Use of the Green transfer in treatment of patients with spastic cerebral palsy: 17-year experience

We retrospectively reviewed Green procedures and transfer of the flexor carpi ulnaris (FCU) in treatment of spastic forearm pronation, wrist volarflexion, and ulnar deviation deformities. Patient's ages ranged from 3 years 5 months to 16 years 5 months. Surgically, a single volar incision was made and the extensor carpi radialis brevis and/or longus (ECRB, ECRL) were used for insertion. The FCU was tensioned at neutral against gravity and immobilized in 5 degrees of dorsiflexion and 45 degrees of supination. Arc of flexion (47 degrees) did not change but was centered about neutral. Supination improved markedly when operation included a pronator procedure. Quadraplegia athetosis and intellectual impairment did not affect the operative result adversely. Patients aged greater than 12 years showed less functional improvement. Eighty-eight percent had cosmetic improvement, and 79% improved functionally. None had a decreased functional rating.     

Neuropathologic changes with experimental spinal instrumentation: transpedicular versus sublaminar fixation.

Fifty-six mature beagles underwent lumbar spine destabilization, followed by fusion using four techniques. Spinal cord neuropathologic analysis was carried out to determine the number of abnormalities within each group. Group I (n = 14) had posterolateral bone grafting without instrumentation. Group IIa (n = 14) had Cotrel-Dubousset (CD) pedicle screws and rods. Group IIb (n = 14) had Steffee pedicle screws and plates. Group III (n = 14) had sublaminar wires and rods. All of the animals remained clinically neurologically normal throughout the 6 months of the study. The incidence of moderate to severe neuropathologic changes was 21% in Group I, 18% in Group II, and 64% in Group III. Thus, a significantly higher percentage of neuropathologic abnormalities occurred with sublaminar instrumentation than with no instrumentation (p = 0.027), or with transpedicular instrumentation (p = 0.027). In this controlled animal study, the theoretical advantage of pedicle screws, which should not violate the spinal canal, over sublaminar devices, which must enter the canal, was confirmed.     

The salvage of rabbit ischaemic epigastric free flaps using the vasodilator calcitonin gene-related peptide

The rabbit epigastric free flap, subjected to 21 hours of warm (25 degrees C) ischaemia, was used as an experimental model to test the ability of two endothelium-dependent vasodilators, calcitonin gene-related peptide (CGRP) and carbamyl beta-methylcholine chloride (MCh, bethanechol chloride, the stable acetylcholine analogue) to improve flap viability. After the period of ischaemia, flaps were infused intra-arterially with either Hanks balanced salt solution (controls), CGRP or MCh for 30 minutes, and received additional intravenous boluses of these drugs at 2 and 32 minutes after revascularisation. The area of flap surviving improved significantly (p less than 0.025) from 39.9% (n = 18) for controls to 70.2% (n = 14) for CGRP treatment at 2 micrograms/kg, but was unchanged at 47.1% (n = 14) for MCh treatment at 50 micrograms/kg. Both CGRP and MCh significantly increased blood flow (p less than 0.05) resulting in 34% lower peripheral resistances compared with controls. These results suggest that CGRP has considerable clinical potential for the salvage of ischaemic flaps. CGRP must have several, as yet undefined, beneficial effects on the ischaemic tissue, since MCh invoked a vasodilatory response but failed to salvage ischaemic flaps.     

A factor analytic study of the Diagnostic Assessment for the Severely Handicapped Scale.

Five hundred six severe and profoundly mentally retarded persons (247 women and 259 men) from Wisconsin and Louisiana were assessed on the Diagnostic Assessment for the Severely Handicapped Scale. A factor analysis yielded six factor scales: tantrums, aggression/conduct, language disorder/verbal aggression, social withdrawal/stereotypy, eating disorders, and sleep disorders. These data demonstrate a nosology of symptoms loading more heavily on vegetative symptoms than what is evident with persons in the mild and moderate ranges of mental retardation and persons who are not mentally retarded. The implications of these findings are discussed.     

