False sexual-abuse allegations by children and adolescents: contextual factors and clinical subtypes.

The authors review the empirical literature concerning the frequency of false allegations of sexual abuse as well as the case report literature that describes individual episodes of false allegations in detail. The authors then construct a clinical typology that is derived from the literature and their own clinical experience with similar cases. The specific subtypes of the typology are: (1) False allegation in the context of a custody dispute, (2) false allegations resulting from psychological disturbance on the part of the accuser, (3) false allegation as a conscious manipulation by the child or adolescent and, (4) false allegations based on iatrogenic factors. Clinical examples of each subtype are presented. The case material presented and reviewed indicates the importance of attending to the contextual factors surrounding the allegation and pursuing a detailed comprehensive evaluation that is as free of bias as possible.


Professionals' attitudes towards sex between institutionalized patients.

Sexual activity among institutionalized patients has always been an issue of concern to institutions. Despite this fact, there has been little consensus about how patient sexuality should be dealt with. Nor have clinical insights with respect to patient sexuality been empirically tested. Given the diversity of beliefs and policies in this area, guidelines concerning sexual activity among hospitalized mental patients seem to be badly needed. We examined the following six factors that we thought might influence staff decisions: (1) the competence of a patient to engage in sexual activity, (2) the degree of consent, (3) the nature of sexual activity (e.g., hugging vs. genital relations), (4) the location of sexual activity (e.g., in bedroom vs. on grounds), (5) the sex of the initiating patient (6) the sex of the other patients. We hypothesized that mental health professionals, both as members of the community at large and as professionals, would have conventional moral views (as defined by Kohlberg) towards sexual activity. Supporting this hypothesis, of the six factors listed above, only location of the sexual activity and form of the sexual activity affected judgements on sexual activity significantly. The professionals interviewed appeared to be most condemning of homosexual acts, and least condemning of hugging. Although we had hypothesized that profession norms of consent and competence would be significant factors, they were not. The core implication of our study is that mental health professionals need training on competence assessment and its use in decision making and must reexamine their own prejudices (e.g., homophobia) to clarify their decision making about institutional policies.


Dynamics for communications data.

To create a complex dynamical model for a complex system, it is normally necessary to have a directed graph of the network, a dynamical model for each node, and a coupling function for each directed edge. But in many applications, the only observable data consists of communications from one node to another. In this situation, the modeler may infer a complex dynamical model for the network without any explicit knowledge of the independent dynamical behavior of the component systems (nodes). Here we present one procedure for this type of modeling problem, inspired by the attractor reconstruction procedure of chaos theory. Part of this proposal consists of a strategy for computer graphic presentation of the interactive dynamics of the complex system (or social network of dynamical schemes) called a netscope. We can imagine applications to diverse situations, such as decision groups, management, forecasting, international relations, classroom monitoring, therapy (personal, family, group, etc.) and distributed processors, to name a few.


On deciphering the book of nature: human communication in psychotherapy.

The tools of contemporary applied mathematics reveal important hidden regularities amidst the ongoing interactive feedback phenomena occurring in interactional or dynamical systems in nature where everything affects everything else. Badalamenti and Langs investigate each therapy session as a continuous sequential emergence of interrelated communicative events (or communicative states) which meet the criteria of a dynamical system. Applying mathematical modeling the authors demonstrate how otherwise hidden regularities occurring between patients and therapists become accessible to us that are unavailable to our unaided powers of observation, intuition, and thought. This is a systems or population investigation of clinical interaction that begins in a qualitative or domain mode, but which opens immediately toward statistical and formal modes of discussion. It can lead to statements of properties and laws that meet the criteria of scientific dialogue and validity. It provides the clinician with guidelines for making interpretations and for assessing their immediate subsequent effect. It is distinguished from the essentialist approach at the foundation of traditional clinical thought which provides no access to such feedback phenomena and their properties. Communicative Psychoanalysts have adopted the systems perspective and are evolving a clinical language and treatment based upon its principles and discoveries.


Clinical consequences of a formal mode of science of psychoanalysis and psychotherapy.

The paper has presented some ways in which existing formal-mode science results are of importance to the practicing clinician. Stress was placed on the quantification and mathematical identification of countertransference difficulties. Formal science results allow for deep insight into the effects of various approaches to doing psychotherapy that have not been previously available. By adding a new dimension to psychoanalytic observation and understanding, formal science studies of the deeper nature of the human mind and of the therapeutic interaction should help in time to lead to major revisions in clinical theory and practice.


Psychotherapy with the neuropsychologically impaired adult.

Despite opinions to the contrary, psychotherapy can be conducted with probably all but severely brain-impaired patients, albeit with some modification. The challenge is for the clinician to tailor his/her training to meet the needs of brain-impaired patients. There are certain real limitations, however, of neuropsychologically impaired patients that make psychotherapeutic attempts difficult. Assessment of patients' awareness of their losses, and of the implications of these losses is basic to an understanding of the emotional reactions observed. Screening and/or evaluation of certain neuropsychological functions is vital, as these functions have direct impact upon treatment efficacy. Traditionally, brain impairment has been thought to exacerbate premorbid or underlying character traits. An explanation is proposed for this traditional view of "exacerbation of premorbid style," in terms of decreased problem-solving skills, greater rigidity, and inherent increased strain of brain impairment. Neuropsychological deficits may interact with premorbid character types to produce some (predictable) behavioral alterations. Adjustments are required to accommodate to the deficits of brain-impaired patients, while retaining the richness of subjective experience in the clinical interaction. In treating neuropsychologically impaired persons, a model of equilibrium is thus suggested to balance patients' deficits with the therapist's interactions.


Working through conflict with self-destructive preschool children.

This case history charts the treatment of a preschooler who first presented at the age of three years and ten months with aggressive and self-destructive behaviors. During the initial months of treatment, the therapist focused upon establishing a therapeutic alliance with the child in order to evoke a transference reaction. Compelling evidence of the transference in this case occurred in the ninth month of treatment when the therapist told the child that she would be going on vacation. The child, whose own mother had abandoned him several times, responded with uncharacteristic physical and verbal abuse. Although the child engaged in aggressive and self-destructive play enactments almost from the onset of treatment, these behaviors intensified from the fifth month of treatment onwards, as it became evident that he had entered the working-through phase. Aggressive impulses were shown in his manipulation of toys and other objects, and self-destructive episodes emerged in the child's incessant efforts to jump from chairs and tables, as well as in repeated threats to "shoot" himself with a toy gun. The therapist was sensitive to the child's need to continually repeat and gradually modify these behaviors. She permitted their display without exhibiting shock or alarm, but at the same time, expressed concern for the child's safety and reinforced this concern by setting limits on his unacceptable behavior. Gradually, the child's self-destructive and aggressive tendencies abated. Further evidence that the conflict had been worked through was also seen in the child's ability to express a more realistic assessment of his home environment, one which reconciled the conflict between "good" and "bad" impulses. This advancement in perception was demonstrated by the child's verbal recognition that while his mother was capable of doing "bad" things, she was still his mother and he loved her. Prior to the termination of treatment, both the child's grandmother and teachers reported significant improvement in the child's behavior and linguistic abilities.


Perspectives on HIV/AIDS epidemiology and prevention from the Eighth International Conference on AIDS.

The Eighth International AIDS Symposium in Amsterdam, the Netherlands, provided updated scientific and programmatic information on the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) to thousands of interested participants. As in the other scientific areas, the amount of information presented in epidemiology and prevention was overwhelming; however, the scientific progress described was steady but incremental. This commentary summarizes progress made in three selected areas that were highlighted during the meeting's scientific session and a fourth that received widespread media attention: (1) the epidemiology of HIV/AIDS in heterosexual women; (2) tuberculosis as an increasing opportunistic pathogen in HIV-infected persons; (3) prevention research, practice, and policy; and (4) preliminary reports of severe immunodeficiency in persons without evident HIV infection. In order to stem HIV transmission worldwide, a safe and effective vaccine is urgently needed. Currently, in the absence of such a vaccine, it is crucial for all of the world's communities to apply the best science-based prevention methods available.


Commentary: methods women can use that may prevent sexually transmitted disease, including HIV.

Although sexually transmitted diseases, including human immunodeficiency virus (HIV), are a major concern for women, few prevention messages are targeted specifically to women. Those that are generally stress abstaining, altering the number or selection of partners, and urging partners to use condoms. But these behaviors may be unrealistic for many women, particularly women who are at highest risk for sexually transmitted diseases, because they require significant changes in life-style or depend on male-controlled condom use. Recommendation of contraceptives for prevention of sexually transmitted diseases depends largely on how well specific methods perform under controlled conditions, either in the laboratory or in clinical trials. Observational studies, which better reflect day-to-day use, indicate that condoms, barriers, and spermicides, used properly and consistently, can provide substantial protection against various sexually transmitted diseases. Condoms can similarly help protect against HIV, but studies of barriers and spermicides are scant and currently inconclusive. Finally, those methods that are controlled by women are consistently more effective in preventing sexually transmitted diseases. Thus, although condoms used well are still the best choice, the imperative for female-controlled methods indicates that diaphragms and spermicides should receive greater emphasis in prevention messages.


Commentary: the quest for women's prophylactic methods--hopes vs science.

