The evolution of indirect reduction techniques for the treatment of fractures

During the last decade, classic AO/ASIF techniques for internal fixation shifted from direct reduction and rigid fixation to biologic internal fixation using indirect reduction techniques. Biologic internal fixation is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute mechanical stability. Reduction is achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length. Stabilization is performed when possible by compression plating for load sharing or by bridge plating in comminuted fractures. Advancements of these techniques and the development of newer implants that minimize vascular damage have contributed to the development of biologic internal fixation. By using indirect reduction, by using longer plates to improve the mechanical leverage, and by applying fewer screws to avoid unnecessary damage to the bone, fracture union rates were high. There also was a decreased need for supplemental bone grafting. All of these factors provided stable fixation and allowed early motion.     

Prognosis in cystic fibrosis treated with continuous flucloxacillin from the neonatal period

All newborn infants in East Anglia are screened for cystic fibrosis by blood immunoreactive trypsin assay at 7 days. Thirty eight infants with cystic fibrosis were randomised to treatment with either continuous oral flucloxacillin 250 mg/day (group P, n = 18) or with episodic antimicrobials as clinically indicated (group E, n = 20). Their progress was monitored from diagnosis to 24 months by a nurse coordinator who visited all infants regularly, at home and in hospital, to collect anthropometric, dietary, clinical, and microbiological data. Mean (range) age of confirmation of diagnosis was 5.7 weeks (1-14 weeks). There was no significant difference in birth weight, genotype, immunoreactive trypsin concentration, neonatal history, symptoms at diagnosis, pancreatic enzyme supplementation, or parental smoking history between the groups. Infants in group E had more frequent cough and a greater number of Staphylococcus aureus isolates than infants in group P. More infants of group E were admitted to hospital, had higher admission rates during the second year (19 v 5), for longer periods (6.4 v 2.2 days), despite receiving more than double the number of courses of antibiotics than group P infants (in addition to flucloxacillin). Continuous prophylactic flucloxacillin from early diagnosis of cystic fibrosis is associated with improved clinical progress during the first two years of life.     

Catamenial Epilepsy

EDITORIAL COMMENTS: We accepted this case so readers can judge when menstruation-related epilepsy may warrant such a radical remedy as bilateral oophorectomy. We have published the report of a case of severe menstrual migraine which also responded to bilateral oophorectomy and hysterectomy, and in which subsequent oestrogen replacement therapy likewise did not cause a relapse (A).
A. Holdaway IM, Parr CE, France J. Treatment of a patient with severe menstrual migraine using the depot LHRH analogue Zoladex. Aust NZ J Obstet Gynaecol 1991; 31: 164–165.     

Direct and indirect costs of schizophrenia

In the present study the costs of schizophrenia in Germany were studied using the "bottom up" prevalence-based method. In a random sample of 180 schizophrenic patients stratified according to the most important care institutions, direct and indirect costs were retrospectively documented for a 12-month period. Depending on the place of recruitment and the extent of care provided, total yearly costs result between about DM 33,000 for a patient treated predominantly on an outpatient basis and about DM 126,000 for a patient requiring hospital care and about DM 135,000 for a patient in job rehabilitation. The direct yearly treatment costs were, as expected, lowest for patients recruited in the private practice of a psychiatrist and predominantly treated on an outpatient basis (DM 5,788), and were the highest in the psychiatric hospital (DM 64,661) and in job rehabilitation (DM 79,996). In the patients recruited in the outpatient domain, doctors' fees and medication together were responsible for only 4.5% of the total costs, whereas the indirect costs (e.g., through work incapacity) were responsible for 87% of the total yearly costs. For methodological reasons the total costs caused by schizophrenic psychoses in Germany per year can at present be estimated only roughly. A conservative estimate is between 8.5 and 18 billion DM per year. The study shows that schizophrenia is a very expensive illness, the direct and indirect costs of which are on the whole comparable to those of the common somatic illnesses. Therefore, also for economical reasons, sufficient financial means should be invested in the research and treatment of this severe illness.     

Solvent/detergent-treated plasma has decreased antitrypsin activity and absent antiplasmin activity

Solvent/detergent (S/D)-treated plasma is currently marketed by the American Red Cross as a virally inactivated alternative to fresh-frozen plasma (FFP). The serpin-type serine proteinase inhibitors have a flexible reactive site loop (RSL) that can convert from the active conformation to the inactive latent or polymerized conformations when exposed to heat and/or detergents. We have compared the conformational stability and inhibitory activity of 3 plasma serpins-antithrombin, antitrypsin, and antiplasmin-in S/D plasma and FFP. In S/D plasma, virtually 100% of the antiplasmin and approximately 50% of the antitrypsin are in either the latent or polymerized conformation and lack inhibitory activity, while in FFP only the active conformation is present. Interestingly, antithrombin is not affected by S/D treatment and remains fully active. These data demonstrate that S/D plasma is not simply a virally inactivated equivalent of FFP. The lack of antiplasmin activity and decreased antitrypsin activity in S/D plasma suggest that it may not be as effective as FFP for the treatment of bleeding in patients with systemic activation of proteolytic cascades, such as disseminated intravascular coagulation and sepsis, acquired fibrinolytic states, and large-volume transfusion. Although there has been extensive use of S/D plasma in several European countries with no reports of adverse effects, clinical studies directly comparing the efficacy of these 2 plasma products are needed to directly evaluate the relative therapeutic efficacy of FFP and S/D plasma for the treatment of these diseases.     