Clinical validation of a nutritional risk index

This research assessed the clinical validity of a nutritional risk index (NRI). Subjects were 377 male veterans, aged 55+, attending general medicine and geriatric outpatient clinics. Data were collected by personal interviews, anthropometric measurements, laboratory assay of nutritional parameters, three-day food records, and medical record reviews. Although the results showed that the NRI correlated significantly with only two nutritional measures (body mass index, total energy intake), critical values or threshold levels of NRI were identified that significantly discriminated low risk from high risk patients on four nutritional parameters (body mass index, total energy intake, laboratory risk, and medications risk). It was concluded that the NRI is a valid measure of health status and contains a nutritional dimension.John M. Prendergast, MD, MPH is Medical Director, Program on Aging, Mercy Hospital, Pittsburgh, PA 15219; Rodney M. Coe, PhD is Professor, Department of Community Medicine, St. Louis University School of Medicine and Education Coordinator, Geriatric Research, Education and Clinical Center (GRECC), VA Medical Center, St. Louis, MO 63104; M. Noel Chavez, PhD, RD is Assistant Professor, Department of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL 60612; James C. Romeis, PhD is Associate Professor, Center for Health Services, Education and Research, St. Louis University and Coordinator, Health Services Research and Development, VA Medical Center, St. Louis, MO 63104; Douglas K. Miller, MD is Assistant Professor, Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO 63104; Fredric D. Wolinsky, PhD is Professor, Department of Sociology, Texas A&M University, College Station, TX 77843.This project was supported in part by grant #84-017 from the Veterans Administration and by K07-AG-00302 and K04-AG00328 from the National Institute on Aging.     

Integrating clinical and support process design for effective health services

With increased capitation and managed care competition, health care systems must demonstrate effective health services with predictable costs, timing, transitions, and health outcomes. By involving patients, payers, and multiple providers, a health care system can design integrated clinical and support processes across the continuum for defined populations. The goals are lower costs, increased payer and patient satisfaction, and improved health status. This article shares examples and experiences from four health care systems that teamed with Premier, Inc., to design an integrated services sequence for defined populations.     

The adenosine transporter, mENT1, is a target for adenosine receptor signaling and protein kinase Cepsilon in hypoxic and pharmacological preconditioning in the mouse cardiomyocyte cell line, HL-1

Brief exposure of the heart to hypoxia results in less cellular damage after subsequent hypoxia, an effect known as preconditioning (PC). PC has been widely studied but is still not fully understood. Adenosine (Ado), adenosine receptors, and protein kinase C (PKC) have been implicated as integral components of PC. Adenosine (nucleoside) transporters (NTs) facilitate flux of Ado across cell membranes, but their role in PC is unknown. Therefore, we used the murine cardiomyocyte cell line, HL-1, and asked if there was feedback regulation of NTs by Ado, Ado receptors, and PKC following either hypoxic or pharmacological PC. Activation (by specific agonists) of A1 or A3 Ado receptors or PKC resulted in PC in HL-1. The A1 (but not A3) receptor is coupled to PKCepsilon, and activation of PKCepsilon (by specific peptide agonist) resulted in PC. Moreover, PKCepsilon stimulates Ado uptake via the predominant NT in HL-1, mouse equilibrative nucleoside transporter 1 (mENT1). Studies in primary neonatal mouse cardiomyocytes confirmed our observations in HL-1 cells. Hypoxic challenge led to a rapid increase in, and efflux of, intracellular Ado from cells, which was blocked by NT inhibitors (dipyridamole/nitrobenzylthioinosine). Moreover, NT inhibition during hypoxia or PC was highly protective, suggesting that Ado loss contributes to decreased cell viability. Our data suggest that hypoxic challenge causes an efflux of Ado via ENTs, activation of A1 and/or A3 receptors, signaling through PKCepsilon, and activation of ENT1. Since Ado is required for ATP synthesis on reperfusion, this feedback regulation of mENT1 would promote reuptake of Ado.