The companion article by Rosenberg and Gollub in this issue summarizes data from 10 observational studies and concludes that female-controlled contraceptive methods, under typical conditions, are comparable to condoms in preventing sexually transmitted diseases and should be merchandized as such. While we agree that chemical and mechanical contraceptives provide protection against some sexually transmitted diseases, we think the authors have overstated the scientific case for these methods, especially in comparison with the condom. We think the current data remain inconclusive regarding the absolute protection of spermicides against the human immunodeficiency virus and their level of protection--relative to that of the condom--against other sexually transmitted diseases. Three reasons account for our differences: the limitations in the comparative data; the reported adverse effects of spermicides on vaginal conditions, including genital ulcers; and the relative value of condoms, even under typical conditions, in preventing sexually transmitted diseases. For these reasons, we would currently counsel both women and men who practice high-risk sexual behaviors to use condoms as their first line of defense. If this is unacceptable, the female barriers become a fallback position to protect against bacterial sexually transmitted diseases.


Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities.

It is critical to extend community-level acquired immunodeficiency syndrome (AIDS) prevention efforts beyond education alone and to develop models that better encourage behavioral changes. Gay men in small cities are vulnerable to human immunodeficiency virus (HIV) infection due to continued high rates of risk behavior. This research introduced an intervention that trained popular people to serve as behavioral change endorsers to peers sequentially across three different cities. Populationwide surveys were conducted of all men patronizing gay clubs in each city to establish risk behavior base rates. After a small cadre of popular "trendsetters" were identified, they received training in approaches for peer education and then contracted to communicate risk reduction recommendations and endorsements to friends. Surveys were repeated at regular intervals in all cities, with the same intervention introduced in lagged fashion across each community. Intervention consistently produced systematic reductions in the population's high-risk behavior (unprotected anal intercourse) of 15% to 29% from baseline levels, with the same pattern of effects sequentially replicated in all three cities. This constitutes the first controlled, multiple-city test of an HIV prevention model targeting communities. The results support the utility of norm-changing approaches to reduce HIV risk behavior.


High-risk sexual behavior and condom use among gay and bisexual African-American men.

Little is known about the human immunodeficiency virus (HIV) high-risk sexual practices of gay and bisexual African-American men. These data are needed so that better interventions can be developed and implemented in this population. The frequency and correlates of unprotected anal intercourse were examined among 250 gay and bisexual African-American men in the San Francisco Bay Area. The cohort was recruited in 1990 from bars, bathhouses, and erotic bookstores, and through African-American gay organizations, street outreach, advertisements in gay mainstream and African-American newspapers, health clinics, and personal referral from other participants. More than 50% of the men in our sample reported having unprotected anal intercourse in the past 6 months, a considerably higher percentage than that among gay White men in San Francisco through 1988 and 1989. Men who practiced unprotected anal intercourse were more likely to be poor, to have been paid for sex, or to have used injection drugs; to have a higher perceived risk of HIV infection; and to report less social support for concerns about risky sexual behavior. Condom norms, condom efficacy, and negative expectations about using condoms predicted these men's failure to use them. In the second decade of the acquired immunodeficiency syndrome epidemic, risk reduction programs are still needed for gay and bisexual African-American men.


The completeness of AIDS case reporting, 1988: a multisite collaborative surveillance project.

The purpose of this study was to evaluate the completeness of acquired immunodeficiency syndrome (AIDS) case reporting. Statewide or hospital-specific 1988 medical records were linked with AIDS surveillance in six sites. Medical records were reviewed for persons who had diagnoses suggesting human immunodeficiency virus (HIV) infection or AIDS but were not reported to AIDS surveillance by September 1989. Among 4500 hospitalized persons diagnosed with AIDS through 1988 in the six sites, completeness of reporting was 92% (95% CI = 89%, 96%; range across sites = 89% to 97%). Completeness of reporting was high in males (92%), females (95%), Whites (95%), Blacks (90%), Hispanics (92%), men reporting sexual contact with men (92%), persons reporting injecting-drug use (91%), and persons exposed to HIV through heterosexual contact (99%). In Medicaid enrollees (two states), completeness of reporting was 99% (95% CI = 95%, 99%) in inpatients and 90% (95% CI = 79%, 90%) in outpatients. Of previously reported persons with AIDS, 82% were reported within 5 months of diagnosis. Completeness of AIDS reporting was high, overall and in each major demographic and HIV exposure group. These results demonstrate that current surveillance data in these six sites provide timely and accurate information regarding persons with AIDS.


The reporting of HIV/AIDS deaths in women.

This study was undertaken to assess the completeness of vital statistics and case reports of acquired immunodeficiency syndrome (AIDS) in measuring human immunodeficiency virus (HIV)-related mortality in women 15 through 44 years of age. We used vital records to determine the number of deaths attributed to HIV infection and excess deaths due to causes that have increased in tandem with the HIV epidemic. In 1988, among women 15 through 44 years of age, there were 1365 deaths with HIV infection listed as the underlying cause, 202 deaths with HIV infection listed as an associated cause, and 149 excess deaths due to conditions highly associated with HIV infection (subtotal = 1716). In addition, there were 780 excess deaths due to causes that may be related to HIV infection or illicit drug use (maximum estimate of HIV-related deaths = 2496). Of the deaths that occurred in 1988, 1532 were reported through AIDS surveillance (1668 deaths when adjusted for reporting delays). Underlying-cause-of-death vital records and AIDS surveillance identified 55% to 80% and 67% to 97%, respectively, of HIV-related deaths in women 15 through 44 years of age in 1988. The wide ranges of these estimates reflect the potential role of both HIV infection and drug use in contributing to excess mortality.


Responses to anonymous questionnaires concerning sexual behavior: a method to examine potential biases.

Low response rates to voluntary surveys raise questions about how representative the responses are. We compared the behavior and attitudes of responders, willing and reluctant, and nonresponders to anonymous questionnaires about behaviors that might expose participants to the human immunodeficiency virus (HIV). Questionnaires were sent to 1080 Danish adults 18 through 59 years including explicit questions about sexual acts and illegal drug use. Identical questionnaires were sent to 3600 other Danes, similarly chosen; packets sent to these persons included cards to be returned separately informing us that they had responded. Questionnaires were sent twice more to nonresponders, who, if they then responded, were considered reluctant responders. One hundred nonresponders were telephoned and asked why they had refused to respond. Enclosing return cards did not affect initial response rate, but prompting boosted replies from 52% to 73%. However, behaviors were generally similar among initial and reluctant responders. One third of nonresponders agreed to respond if we wished (total potential response: 82%). In general, the reasons for nonresponse did not suggest that the life-styles of nonresponders placed them at risk for HIV infection. This method provides a simple, inexpensive approach to improving response rates and learning about the biases of reluctant responders and nonresponders.


Pneumococcal bacteremia in Monroe County, New York.

Knowledge of the epidemiology of pneumococcal disease is critical for public health planning, evaluation of preventive strategies, and development of immunization recommendations. We studied the incidence and case-fatality rates of pneumococcal bacteremia as a proxy for pneumococcal disease in Monroe County, New York, from 1985 through 1989 by reviewing the laboratory and clinical care records of all cases occurring among residents. There were 671 cases identified, for an overall yearly rate of 18.8 per 100,000. The rates were highest in the very young, in the very old, and in non-White populations. Age-specific rates were consistently higher in Blacks than in Whites. Predisposing medical conditions were present in 61% of cases. Case-fatality rates were 15% overall, 27% in those with predisposing medical conditions, and approximately 30% in Blacks older than 55 years and Whites older than 65 years. This study documents the incidence of and mortality from pneumococcal bacteremia. It supports previous observations that Black populations have an increased risk of invasive pneumococcal infection and suggests that immunization should be considered for Blacks older than 55 years.


Disability in occupations in a national sample.

We sought to develop lists of jobs whose members reported high and low levels of functional disability. Samples of women (n = 6096) and men (n = 3653) were drawn from the National Health and Nutrition Examination Survey I Epidemiological Follow-up. Disability was measured with a modified Stanford Health Assessment Questionnaire. We analyzed women and men separately, and we calculated average disability indices within longest-held occupations while adjusting for age, age-squared, married spouse present, and education. We minimized attrition bias with an econometric technique. From highest to lowest association with disability, the female broad occupations ranking was as follows: farming, no occupation, laborers, service, technicians, operatives, crafts workers, transportation operators, professionals, sales workers, administrative support, and managers. The male broad occupations ranking was as follows: no occupation, farming, operatives, crafts workers, service, technicians, manager, administrative support, sales, and professionals. The highest levels of disability for women and men occurred among nonconstruction laborers, farm workers, twisting machine operators, servants, machinery maintenance workers, mining machine operators, and bus drivers. Our results suggest that, in understanding levels of functional disability, occupational safety and health play a larger role than is generally assumed.


Passive smoking and lung cancer in nonsmoking women.

The causes of lung cancer among nonsmokers are not clearly understood. To further evaluate the relation between passive smoke exposure and lung cancer in nonsmoking women, we conducted a population-based, case-control study. Case patients (n = 618), identified through the Missouri Cancer Registry for the period 1986 through 1991, included 432 lifetime nonsmokers and 186 ex-smokers who had stopped at least 15 years before diagnosis or who had smoked for less than 1 pack-year. Control subjects (n = 1402) were selected from driver's license and Medicare files. No increased risk of lung cancer was associated with childhood passive smoke exposure. Adulthood analyses showed an increased lung cancer risk for lifetime nonsmokers with exposure of more than 40 pack-years from all household members (odds ratio [OR] = 1.3; 95% confidence interval [CI] = 1.0, 1.8) or from spouses only (OR = 1.3; 95% CI = 1.0, 1.7). When the time-weighted product of pack-years and average hours exposed per day was considered, a 30% excess risk was shown at the highest quartile of exposure among lifetime nonsmokers. Ours and other recent studies suggest a small but consistent increased risk of lung cancer from passive smoking. Comprehensive actions to limit smoking in public places and worksites are well-advised.


