development of hypertension, proteinuria, and intrauterine growth restriction. In addition, the mean blood nitrite/nitrate concentration was reduced in the PDS rats compared with their NP counterparts. We propose that this model may prove to be useful in the study of the human condition.     

Colon perforation following percutaneous nephrostomy and renal calculus removal

Two patients had colonic perforation as a result of percutaneous nephrostomy placement followed by track dilatation and renal calculus removal. We present the technical aspects of nephrostomy placement and stone removal, as well as the clinical diagnosis and management of these cases. Both patients recovered well with conservative therapy and required no surgical intervention. This report reviews the anatomic considerations for percutaneous nephrostomy in patients undergoing renal stone removal.