One-stage correction of the spastic dislocated hip. Use of pericapsular acetabuloplasty to improve coverage.

We performed a combined one-stage approach for the treatment of eighteen spastic subluxated or dislocated hips in eleven children who had cerebral palsy. All patients were between five and thirteen years old and had spastic subluxation or dislocation of the hip and severe acetabular dysplasia. The operation consisted of release of the adductors, psoas, and proximal hamstrings; a femoral-shortening varusderotation osteotomy; and a pericapsular pelvic osteotomy. The pelvic osteotomy was designed to increase superolateral coverage of the femoral head in the elongated acetabulum, which had erosion of the superior and lateral aspects. At the latest follow-up (mean duration, six years and ten months), seventeen of the eighteen hips remained anatomically reduced.     

Support networks and dementia

Based on data from a sample of 4500+ people aged 65+ living in the community (ie not in residential care) in Liverpool, this article presents data on the availability of kin and levels of contact with family, friends neighbours and community groups, and compares the distribution of support network types of those identified as cases of dementia with non-cases. It is shown that dementia sufferers are more likely to live with others and to have more contact with family members and less contact with friends, neighbours and community groups than non-sufferers. It is also shown that the distribution of network type is distinctively different for cases and non-cases and it is suggested that this reflects the greater ability of some types of network to support continued community residence in the face of the onset of dementia.     

Physician performance of laboratory tests in self-service facilities. Residents' perceptions and performance

Primary care physicians perform simple laboratory tests in clinical practice, frequently with little formal training. To determine the frequency of tests that are performed and evaluate house officer laboratory skills, we surveyed house officer attitudes and tested their ability to perform four common laboratory tests. We received 193 responses from 254 house officers at one university teaching hospital. While most perceived the need to use ward laboratories (ie, self-service laboratories located on patient care wards), 67% used them infrequently. Barriers included poor laboratory condition, inadequate time, accuracy, and infectious exposure concerns. Twenty-four percent felt they did not know or were unsure if they knew how to perform simple tests. Forty-seven house officers completed the practical examination. Most accurately reported a spun hematocrit and correctly identified white blood cell findings on a blood smear. Only 50% counted 100 cells. Urinary dipstick interpretation was generally acceptable but the microscopic examination was less accurate. Twenty-three percent failed to identify gram-negative rods on a slide with both gram-positive cocci and gram-negative rods. If physicians are to perform selected laboratory tests, these data suggest, at least in one institution, more formal training, practice, and evaluation are necessary to ensure their performance with adequate proficiency.     

Cobas-Bact system for identification of members of the family Enterobacteriaceae in 4 h 20 min

The Cobas-Bact (Roche Diagnostics, Basel, Switzerland) new rotor for the identification (ID) in 4 h 20 min of 33 members of the family Enterobacteriaceae to genus and species level was evaluated by testing 444 strains of which 398 belonged to common species and 46 belonged to rare species of Enterobacteriaceae. Each strain was identified by the API 20E system (Analytab Products, Plainview, N.Y.), and additional discriminating tests were set up if necessary. Only first-choice ID were considered in this study and were classified either as high-confidence ID (normalized likelihood, greater than or equal to 80%) or as low-confidence ID (normalized likelihood, less than 80%) requiring additional tests for confirmation. The data were analyzed by two versions of Cobas-Bact software. With the first version of the software (SW8446), the overall accuracy of Cobas-Bact was 95.5% (424 correct ID of 444). When restricted to high-confidence ID it rose to 99.4% (350 of 352) for the common species and 96.9% (31 of 32) for the rare species. Only three strains of the high-confidence group were misidentified. Sixty ID were considered unacceptable because of their low confidence. Using the first software version (SW8446) they represented 12% (46 of 398) of the common species (17 typical strains, 10 Shigella species, 10 inactive Escherichia coli strains, and 9 rare biotypes) and 30% (14 of 46) of the rare species. The same data analyzed by the new version (SW8524) of the Cobas-Bact software resulted in an overall accuracy of 93.9% (417 correct ID). The number of high-confidence ID rose to 401, of which 392 (97.7%) were accurate. The decrease in low-confidence ID (43 versus 60) was mainly due to the Shigella species. In conclusion the accuracy of Cobas-Bact identification system was very good when restricted to high-confidence ID. The Cobas-Bact performance for rare species ID was poorer, but the small number of strains tested does not allow definitive conclusions.     

Cardiovascular disease in the elderly.