HIV antibody testing and posttest counseling in the United States: data from the 1989 National Health Interview Survey.

To see how successful human immunodeficiency virus (HIV) counseling and testing efforts have been in testing the United States population, particularly among those at increased risk for HIV infection, we analyzed data from the 1989 National Health Interview Survey. Twenty percent of the NHIS sample (or, in terms of the general US population, an estimated 36 million persons) reported having been tested for HIV antibodies, mostly through blood donations. Although persons with increased risk of HIV infection had been tested and counseled at a much higher rate than the general population, the majority of this group had not yet been tested.


Decontamination of an HIV-contaminated CPR manikin.

There has been a concern that the number of persons engaging in cardiopulmonary resuscitation (CPR) training could decline because of questions about human immunodeficiency virus (HIV-1) transmission. We investigated the theoretical possibility that a CPR manikin might serve as a fomite for HIV-1 transmission. Decontamination protocols were tested by using elevated levels of virus and decreasing decontamination times. Even under these compromising conditions, however, decontamination was effective.


Trends in prevalences of behavioral risk factors: recent Hawaiian experience.

Recent time trends were studied for the prevalences of behavioral risk factors in Hawaii during the 5-year period from 1986 through 1990. The presence of linear time trend was analyzed by the multiple logistic regression method on weighted data, adjusting for confounding factors. The risk factors studied were seatbelt nonuse, lack of exercise, obesity, hypertension, smoking, acute drinking, chronic drinking, and driving while intoxicated. Seatbelt nonuse showed a significant decline, from 8.6% to 4.8%, with a mean annual decrease of 0.9 percentage point. Lack of exercise and obesity increased steadily, from 48.0% to 62.4% and from 16.7% to 21.6%, respectively, with respective annual mean increases of 3.3 and 1.4 percentage points.


Predictors of shelter use among low-income families: psychiatric history, substance abuse, and victimization.

For poor housed and homeless families in New York City, NY, we examined the degree to which psychiatric and substance-abuse problems and victimization placed the families at elevated risk of requiring emergency housing, and we documented the prevalence of such problems. These problems were infrequently reported by both groups. However, past mental hospitalization, treatment in a detoxification center, childhood sexual abuse, and adult physical abuse were associated with increased risk of homelessness.


Cumulative trauma disorders of the hand and wrist in the auto industry.

Surveillance for cumulative trauma disorders (CTDs) of the hand and wrist was carried out in five US automotive plants from 1985 to 1986, using Occupational Safety and Health Administration (OSHA) Form 200 injury and illness logs and medical insurance claims. Results using both record sources indicated that hand and wrist disorders may be more common in foundries than in other types of automotive plants. Similarly, in assembly plants, employees in certain departments appeared to be at higher risk for CTDs. Although our results are based on small numbers of cases, they suggest plants and departments that might be targeted for more detailed investigation.


A quality-of-life method for estimating the value of avoided morbidity.

We developed a quality-of-life method for valuing changes in health status. Our model determines changes in health attributes for different illnesses and then estimates the dollar value of the corresponding welfare losses. We used our quality-of-life approach to estimate willingness to pay to avoid asthma, a headache, a cough, bronchitis, and arthritis. Estimates derived using our method are similar to those obtained from more expensive and restrictive traditional methods.


The Supreme Court, abortion, and the jurisprudence of class.

The US Supreme Court's decision in Planned Parenthood of Southeastern Pennsylvania v Casey both protects a woman's liberty to choose to terminate her pregnancy and permits the state to make it more difficult for her to exercise her choice. In their opinion on the case, Justices O'Connor, Kennedy, and Souter eloquently defend constitutional protection of the right to make intimate decisions like continuing or ending a pregnancy. At the same time, they permit the state to try to persuade pregnant women not to have abortions and to make abortion harder to obtain and more costly, as long as the state's methods do not create an "undue burden" on the decision. Any restriction on abortion is a burden; whether it is "undue" (and therefore unconstitutional) depends on one's circumstances. The Court appears to view the difference between an undue burden and mere inconvenience from the perspective of privilege. The restrictions that were upheld may not significantly affect middle-class access to abortion, but they could prove insurmountable for many less privileged women.


Arthroscopic treatment of sports-related synovitis of the ankle.

We describe nine cases of sports-related synovitis of the ankle joint with a followup of 24 to 44 months (average, 30.9). It affects young athletes and occurs after episodes of acute or recurrent inversion ankle sprains or undisplaced ankle fractures. The patients complain of morning pain and stiffness along with increased pain and swelling with attempted athletic participation. All ankles were stable and all failed to respond to at least 6 months of conservative treatment. The technetium bone scans were positive in eight of the cases. During arthroscopy, a hypertrophic anterior-chamber synovitis was found and treated by arthroscopic partial synovectomy. The results were excellent in eight of the patients in whom symptoms resolved, allowing full return to their previous sports, and fair in one case. The only complication was one superficial wound infection.


Loss of motion after anterior cruciate ligament reconstruction.

We did a retrospective review and follow-up examination to investigate the incidence, risk factors, and outcome of patients who developed loss of motion after arthroscopic anterior cruciate ligament reconstruction. Two hundred forty-four patients with a minimum followup of 1 year were reviewed. Loss of motion (defined as a loss of extension of more than 10 degrees or flexion of less than 125 degrees) was identified in 27 patients for an overall incidence of 11.1%. Factors associated with loss of motion included acute reconstruction (less than 1 month from initial injury), male sex, and concomitant medial collateral ligament repair or posterior oblique ligament reefing or both. Twenty-one patients required surgery to regain their motion; three patients required a second procedure. Twenty-one of 27 patients with loss of motion underwent a detailed followup and were compared with 24 randomly chosen controls who had a normal range of motion after anterior cruciate ligament reconstruction. At followup, patients who experienced loss of motion had a significant decrease in noninvolved to involved knee extension and flexion compared to the control patients. There was no difference between our patients and the controls regarding patellofemoral problems, anterior knee laxity, and functional strength. Sixty-seven percent of patients with loss of motion had a good or excellent result in comparison to 80% of the controls.


Anterior cruciate ligament reconstruction using a composite collagenous prosthesis. A biomechanical and histologic study in rabbits.

We evaluated a prototype composite collagenous anterior cruciate ligament replacement device designed to possess the advantages of biological grafts and synthetic materials. Collagenous anterior cruciate ligament prostheses were made by embedding 225 reconstituted type I collagen fibers in a type I collagen matrix, and placing polymethylmethacrylate bone fixation plugs on the ends. The collagenous prosthesis was used to replace the anterior cruciate ligament of 31 mature rabbits. At 4 and 20 weeks postimplantation, histologic and mechanical studies were performed on the developing neoligament tissue, and compared to values for the contralateral sham-operated control. At 4 weeks, neoligament tissue infiltrated the collagen fibers of the prostheses. The tibial bone tunnel attachment site contained new bone approaching the fibrous neoligament. The glutaraldehyde-treated prosthetic fibers appeared intact, while the carbodiimide-treated prosthetic fibers began to resorb. The ultimate load and ultimate tensile strength of femur-neoligament-tibia complexes had decreased. At 20 weeks, glutaraldehyde-treated fibers appeared partially intact; in contrast, the carbodiimide-treated prostheses appeared to be completely degraded, and were replaced by organized, crimped neoligament tissue. The ultimate tensile strength and ultimate load increased substantially due to deposition and remodeling of neoligament tissue. The neoligament ultimate load was 2 to 4 times the initial load value of the prosthesis. Implantation of a resorbable, composite collagenous anterior cruciate ligament prosthesis encourages the development of functional neoligament tissue. Studies are underway to optimize the mechanical and biological properties of the prostheses.


Cryotherapy-induced nerve injury.

Cryotherapy is a frequently used therapeutic modality in the treatment of athletic injuries. Peripheral nerve injury can result from the use of cryotherapy and cause temporary disability for the athlete. Six cases of peripheral nerve injury are reviewed. All cases resolved spontaneously. To avoid this complication, one should consider the location of major peripheral nerves, the thickness of the overlying subcutaneous fat, and the duration of tissue cooling.


Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction.

We evaluated extensor mechanism function in 10 patients after they had arthroscopically assisted ACL reconstruction using the central third of the patellar tendon. The patients were randomly selected 12 to 24 months after reconstruction. All had rehabilitation where range of motion was initiated within the 1st postoperative week. All patients stated that they were satisfied and considered their knee to be stable. The KT-1000 maximum measurements (30 to 40 pounds) averaged an increase of 1.7 mm when compared with the opposite knee. Subjective complaints, such as anterior knee pain, grating, and weakness, were common and only 3 of 10 patients returned to all of their preinjury sports. Persistent radiographic abnormalities were common. Physical examination and functional testing also revealed persistent dysfunction of the extensor mechanism in patients with radiographic abnormalities. Isokinetic testing at 60 deg/sec showed an average quadriceps deficit of 18% compared to the normal extremity. Axial computed tomography scans revealed significant decrease in quadriceps cross-sectional area. Magnetic resonance imaging and computed tomography confirmed persistent defects at the harvest site; there was significant anterior knee scar formation in these patients. Despite achieving ligamentous stability, patients still experienced permanent weakness, functional deficits, patellar chondrosis, and pain after ACL reconstruction using the central one-third of the patellar tendon.


