Rupture of the posterior tibial tendon: CT and surgical findings

Computed tomography (CT) was performed in 42 patients with 49 clinically suspected tears of the posterior tibial tendon. Twenty-eight of the 49 suspected tears were subsequently surgically explored and repaired. Three patterns of tendon abnormalities were recognized on CT scans: type I-intact, hypertrophied, heterogeneous tendon; type II-attenuated tendon; and type III-absence of a portion of a tendon. Types I and II correlated with partial rupture seen during surgery, and type III correlated with complete rupture of the tendon. CT findings were accurate in 96% of the patients who underwent surgery. In four cases (14%), tendon rupture was seen on CT scans, but the extent of the injury was underestimated and the rupture was misclassified. Reactive periostitis of the distal tibia was seen in 71% of diseased tendons and may represent an important factor in the diagnosis of tendon rupture.     

Spread of a newly found trimethoprim resistance gene, dhfrIX, among porcine isolates and human pathogens.

A plasmid-borne gene mediating trimethoprim resistance, dhfrIX, newly found among porcine strains of Escherichia coli, was observed at a frequency of 11% among trimethoprim-resistant veterinary isolates. This rather high frequency of dhfrIX could be due to the extensive use of trimethoprim in veterinary practice in Sweden. After searching several hundred clinical isolates, one human E. coli strain was also found to harbor the dhfrIX gene. Thus, the dhfrIX gene seems to have spread from porcine bacteria to human pathogens. Furthermore, the occurrence of other genes coding for resistant dihydrofolate reductase enzymes (dhfrI, dhfrII, dhfrV, dhfrVII, and dhfrVIII) among the porcine isolates was investigated. In addition, association of dhfr genes with the integraselike open reading frames of transposons Tn7 and Tn21 was studied. In colony hybridization experiments, both dhfrI and dhfrII were found associated with these integrase genes. The most common combination was dhfrI and int-Tn7, indicating a high prevalence of Tn7.     

Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder.

BACKGROUND: The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS: Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS: Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS: In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.     

Cognitive behavioral treatment for young children with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.     

Acute Cholecystitis and Severe Ischemic Cardiac Disease: Is Laparoscopy Indicated?

BACKGROUND AND OBJECTIVES: Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication. METHODS: We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined. RESULTS: The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).