The current worldwide explosive increase in the numbers of older persons is unprecedented in history. In the 1990s and beyond, the preponderance of patients with cardiovascular illness will be elderly, with a substantial subset among the frail elderly, 85 years old and older. Cardiovascular disease remains the leading cause of death and disability in this population, and cardiovascular risk increases steadily with age. Pascal defined old age as "just a time that is farther from the beginning and nearer to the end." Elderly persons, with and without cardiovascular disease, vary widely in their physical, behavioral, cognitive, and emotional functioning; severity of illness; and expectations from medical care. The challenge to the clinical and research communities alike is to delineate the appropriate components of preventive, diagnostic, and therapeutic care for elderly cardiac patients in our society, interventions that are likely to relieve suffering, restore function so as to limit disability and dependency, and maintain a dignified and meaningful life-style for the end years of life. Major societal strides have been made in redefining both the onset of old age and its limitations. The eighteenth century poet, Robert Burns, wrote of his fears that he would be 45 years old at a time when life expectancy was 40 years; he saw himself as being weary, wrinkled, creeping, and joyless. For, ance that five-and-forty's speel'd, See crasy, weary, joyless Eild, Wi' wrinkled face, Comes hostin', hirplin', owre the field, Wi' creepin' pace. Burns died at the age of 37 years. A more attractive option is offered by Abraham Joshua Heschel, 1907-1972. According to all the standards we employ ... the aged person is condemned as inferior. ... Conditioned to operating as a machine for making and spending money, with all other relationships dependent upon its efficiency, the moment the machine is out of order and beyond repair, one begins to feel like a ghost without a sense of reality. ... Regarding himself as a person who has outlived his usefulness, he feels as if he has to apologize for being alive. May I suggest that ... old age be regarded not as the age of stagnation but as the age of opportunities for inner growth. ... The years of old age ... are indeed formative years, rich in possibilities to unlearn the follies of a lifetime, to see through inbred deceptions, to deepen understanding and compassion, to widen the horizon of honesty, to refine the sense of fairness.     

The controversy about a sexual dimorphism of the human corpus callosum

A sexual dimorphism of the splenium corporis callosi in man was reported in 1982. The authors described the posterior part of the female corpus callosum to be larger and more bulbous than its male counterpart. From the lateralization research, it has previously been stated that the female brain is less well lateralized for visuospatial functions than the male. The authors postulated that a larger splenium implies a larger number of fibers and that the number of interhemispheric fibers correlates inversely with lateralization of function. However, their sample was very small and not adequately matched for sex. Therefore, we reinvestigated this question. A standardized computer assisted program will be presented. With this program the "classical" parameters have been evaluated and the "rotatory diameter measurement" was performed. No differences between the sexes were seen either for the splenium corporis callosi or for the other parts of the corpus callosum.     

Mosaic ring 12p and total anomalous pulmonary venous return

An infant born with total anomalous pulmonary venous return (TAPVR) was found to have an extra chromosome present as a small ring. Spectral karyotyping and FISH analysis identified the material as a duplication involving the short arm of chromosome 12. Previous cases describing a variety of cytogenetic abnormalities that have been associated with TAPVR are reviewed along with prior cases of duplication 12p with their associated findings. We believe ours is the first case to report the occurrence of mosaic ring 12p and its association with TAPVR.     

Cutaneous manifestations of opportunistic infections in patients infected with human immunodeficiency virus.

Bacillary angiomatosis (BA) presents most commonly as a cutaneous disease and is caused by two organisms. Bartonella (Rochalimaea) henselae and Bartonella (Rochalimaea) quintana. Biopsy confirmation of cutaneous BA is essential because lesions can mimic nodular Kaposi's sarcoma in appearance. Although the vast majority of human immunodeficiency virus (HIV)-infected patients with BA have CD4 lymphocyte counts of less than 100 cells per mm3, the disease responds well to antimicrobial therapy. Staphylococcus aureus is the most common bacterial skin pathogen affecting HIV-infected patients. The prevalence of skin disease due to S. aureus may be explained by high nasal carriage rates for the organism ( > or = 50%) and altered immune function in conjunction with an impaired cutaneous barrier. Herpes simplex virus causes mucocutaneous disease early in the course HIV infection and ulcerative lesions at any site in advanced HIV infection. Herpes zoster is common early in the course of HIV infection; recurrent and disseminated herpes zoster infections are characteristic of patients with advanced HIV disease. Acyclovir resistance is usually seen in patients with large, untreated, ulcerative lesions of herpes simplex virus and in patients with chronic, verrucous lesions of varicella-zoster virus. Cutaneous cryptococcosis, histoplasmosis, and coccidiomycosis are markers of disseminated disease and require biopsy confirmation. Scabies is easily diagnosed but may be atypical in presentation and difficult to eradicate in advanced HIV disease.