Quadriceps femoris muscle activity in patellofemoral pain syndrome.

To elucidate and attempt to dissociate the two mechanisms, neuromuscular and mechanical, underlying patellofemoral pain syndrome, 18 subjects, divided into two groups based on a diagnosis of patellofemoral pain syndrome and the knee Q angle, were studied. The control group was asymptomatic and exhibited a normal Q angle (mean, 8.25 degrees), whereas the other group, diagnosed as patellofemoral pain syndrome patients, reported knee pain and had an above-normal Q angle (mean, 21.05 degrees). All subjects were tested for isometric maximum knee extension at 90 degrees, 30 degrees, and 15 degrees of knee flexion while they were seated in a special restraining chair. During testing, surface electromyography at the oblique and long fibers of the vastus medialis, and at the vastus lateralis were recorded along with the knee moment of force. The integrated electromyographic signals associated with the peak torque for all of the vastus muscles, along with the vastus medialis obliquus:vastus lateralis and vastus medialis longus:vastus lateralis activity ratios showed no significant differences between groups nor between the three angles, suggesting that all vasti measured were consistently active throughout the studied range of motion. This suggests that the neural drive was not affected in the patellofemoral pain syndrome patients. However, when the five patients showing the largest Q angles were isolated, they revealed a significantly smaller vastus medialis obliquus:vastus lateralis ratio when compared to the other group. The same ratio was also significantly smaller at 15 degrees compared to 90 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)


Os trigonum impingement in dancers.

Sixteen patients underwent surgical excision of an impinging ossicle through a posterior lateral approach. Twelve of these patients (15 ankles) were available for followup and were retrospectively surveyed at an average of 28 months after surgery. There were 9 women and 3 men. Nine were professional ballet dancers and 3 were students of advanced ballet schools. Preoperative symptoms included pain localized to the posterior ankle, limitation of motion, weakness, swelling, or neurologic changes associated with dance activities. All patients were severely hampered in their dance participation and had failed nonsurgical therapies. Postoperatively, all patients followed an aggressive rehabilitation protocol. All had improvement in their impingement symptoms; eight (67%) still had occasional discomfort. All professional dancers returned to unrestricted dance activity. The mean time to full activity was 3 months. One patient had a superficial wound infection requiring antibiotic treatment and another suffered a transient tibial nerve neurapraxia. Both of these complications resolved without sequelae. We conclude that posterior ankle impingement in ballet dancers, caused by an os trigonum and resistant to nonsurgical therapies, is effectively treated with simple excision of the offending structure.


Meniscal repair using fibrin sealant and endothelial cell growth factor. An experimental study in dogs.

The effect of fibrin sealant and endothelial cell growth factor on the healing of defects of the avascular portion of canine menisci was investigated in 30 menisci of 15 adult mongrel dogs. The defects were treated in one of three ways: Group 1, the defect was left empty; Group 2, the defect was filled with fibrin sealant; and Group 3, the defect was filled with fibrin sealant and endothelial cell growth factor. The healing process was evaluated macroscopically and histologically at intervals of 1, 2, 6, 12, and 24 weeks. The average percentage of each defect that was filled with connective tissue was 5% in Group 1, 76.6% in Group 2, and 89.4% in Group 3. In the early phase of this repair, the extrinsic pannus-like tissue that contained many capillary vessels extended from the meniscosynovial junction into the defect. Subsequently, organized fibrous connective tissue was formed, which had changed to cartilaginous tissue at 12 to 24 weeks. The combination of fibrin sealant and endothelial cell growth factor enhanced the neovascularization and formation of granulation tissue, which accounted for the increased healing level in the avascular portion of the meniscus.


Patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers.

To determine if the incidence and patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers are different from those seen in individuals injured in nonskiing athletic activities, we reviewed the records of 150 patients with acute anterior cruciate ligament injuries. All patients had undergone arthroscopic evaluation within 21 days from the time of injury. There were 75 individuals who were injured while skiing and 75 individuals who sustained an injury in some other high-load athletic activity. Associated meniscal injury was documented at the time of arthroscopy and characterized by location, region, zone, depth, shape, size, and stability. Thirty-one of 75 skiers had an associated meniscal injury as compared to 47 of 75 of the nonskiers. This suggested a strong trend of decreased incidence of meniscal injury in the skier group, but the nonskiers had a higher incidence of major meniscal tears that required repair or partial meniscectomy. The location of the meniscal tear was also significantly different. The incidence of isolated lateral meniscal injury in skiers was higher than in nonskiers. There was a strong trend of increased incidence of medial meniscal involvement in the nonskiers than in the skiers. While there was no difference in the zone or region of tear between the two groups, the skier group was more likely to have a longitudinal tear of the posterior horn of the lateral meniscus. In both groups, lateral meniscal tears were more likely to require conservative treatment or partial meniscectomy while medial meniscal tears were more likely to be repaired than excised.


Snow skiing injuries in physically disabled skiers.

This study, through retrospective review, examines the injury rate of selected disable skiing populations in general and as compared to able-bodied skiers in areas where comparison was possible. Data on disabled skiers gathered from instructional programs at multiple sites indicate that the disabled skier had a very low rate of injury occurrence. Where comparison could be make, it was found that there was no significant difference in overall injury rates between able-bodied and physically disabled skiers. Disabled skiers appear to sustain less severe injuries, and they do not show the trend in increasing injury rates that able-bodied skiers in this study show. In addition, the uphill transport of skiers with a disability who use sit- or mono-skis was examined in one large program and found to be efficient and exceedingly safe, with no injuries reported. A major limitation of this study is the inconsistency in methods of data collection and reporting. There is a need for further prospective studies in the general able-bodied and disabled skiing populations with direct comparisons of rate, location and severity of injury, type of disability, and experience level of the skier. We hope that this study will stimulate more ski areas to allow disabled skiers on their slopes, even it limited to participation in supervised, instructional programs.


Fluoroscopic evaluation for subtle shoulder instability.

Fifty patients with unilateral shoulder symptoms and a variety of diagnoses were evaluated with stress testing of both shoulders under general anesthesia using fluoroscopic documentation just before surgery. An axillary lateral view of the glenohumeral joint was taken in neutral rotation and 90 degrees of abduction; this was termed "neutral position." Anterior and posterior translational stresses were then applied and spot radiographs taken. Measurements were made and the translation was expressed as a percentage of displacement of the humeral head with respect to the glenoid. The asymptomatic side was used as a control. We determined that up to 14% anterior translation and up to 37% posterior translation is normal. Using these guidelines, attempts were made to confirm or predict the presence of stability or instability. Thirty-one patients were correctly identified as stable; 14 were correctly identified as unstable. Three patients with anterior shoulder pain were classified as unstable and found to have Bankart lesions at surgery. Overall, specificity was 100% and sensitivity was 93%. Using discriminant function analysis, a difference score of 10% between the symptomatic and control shoulder was generated. This was useful in eliminating interobserver variations in the examination for predicting stability or instability. We recommend this examination as a valuable adjunct to confirm the presence and direction of shoulder instability and predict subtle instability patterns in patients with recalcitrant undiagnosed shoulder pain.


Healing of the patellar tendon autograft after posterior cruciate ligament reconstruction--a process of ligamentization? An experimental study in a sheep model.

Forty-eight skeletally mature sheep underwent posterior cruciate ligament reconstruction with free patellar tendon autografts in one knee; the contralateral knee served as a control. Immediate rehabilitation without immobilization followed. Autograft healing was evaluated by histologic, roentgenographic, and biomechanical techniques up to 2 years postoperatively. After implantation, the autograft tissue underwent necrosis and degeneration, followed by a gradual healing process comprising revascularization, cellular migration, and formation of an extracellular matrix. The autograft bone pegs were osseously incorporated by 6 weeks. After an initial loss of strength, the material properties of the operated knee recovered to only about one-third that of the control. Better alignment of the collagen fiber bundles resulted in increased material properties, up to approximately 50% of the control at 52 weeks. After 2 years, the autograft tissue was found to differ structurally and mechanically from a ligament, suggesting that the autograft may never approach normal ligament characteristics. Degenerative alterations, the wide-spread presence of type III collagen, and abnormal accumulations of glycosaminoglycans in the autograft correlated with a maximum stress of 60% and an elastic modulus of 70% of the control. Although ligamentization was not seen, the staging of autograft healing into different phases based on distinct morphologic manifestations (necrosis, revitalization, collagen formation, and remodeling) and correlating with changing mechanical properties may provide a rationale for rehabilitation protocols with a realistic evaluation of the loading capacity of the replacement tissue.


In vitro comparison of over-the-top and through-the-condyle anterior cruciate ligament reconstructions.

Knee kinematics, during standard knee examination maneuvers, were measured on 15 fresh cadaveric knees in their normal state and after isolated sectioning of the anterior cruciate ligament using a six degree of freedom electrogoniometer. Proximal iliotibial band autografts were used to perform two anterior cruciate ligament reconstructions on the cadaveric knees: an over-the-top reconstruction and a through-the-condyle procedure. Both of these reconstructions reduced the abnormal anterior translation of the anterior cruciate ligament-deficient knee seen in Lachman testing. However, neither reconstruction restored the normal anterior translation. In addition, other motions remained uncorrected: 1) the internal rotation due to internal torque at full extension; 2) coupled anterior translation during internal rotation at full extension; and 3) coupled medial translation with anterior translation in Lachman testing. There were no statistical differences noted in the joint kinematics created by either reconstruction.