Delirium? Admission to the general hospital, rather than a psychiatric hospital

Delirium is often not recognized either by psychiatrists or by other physicians. In two men, aged 78 and 70 years, a diagnosis of delirium was not recognized at admission. The first patient had Alzheimer's disease with superimposed delirium caused by pulmonary embolism, which led to cardiopulmonary arrest during his stay in a psychiatric hospital. The other patient had a delirium due to multiple somatic causes (carbon monoxide poisoning with cerebral damage, pulmonary infection, heart attack) which was not recognized leading to an early discharge from the general hospital. The first patient died later on because of complications of a pneumonia and the other patient was transferred to a nursing home on a maintenance dose of haloperidol. Since delirium is a symptom of a medical disorder, delirious patients should be referred primarily to a general hospital.     

A longitudinal study of TGF-beta1 protein levels in renal allograft recipients converted from CsA to MMF or AZA

Cyclosporine (CsA) is thought to enhance transforming growth factor (TGF)-beta1 production in vitro and in vivo and this may have a negative effect on long-term graft survival. Therefore, we studied TGF-beta1, plasma levels in 30 patients before kidney transplantation, after transplantation during CsA treatment and after conversion from CsA to azathioprine (AZA) or mycophenolate mofetil (MMF). We questioned whether TGF-beta1 plasma levels would decrease after the discontinuation of CsA and whether the TGF-beta1 plasma levels did correlate with CsA trough levels and kidney function, measured by serum creatinine levels. TGF-beta1 plasma levels measured 1 yr after transplantation were lower compared to levels measured before transplantation, however not significantly (p = 0.08). After conversion from CsA to MMF or AZA, a slight increase was observed in some patients, but in the total group TGF-beta1 levels remained unaffected. No correlation was found between the TGF-beta1 levels and CsA trough levels nor with creatinine levels. In conclusion, we did not observe higher TGF-beta1 plasma levels in plasma levels of patients receiving CsA treatment compared to blood from the same patients while on AZA or MMF.     

Clinical and laboratory findings in referrals for mitochondrial DNA analysis

BACKGROUND: Increasingly, mutations of mitochondrial DNA (mtDNA) are being considered when investigating the aetiology of neurological diseases in childhood. However, they are often difficult to predict clinically. METHOD: Mitochondrial DNA analysis was carried out on 190 children from 1992 to 1996. Most patients were screened for large scale rearrangements and point mutations at nucleotide positions 3243, 3271, 8344, and 8993. RESULTS: Mutations were found in only 15 patients (7.9%) and were either large scale rearrangements (seven patients) or point mutations at nucleotide position 3243 (eight patients). Other point mutations were screened for depending on the clinical picture. The age of symptom onset was significantly older in children with an mtDNA mutation (mean 7.0 years) compared with children without a mutation (mean 2.8 years). Neither Leigh's syndrome (28 cases) nor severe infantile lactic acidosis (12 cases) was associated with mtDNA mutation. Only three clinical features were significantly associated with an mtDNA mutation: progressive external ophthalmoplegia, myopathy, and pigmentary retinopathy. Family history was valuable: the point mutation at nucleotide 3243 (but not the large scale rearrangements) was associated with maternal inheritance; and consanguinity was not associated with mtDNA mutations. The only investigation that provided specific evidence of an underlying mtDNA mutation was histochemical staining of muscle biopsy specimens. The large scale mutations associated with Kearns-Sayre syndrome and progressive external ophthalmoplegia were found in DNA from muscle only, not leucocyte DNA; whereas point mutations were found in leucocyte DNA. CONCLUSIONS: Even among children seen at a neurogenetic referral centre, mtDNA mutations were very uncommon. Muscle biopsy was the only investigation to provide evidence of mtDNA abnormality.     

转化生长因子β对体外破骨细胞分化的影响

目的:研究在核因子κB受体活化因子配基(RANKL)和巨噬细胞集落刺激因子(M-CSF)联合应用诱导体外骨髓细胞培养系统中,转化生长因子(TGF-β)对破骨细胞分化的影响。方法:选用小鼠M-CSF依赖性非附着性骨髓细胞,在含有25 ng/m l sM-CSF和30 ng/m l sRANKL的α-MEM培养液中进行培养,比较加入和不加入1 ng/m lTGF-β1培养4、9 d后,所形成的抗酒石酸酸性磷酸酶染色(TRAP)阳性多核细胞的数目和骨吸收面积。结果:小鼠骨髓细胞在RANKL和M-CSF共同作用下可形成TRAP阳性多核巨细胞,并具有骨吸收功能。加入TGF-β后,破骨样细胞的数目及骨吸收面积显著增加。结论:TGF-β对RANKL和M-CSF诱导的破骨细胞的分化及其功能的促进作用,可能为炎症状态下发生过度骨吸收的机制之一。