Incidence of injury in Texas high school football.

This study was undertaken to determine the incidence of injury in high school football based on evaluation of 100 high schools in the State of Texas during a single football season (1989). Certified athletic trainers were the initial medical professionals providing on-site diagnosis and treatment of all injuries. An injury was defined as: 1) an incident causing an athlete to miss all or part of a single practice or game; 2) any incident treated by a physician; and 3) all head injuries reported to the athletic trainer. Data were collected that allowed calculation of the time of exposure to injury per athlete in the sample. There was 75.5% participation in the study by the certified athletic trainers in the 100 schools. A total of 4399 athletes in varsity football programs participated in the study. There were 2228 injuries, as defined in the study, during the period of study, giving an incidence of injury of 0.506 injury per athlete per year. Severe injuries--those requiring hospitalization--were found in 137 cases, for an incidence rate of 0.031 injury per athlete per year. The incidence of reportable defined injury was calculated to be 0.003 injury per hour of exposure per student athlete. The knee was found to be the most commonly injured anatomic site; the ankle ranked second.


Human torque velocity adaptations to sprint, endurance, or combined modes of training.

We had groups of athletes perform sprint and endurance run training independently or concurrently for 8 weeks to examine the voluntary in vivo mechanical responses to each type of training. Pre- and posttraining angle-specific peak torque during knee extension and flexion were determined at 0, 0.84, 1.65, 2.51, 3.35, 4.19, and 5.03 radian.sec-1 and normalized for lean body mass. Knee extension torque in the sprint-trained group increased across all test velocities, the endurance-trained group increased at 2.51, 3.34, 4.19, and 5.03 radian.sec-1, and the group performing the combined training showed no change at any velocity. Knee flexion torque of the sprint and combined groups decreased at 0.84, 1.65, and 2.51 radian.sec-1. Knee flexion torque in the sprint-trained group also decreased at 0 radian.sec-1 and in the combined group at 3.34 radian.sec-1. Knee flexion torque in the endurance-trained group showed no change at any velocity of contraction. Mean knee flexion:extension ratios across the test velocities significantly decreased in the sprint-trained group. Knee extension endurance during 30 seconds of maximal contractions significantly increased in all groups. Only the sprint-trained group showed a significant increase in endurance of the knee flexors. These data suggest that changes in the voluntary in vivo mechanical characteristics of knee extensor and flexor skeletal muscles are specific to the type of run training performed.


Ruptures of the pectoralis major muscle. An anatomic and clinical analysis.

We evaluated 12 patients with 14 ruptures of the pectoralis major muscle to compare surgical and conservative management of this injury. Because 9 of the injuries occurred while weight lifting, we performed an anatomic study on human hemithorax specimens during a simulated bench press to determine the mechanism of this rare occurrence. Excursion of individual pectoralis muscle fibers was measured at seven points along the broad muscle origin by the use of fine wires connected to the humeral insertion and to dial gauges on the study apparatus. Excursions in the concentric and eccentric phases of the lift were expressed as a percentage of resting fiber length. The short, inferior fibers of the muscle lengthened disproportionately during the final 30 degrees of humeral extension. We concluded that the inferior fibers have a mechanical disadvantage in the final portion of the eccentric phase of the lift, and application of high loads to these maximally stretched fibers produces rupture. We repaired five acute and two chronic ruptures, and measured peak torque and work production against the contralateral side using Cybex isokinetic testing. Surgically treated patients showed comparable torque and work measurements, while conservatively treated individuals demonstrated and marked deficit in both peak torque and work/repetition. We recommend repair of complete pectoralis muscle ruptures in active patients who require maximum strength in vocational or avocational activities.


Ultrasound examination of soft tissue injury of the lower limb in athletes.

We performed ultrasonography on 32 athletes complaining of intense pain in a swollen and tender thigh or calf after a contusion or stretching trauma. The ultrasonogram was used to visualize the presence and size of a suspected hematoma. The findings included the following: 7 patients with a circumscribed, anechoic lesion compatible with a liquefied hematoma; 10 patients with a circumscribed lesion of mixed echogenicity compatible with areas of liquefied hematoma, coagulated blood, and edema; and 15 patients with a diffuse change in echogenicity of the whole muscle. The circumscribed liquefied, and mixed hematoma were more common after contusion trauma, while the diffuse type was more common after injury caused by stretching. Ultrasonography is useful in localizing the hematoma and in characterizing the different types. Differentiation is important in diagnosis and choice of treatment.


A biomechanical analysis of solvent-dehydrated and freeze-dried human fascia lata allografts. A preliminary report.

This study compares the basic mechanical properties of two groups of commercially available fascia lata allografts processed by different means (solvent-dehydrated and sterilized via gamma radiation, and freeze-dried without secondary sterilization). The results reveal significantly (P less than 0.05) higher stiffness, higher maximum load to failure, and higher maximum load per unit width of graft with the solvent-dried as opposed to the freeze-dried fascia lata. Subsections of individual solvent-dried specimens were also more uniform in their mechanical properties than those of the freeze-dried allografts. Fascia lata is used as a graft material in a variety of orthopaedic procedures. Allograft fascia lata offers an increased cross-sectional area of material and eliminates the morbidity associated with the harvesting of autologous tissues. However, the structural uniformity of such large grafts has been questioned. Processing techniques used in the sterilization and storage of such grafts is varied and represents a potential source of variation in the mechanical properties of allograft specimens. The results of this study suggest that a commercially available solvent-dehydrated form of fascia lata provides a more suitable grafting material than freeze-dried specimens obtained from tissue banks.


Reconstruction of the lateral ankle ligaments. A biomechanical analysis.

The purpose of this study was to perform a biomechanical analysis of several commonly performed operative procedures used to stabilize the lateral ankle. We performed the Evans, Watson-Jones, and Chrisman-Snook procedures on 15 cadaveric ankles and tested the ankles for stability, motion, and isometry of graft placement. The Evans procedure allowed increased anterior displacement, internal rotation, and tilt of the talus when compared to ankles with intact ligaments. Subtalar joint motion was restricted by the Evans procedure. The Watson-Jones procedure controlled internal rotation and anterior displacement of the talus, but was less effective in controlling talar tilt and also restricted subtalar joint motion. The Chrisman-Snook procedure allowed increased internal rotation and anterior displacement of the talus when compared to ankles with intact ligaments. The procedure was effective in limiting talar tilt, but restricted subtalar joint motion. Based on the biomechanical data obtained, we devised a lateral ankle reconstruction with bone tunnels that reproduce the anatomic orientation of both the anterior talofibular and calcaneofibular ligaments. This ankle ligament reconstruction resists anterior displacement, internal rotation, and talar tilt without restricting subtalar joint motion. We found considerable mechanical differences among the more commonly performed lateral ankle reconstructions. It is possible to locate bone tunnels and graft placement so that a more anatomic configuration is achieved.


Purification of native dengue-2 viral proteins and the ability of purified proteins to protect mice.

Both the envelope structural protein and the non-structural NS1 protein have been purified from the flavivirus dengue-2 by high-pressure liquid chromatography. These purified proteins maintain their reactivity with monoclonal antibodies. When tested in mice, the envelope protein elicited neutralizing antibodies and partially protected the animals against a lethal viral challenge. The mice responded to the non-structural protein by producing antibodies; however, these antibodies were not neutralizing and the mice were not protected.


Echographic and Doppler screening of the forearm arteries in professional volleyball players.

We evaluated nine professional volleyball players by clinical, echographic, and Doppler technique examination of the forearm and digital arteries to determine vascular damage caused by repeated trauma. The results of these tests showed that one-third of the subjects had vascular lesions in the right hand; only one of these was symptomatic. This suggests that noninvasive screening should be recommended and included in the regular medical check-ups of professional athletes in whom repeated trauma to the hand is likely, such as volleyball players.


Antibodies to the major merozoite surface coat protein of Plasmodium falciparum (gp195) in a human population living in a malaria-endemic area of the Philippines.

The seroprevalence of naturally acquired antibodies against Plasmodium falciparum merozoite surface protein gp195 was assessed in 726 individuals living in the Napsan region of Palawan in The Philippines. Antibodies against gp195 were detected using parasite-derived antigens in an enzyme-linked immunosorbent assay. The lowest seroprevalence of anti-gp195 antibodies (45%) was found in the 0-4-year-old age group. By 10-19 years of age, the seroprevalence of anti-gp195 antibodies had leveled off at approximately 90%. Anti-gp195 antibody titers were determined for 59 randomly selected individuals using parasite-derived gp195 and two yeast recombinant polypeptides corresponding to the N-terminal (195A) and C-terminal (p42) processing fragments of gp195. For each antigen, the lowest antibody titers were found in the 0-4-year-old age group. The 5-9-year-old age group had anti-gp195 antibody titers comparable with the older age groups. Immunoblotting experiments with parasite-derived gp195 revealed that all serum samples tested had detectable antibodies to the 195-kD gp195 precursor molecule and the 83-kD N-terminal processing fragment. Individuals with anti-gp195 titers greater than 1:400 had antibodies against both the N-terminal and C-terminal processing fragments of gp195. These results suggest that the gp195 C-terminal region may be less immunogenic than the N-terminal region when presented on the parasite surface during natural malaria infections.


Characterization of naturally acquired antibodies to the non-repetitive flanking regions of the circumsporozoite protein of Plasmodium falciparum.

Antibody responses to the circumsporozoite (CS) protein of Plasmodium falciparum have previously been reported against the central repeating tetrapeptides of this protein. Segments of the protein flanking the repeat region also contain B-cell epitopes, but specific antibody responses have not been previously characterized. Longitudinal serum sets from 16 Thai adults who developed acute falciparum malaria were selected to represent a spectrum of antibody response to the repeat region (R32). These sera were assayed by enzyme-linked immunosorbent assay using as capture antigen a recombinant fusion protein, NS1(81)RLF, which contains both flanking regions, but lacks the NANP and NVDP repeats of the P. falciparum CS protein. Antibody responses to the repeatless flanking (RLF) regions were observed in all subjects, including five individuals who lacked detectable anti-R32 antibody responses. Anti-RLF antibody responses induced by natural infection appear to be short-lived and of low-to-moderate magnitude. Thus, if anti-RLF antibodies prove to be protective, derived vaccine candidates may require presentation of these epitopes with adjuvants or delivery systems that enhance immunogenicity.


Rapid in vivo detection of chloroquine resistance by the Quantitative Buffy Coat Malaria Diagnosis System.

The use of the Giemsa-stained thick blood smear for the diagnosis of malaria has not been supplanted since the discovery of the parasite by A. Laveran in 1880. Recently, a new direct diagnosis technique, the Quantitative Buffy Coat (QBC)* Malaria Diagnosis System, has been developed. We compared this technique with the thick blood smear diagnosis in a study of the efficacy of chloroquine therapy in Zaire. A total of 815 subjects were screened; 71 participated in the trial. They were given chloroquine at a dose of 25 mg/kg of body weight over three days and were examined for parasitemia two and seven days after treatment. Chloroquine resistance was detected in 38% of the subjects by thick blood smear and in 45% by the QBC test. Of greater interest was the time required for each diagnosis: an average of 17 min was required to examine microscopic fields with 1,000 leukocytes by thick blood smear analysis compared with less than one min by the QBC system. In addition, we did not observe diminished attention from fatigue by microscopists using the QBC system despite the large number of tests conducted. We conclude that the QBC system is an important tool for studies of drug resistance.


Detection of Cryptosporidium parvum DNA in fixed, paraffin-embedded tissue by the polymerase chain reaction.

The objective of this project was to demonstrate detection of Cryptosporidium parvum DNA in fixed, paraffin-embedded tissue using the polymerase chain reaction (PCR). DNA was purified from six samples of fixed, paraffin-embedded tissue that were histologically positive for C. parvum and used in the PCR. Previously developed oligonucleotide primers specific for C. parvum were used to amplify a 452-base target sequence, and a 20-base synthetic probe labeled with digoxigenin-11-dUTP was used to detect the amplification product by chemiluminescence. All six samples were positive by PCR; negative controls showed no amplification or hybridization. This approach could provide a sensitive and specific method for detection of parasite material in fixed, paraffin-embedded tissue samples, and prove to be of significant value in retrospective studies of archival material.


Diagnosis of Encephalitozoon cuniculi infection by western blot and the use of cross-reactive antigens for the possible detection of microsporidiosis in humans.

Microsporidia are very primitive, eukaryotic, obligate, intracellular, protozoan parasites. Encephalitozoon cuniculi, a microsporidian originally described from a rabbit infection, has been described in humans as well as in many species of laboratory animals. We report the detection of E. cuniculi by Western blotting in a rabbit with torticollis that was obtained from an Encephalitozoon-free colony. Cross-reactivity of this serum was observed with antigens prepared from several genera of microsporidia. Identical Western blotting patterns were obtained with sera obtained from a rabbit immunized with E. cuniculi that was purified from tissue culture cells. In addition, we were able to demonstrate cross-reactivity between E. cuniculi rabbit antisera and Enterocytozoon bieneusi antigens by indirect immunofluorescent assay techniques in human intestinal biopsy samples. These cross-reactions between microsporidia may be useful in developing diagnostic tests for non-cultivatable microsporidia such as Enterocytozoon bieneusi.


Improved diagnostic performance of the circulating antigen assay in human schistosomiasis by parallel testing for circulating anodic and cathodic antigens in serum and urine.

Serum and urine levels of two Schistosoma circulating antigens, the circulating anodic antigen (CAA) and the circulating cathodic antigen (CCA), were determined by monoclonal antibody-based enzyme-linked immunosorbent assays in 56 Egyptian patients infected with S. mansoni and in 12 patients infected with both S. mansoni and S. haematobium. Both CAA and CCA could be specifically demonstrated in 82% and 88% of the serum samples and in 88% and 87% of the urine samples, respectively. While complete specificity was maintained, sensitivity was increased to a range of 91-98% by parallel use of the two circulating antigen assays, i.e., an individual with a positive titer for at least one of the assays was considered to be infected. A combination of CAA and CCA determinations in urine samples only resulted in a sensitivity of 94%. However, the highest sensitivity was achieved when the serum-CCA assay was combined with the urine-CCA assay (98%) or with the urine-CAA assay (97%). Sensitivity could not be increased further by combining more than two tests. A significant correlation was demonstrated between the level of circulating antigen and the number of parasite eggs in feces in each of the four assays. In addition, the levels of CAA and CCA in serum and urine were significantly correlated with each other. Our results indicate that diagnosis of schistosome infections by detection of circulating antigens can be significantly improved by parallel testing for multiple antigens.


Tuberculous peritonitis in Egypt: the value of laparoscopy in diagnosis.

Abdominal laparoscopy was performed on 200 patients with undiagnosed ascites. It was unsuccessful in one patient with tuberculous peritonitis because of extensive adhesions. A presumptive diagnosis of tuberculous peritonitis based on clinical findings and peritoneal tubercles or adhesions visualized during laparoscopy was made in 90 of these patients. The diagnosis was confirmed in 88 by histopathology, bacteriology, or therapeutic response. Two of the 109 remaining patients who had other presumptive diagnoses made during laparoscopy were eventually confirmed to be cases of tuberculous peritonitis. Of 91 patients with tuberculous peritonitis included in this series, 79% were females, with the majority (79%) of them being of child-bearing age. Half had been ill for longer than one month. The most frequent complaints were abdominal pain, fever, anorexia, night sweats, abdominal swelling, and weight loss. Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions. Pleural effusion was present in 15% and pulmonary tuberculosis was detected in only two patients. Biopsy samples taken during laparoscopy showed that 60% had noncaseous granulomas and 33% had caseous granulomas. Mycobacterium tuberculosis was detected in 77%, with guinea pig inoculation having the highest sensitivity, followed by culture, and lastly by acid-fast smear. Mycobacterium tuberculosis was isolated more easily from biopsy samples than from ascitic fluid. Nine of 20 M. tuberculosis isolates that were identified as to species were M. bovis. Tuberculous peritonitis, a frequent cause of febrile ascites in Egyptian women, was easily diagnosed by histopathologic and bacteriologic studies of biopsy samples taken at laparoscopy. All patients responded rapidly to antituberculosis therapy.


Field evaluation of an enzyme-linked immunosorbent assay for estimating the sporozoite rate in Anopheles albimanus.

We have verified for specimens of Anopheles albimanus that an enzyme-linked immunosorbent assay (ELISA) used to assess Plasmodium vivax and P. falciparum sporozoite antigen rates gives results comparable to the salivary gland dissection method for estimating sporozoite rates. For 14,150 adults of An. albimanus, captured at five locations in Guatemala, we report sporozoite antigen rates of 0.03-0.57%, which correlate with the malaria prevalences at the study sites. We also present data that suggest that specimens of An. albimanus for the ELISA can be obtained more efficiently by cattle corral collections than by the human bait capture method.


Effect of Plasmodium falciparum on blood feeding behavior of naturally infected Anopheles mosquitoes in western Kenya.

Feeding behavior was compared between infected and uninfected field-collected groups of Anopheles gambiae sensu lato and An. funestus from western Kenya. A significantly greater percentage (81%) of Plasmodium falciparum-infected An. gambiae s.l. females probed on experimental hosts (hamsters) than did uninfected females (38%). Among those females that initiated probing, there was no effect of infection status on the ability to take a bloodmeal. Plasmodium falciparum-infected An. gambiae s.l. probed more often (mean = 4.0) and for a longer time (mean = 277 sec) than did their uninfected counterparts (mean = 2.4 probes and mean probing time = 214 sec). Results for the small number of An. funestus that fed followed the same trend. Among infected An. gambiae s.l. females, there was no effect of sporozoite density on either the number of probes made or the total probing time. Among uninfected females, there was no difference in feeding behavior between nulliparous and parous females. In laboratory experiments, female age had no effect on blood-feeding behavior. Our findings provide evidence that natural malaria infection modifies the feeding behavior of Anopheles females.


Circumsporozoite antibody as a serologic marker of Plasmodium falciparum transmission.

In a longitudinal study of a malaria-endemic village in southeastern Thailand, circumsporozoite (CS) antibody to sporozoites of Plasmodium falciparum was measured by an enzyme-linked immunosorbent assay to determine its usefulness as a seroepidemiologic marker of malaria transmission. The CS anti-(NANP)n antibody level and prevalence during a 25-month period paralleled the pattern of seasonal transmission consistent with conventional parasitologic and entomologic measurements. The prevalence and level of antibody decreased during the non-transmission wet season, and increased over a 1-2-month transition period between the end of monsoon rains and the onset of dry conditions, an interval of maximum vector activity. Antibody increased with age in the population. The prevalence of antibody to the asexual blood stage as measured by conventional indirect fluorescent antibody assay did not coincide with changes in transmission and was sustained throughout the study period. Thus, CS antibody appeared to reflect the relative population exposure to mosquito inoculation of P. falciparum sporozoites and provided a useful measure of malaria transmission dynamics.


Schistosoma mansoni infection in diapausing Biomphalaria glabrata snails: studies of temperature and genetic influences on diapausing behavior.

Snails that are capable of undergoing diapause can circumvent unfavorable environmental conditions, including long periods of drought. Studies were performed to investigate possible temperature and/or genetic factors that may trigger lamella formation and diapausing behavior. The influence of diapause in Biomphalaria glabrata snails on susceptibility to Schistosoma mansoni infection and levels of cercarial production was also investigated. Rearing temperatures of 23 degrees C or higher did not induce lamella formation or diapause, regardless of the parental phenotype. However, substantial percentages of progeny from lamellated or lamellated/diapausing parental snails developed lamellae at 18 degrees C and underwent diapause. Only a small percentage of offspring from nonlamellated parents formed lamellae at this temperature. Juvenile snails exposed just prior to diapause, or immediately following a diapause period of three weeks, were highly susceptible to infection by S. mansoni miracidia. Snails that underwent diapause produced comparable or only slightly fewer cercariae than did nondiapausing snails. These studies indicate that diapause in B. glabrata does little to decrease a snail's ability to act as an intermediate host for S. mansoni or to interrupt the development of the parasite. For these reasons, we believe that greater attention should be given to diapausing snail populations when planning field surveys or mollusciciding programs.


Albendazole in the treatment of onchocerciasis: double-blind clinical trial in Venezuela.

A double-blind clinical trial was conducted in Monagas State, Venezuela to assess the tolerance and efficacy of albendazole in the therapy of Onchocerca volvulus infection. Forty-nine patients (26 treated and 23 controls) received a 10-day course of albendazole (400 mg/day) or a placebo. Consistent with the excellent tolerance observed, albendazole did not kill microfilariae. However, analysis of changes in microfilarial densities (mf/mg of skin) over one year showed that albendazole was active against O. volvulus, presumably by interfering with embryogenesis. The nature, degree, and duration of this effect remain to be determined.


In vitro activity of halofantrine and its relationship to other standard antimalarial drugs against African isolates and clones of Plasmodium falciparum.

The in vitro activity of halofantrine was studied in chloroquine-susceptible and chloroquine-resistant African clones of Plasmodium falciparum over a period of six months. The susceptibility level remained stable in both clones. The chloroquine-susceptible clone (50% inhibitory concentration [IC50] 6.88 nM) was less susceptible to halofantrine than the chloroquine-resistant clone (IC50 2.98 nM). Using an isotopic semimicro drug susceptibility test, the in vitro activity of halofantrine was compared with the activities of chloroquine, quinine, and mefloquine to study the cross-resistance patterns against 76 African isolates of P. falciparum isolated from cases of malaria imported into France. Chloroquine-resistant isolates (n = 47) were significantly less susceptible to quinine (IC50 234 nM), but were more susceptible to both mefloquine (IC50 3.20 nM) and halofantrine (IC50 1.14 nM) compared with the chloroquine-susceptible isolates (n = 29; IC50 147 nM for quinine, 7.16 nM for mefloquine, and 2.62 nM for halofantrine). A significant positive correlation was found between the activities of chloroquine and quinine and between those of mefloquine and halofantrine, indicating cross-resistance between these drugs, while a negative correlation was observed between chloroquine and mefloquine or halofantrine. The responses to quinine and mefloquine or halofantrine showed no correlation with each other. These results reinforce the importance of a cautious use of antimalarial drugs in Africa.


Comparative study of single-dose cefotaxime and multiple doses of cefoxitin and cefazolin as prophylaxis in gynecologic surgery.

In this comparative, randomized, multicenter trial, 273 patients scheduled for gynecologic surgery were studied: 87 received a single 1-g dose of cefotaxime 30 minutes before surgery; 81 were given a 1-g dose of cefoxitin 30 minutes before surgery and 1 g every 6 hours for 24 hours after surgery (total dose 4 g); and 105 received a 1-g dose of cefazolin 30 minutes before surgery, followed by 1 g every 8 hours for 48 hours (total dose 6 g). Patients who received cefotaxime had a significantly lower incidence of postoperative fever compared with those treated with cefoxitin or cefazolin (p < 0.01). The incidence of positive urinary cultures was lower in the cefotaxime and cefazolin groups when compared with the cefoxitin group (p < 0.01 and p < 0.05, respectively). The results of this study confirm the efficacy of cefotaxime as prophylaxis in surgical infections and demonstrate that single-dose cefotaxime is more effective than a four-dose regimen of cefoxitin.


New clinical data on the prophylaxis of infections in abdominal, gynecologic, and urologic surgery. Multicenter Study Group.

Two dose schedules of the antibiotic cefotaxime were compared in a prospective, randomized 226-center study of 3,670 patients undergoing abdominal, gynecologic, and urologic surgery. Schedule A consisted of a single preoperative dose and schedule B consisted of one preoperative dose followed by two postoperative doses. There was no significant difference in the frequency of wound infection or bacteriuria between the two schedules. Schedule B was associated with a significantly higher incidence of postoperative pyrexia, further antibiotic therapy, local side effects, and extended hospital stay. One dose probably has less impact on the intestinal flora. Therefore, single-dose cefotaxime is as effective and less costly when compared with multiple-dose cefotaxime for common surgical procedures lasting less than 3 hours.


Which prophylactic regimen for which surgical procedure?

For optimal prevention of infection subsequent to a surgical intervention, it is necessary to follow a series of general principles, including the classification of the type of surgical intervention, the characteristics of the antibiotic used, and the route and the time of its administration. Moreover, with reference to the different types of surgery, other factors assume importance: the etiology of the infection and the ability of the antibiotic to achieve adequate levels in the tissues at the beginning of the infective process. In general abdominal, biliary, and obstetric-gynecologic surgery, which covers many clean-contaminated and contaminated interventions for which antibiotic prophylaxis has been shown to be the most effective, the etiology is often mixed (aerobic and anaerobic flora) with a predominance of gram-negative microorganisms. Thus, an appropriate prophylactic regimen must consider a third-generation cephalosporin, such as cefotaxime, that is effective against most gram-negative bacteria, in particular against Klebsiella pneumoniae. Acylureido penicillins can also be used because of their activity against enterococci, gram-positive microorganisms that are also causes of infection in this area of surgical intervention. Combining an antimicrobial such as clindamycin or metronidazole, which are particularly active against anaerobes, may be recommended as well. In urologic surgery, most infections are caused by Enterobacteriaceae; in addition to the antimicrobial spectrum, the ability of the antibiotic to concentrate adequately in the urine and renal tissue must also be considered. Beta-lactam antibiotics are the agents of choice, in particular, third-generation cephalosporins, aztreonam, and acylureido penicillins. In cardiac, orthopedic, and partially in neurologic surgery, where most infections are due to gram-positive bacteria (primarily methicillin-resistant staphylococci), antibiotic prophylaxis should include a glycopeptide agent (teicoplanin, vancomycin). In the field of surgical prophylaxis, more experience has been accumulated with cefotaxime, used as a short-course regimen or as a convenient single dose, than with any other newer cephalosporin. Cefotaxime's broad spectrum of action provides coverage against most potential pathogens and, when used as a single dose, is both convenient and cost-effective.


Timing of antibiotic prophylaxis with cefotaxime for prostatic resection: better in the operative period or at urethral catheter removal?

There are two critical moments for the development of severe infectious complications following transurethral prostatectomy (TURP): the operative and immediate postoperative periods, and the day that the postoperative drainage catheter is removed. To optimize the timing of antibiotic prophylaxis with cefotaxime, two prospective randomized studies were conducted in patients with preoperatively sterile urine. In Study 1, all patients (n = 50) received cefotaxime 1 g intramuscular (i.m.) 1 hour preoperatively and were then randomized to receive either a second identical dose of cefotaxime 1 hour before catheter removal 24 hours later, or no further antibiotic treatment. In Study 2, patients (n = 89) were randomized to receive either cefotaxime 1 g i.m. 1 hour preoperatively or no preoperative antibiotic, after which all received cefotaxime 1 g i.m. 1 hour before catheter removal. Results were compared using identical evaluation criteria for infection in both studies: incidence of fever (temperature > 38 degrees C), bacteriuria (10(5) organisms/mL) and positive blood cultures, and duration of hospital stay (days). In Study 1, infection was significantly reduced with respect to all parameters in the group receiving two doses of cefotaxime, and total drug treatment costs were halved. In Study 2, the groups did not differ with respect to any parameter. We conclude that a single dose of cefotaxime 1 g i.m. 1 hour preoperatively provides inadequate cover for urethral catheter removal 24 hours later, and that prophylaxis with a single dose of cefotaxime 1 g i.m. 1 hour before catheter removal is just as effective as two doses given 1 hour preoperatively and 1 hour before catheter removal. Prophylactic coverage is essential during the action of removing the catheter and the time immediately following the operation. Long-term antibiotic coverage (24 hours or more) is not necessary. Thus, following TURP in patients with preoperatively sterile urine undergoing continuous bladder irrigation for 24 hours postoperatively, the optimal dose schedule for antibiotic prophylaxis with cefotaxime is a single 1-g dose given i.m. 1 hour before catheter removal.


A reassessment of the activity of the third-generation cephalosporins against anaerobes and Staphylococcus aureus.

The in vitro activity of cefotaxime (CTX) alone and in combination with its metabolite desacetylcefotaxime (dCTX) was evaluated against 106 isolates of Bacteroides species. and 32 strains of Staphylococcus aureus. All strains were recovered from infected tissues of diabetic patients. Addition of dCTX to the parent compound markedly increased the inhibitory activity against Bacteroides species in general and Bacteroides fragilis and Bacteroides vulgatus in particular. No effect of the combination of both agents on Bacteroides thetaiotaomicron or Bacteroides ovatus was observed; 50% of B. fragilis infections were susceptible to CTX alone and 81% became susceptible to CTX plus dCTX. In addition, a partial synergistic interaction against 20 strains of B. fragilis resulted in a four- to nine-fold reduction in the minimal inhibitory concentration (MIC) after dCTX was added to CTX. Interestingly, 10 of 20 strains that exhibited an MIC of 64-128 micrograms/mL with CTX alone became very susceptible after the combination of parent and metabolite. This favorable positive interaction of both agents was also observed with S. aureus; a two- to four-fold reduction in MIC values was observed when dCTX was added.


Cefotaxime is extensively used for surgical prophylaxis.

Cefotaxime, a broad-spectrum third-generation cephalosporin, has been extensively used worldwide for chemotherapy of serious infections. Based on the characteristics of its antimicrobial spectrum, low incidence of allergy, and lack of adverse effects, cefotaxime has been used successfully for prophylaxis of a number of different surgical procedures. Extensive data have been accumulated for single-dose or short-course cefotaxime prophylaxis regimens. These cefotaxime regimens have been demonstrated to be very effective and inexpensive. For this article, over 11,500 published cefotaxime prophylaxis cases are reviewed (10,500 control cases) and 98 references are cited. Single-dose cefotaxime was clearly indicated for hysterectomies, cesarean sections, upper gastrointestinal cases, bone and joint operations, biliary tract procedures, transurethral resections, open urologic surgeries, and some vascular procedures. Short-course (3-4 doses) may be required for colorectal resections, cardiac surgeries, head and neck surgeries, organ transplants, specific pediatric surgical cases, and for some patients with compromised immune function, regardless of origin. Cefotaxime has reduced wound morbidity of contaminated abdominal operations to < 10%. This change from multiple-dose regimens to the single-dose or short-course regimens, enabled by cefotaxime use, decreases the risk of inducing or selecting bacterial resistance; the change would generate a significant reduction in hospital costs. Surgeons should not hesitate to employ cefotaxime and other third-generation cephalosporins with proven limited-dose indications to greatly benefit their patients and the hospital environment.


Measuring the cost-effectiveness of antibiotic prophylaxis in surgery.

Cost-effectiveness analysis is primarily a decision-making aid for budget holders. The first questions that must be answered are: Costs to whom? Effects on whom? Ideally cost-effectiveness analysis should address these questions separately from the perspective of the hospital, the community health services, the patient, and society in general. However, it may not always be practical to perform such a wide-ranging study. Moreover, if the decision maker is primarily concerned with the hospital budget, it is tempting to confine the detailed analysis to items that affect that budget. A good analysis should acknowledge these inevitable limitations and explicitly state whose perspective is being used. Even if a detailed study of community health services is not possible, the analysis should include some evidence about the likely impact of the program on others outside the immediate sphere of the budget holder. Two situations commonly arise in applying cost-effectiveness analysis to surgical prophylaxis: (a) The prophylaxis is more expensive than current practice and its costs must be justified, e.g., the use of a more expensive drug for a recognized indication or the introduction of prophylaxis for a new indication. (b) The prophylaxis is cheaper than current practice and must be shown to be as cost-effective, e.g., the use of a single-dose prophylaxis instead of multiple-dose regimens or the administration of an oral dose instead of an intravenous dose. We believe that cost-effectiveness analysis adds a useful extra dimension to the evaluation of surgical prophylaxis.


Current perspectives on antibiotic use in the treatment of surgical infections.

Infections that involve the attention of the surgeon include those that require operations for cure as well as those that complicate emergency and elective surgical procedures. Mechanical correction is of paramount importance in the eradication of such infections with antibiotics serving an adjuvant role, primarily to clear lymphatics and prevent bacteremia and seeding of distant sites. Review of the current hospital antibiotic susceptibility profile is important to determine likely sensitivity to expected pathogens. Infection of the urinary tract remains the most common nosocomial infection, but in surgical patients the severe infections are pneumonia, fasciitis, and peritonitis. Often caused by the gram-negative Enterobacteriaceae, empiric broad spectrum antibiotic therapy is initiated after cultures are obtained. Bacterial infection of the respiratory tract is often difficult to diagnose in severely ill patients because the underlying fever, leukocytosis, and chest X-ray changes are often nonspecific. Reliance on sputum gram stain and culture is important to guide antibiotic therapy. Empiric treatment of peritonitis requires knowledge of the normal enteric flora and the likely pathogenic organisms. The most lethal agent against obligate anaerobic organisms is atmospheric oxygen, yet antibiotic coverage against these organisms appears wise, particularly when debridement or resection will be delayed or not performed. Staphylococcus aureus is still the most commonly cultured organism from our Surgical Intensive Care Unit and Burn Unit and S. aureus is often responsible for central line and burn wound infection. For patients in septic shock, we favor administration of a broad-spectrum penicillin or cephalosporin combined with an aminoglycoside, with subsequent narrowing of the antibiotic spectrum based on culture results. Antibiotic efficacy, toxicity, efficiency, and cost all must be weighed in the decision-making process.


Infections in the surgical setting: epidemiology and effect of treatment with cefotaxime in a multicenter trial including 3,032 patients.

Hospital-acquired infections still represent a serious threat to the surgical patient. A nationwide survey of 259 Italian surgical wards involving 11,343 patients was conducted in October 1988. Hospital-acquired infections were recorded in 565 (5%) patients: the microorganisms most commonly involved were gram-negative rods (60% of all isolates), 41% of the infected patients presented one or more intrinsic predisposing factor, and 65% had undergone some invasive procedure. The studied group represented 23% of all surgical patients in the country on the days of the survey. Following the epidemiologic survey, an open multicenter study was conducted in the same wards to evaluate the efficacy and tolerability of cefotaxime (1 g, 2 or 3 times per day) in the treatment of nosocomial surgical infections. Among 3,032 evaluable patients, 1,295 intra-abdominal, 610 wound and soft tissue, 554 urinary, and 367 respiratory infections were observed. Treatment was judged to be clinically effective in 94% of patients, and side effects, mostly involving the gastrointestinal tract, were observed in 1.4% of patients; but interruption of the treatment was required only in 19 patients (0.6%). This study confirms that cefotaxime, after over a decade of use, retains high efficacy in the treatment for nosocomial infections and induces a low rate of side effects.


Everything you wanted to know about Graves' disease.

Graves' disease is an autoimmune thyroid disease characterized by a genetic predisposition, an increased incidence in young women, the presence of thyroid-stimulating immunoglobulins, and an uncertain etiology. The onset occasionally follows a frightening episode in the patient's life or separation from a loved one. On physical examination, the patient has a diffuse goiter with secondary hyperthyroidism, a noninfiltrative/infiltrative ophthalmopathy, and, on occasion, an infiltrative dermopathy. Atypical symptoms, signs, and presentations such as "apathetic thyrotoxicosis" are not rare and may delay the diagnosis in some patients. The diagnosis is confirmed by elevations of bound thyroxine (T4), free T4, or bound triiodothyronine in the presence of thyroid-stimulating hormone levels of less than 0.1 mU/L. When the diagnosis is suspected, but unclear, the thyrotropin-releasing hormone stimulation test is indicated. Medical therapy must be long-term when propylthiouracil or methimazole is used, and results in only 25% to 50% remissions at 1 to 2 years. Radioactive iodine therapy has resulted in a need for retreatment in 25% to 33.7% of patients in the past, and hypothyroidism occurs in 70% to 100% of treated patients at 10 years, depending on the dose. Evolving changes in operative technique have led to a 95% to 100% cure rate with complications such as reoperation for hemorrhage (0% to 1.3%), recurrent nerve palsy (0% to 4.5%), and permanent hypocalcemia (0% to 0.6%) at extraordinarily low levels in experienced hands. Greater than 90% of patients have remained euthyroid 2 years after thyroidectomy in several series. Surgery continues to offer the highest cure rate in the shortest period of time.


Occult fever in surgical intensive care unit patients is seldom caused by sinusitis.

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.


Are modified radical mastectomies done for T1 breast cancers because of surgeon's advice or patient's choice?

Clinical trials show that T1 breast cancers are equally well treated with breast-conserving surgery as with modified radical mastectomy. However, the Colorado Central Cancer Registry indicates that, for the past 5 years, the majority of women (72%) with T1 breast cancer in Colorado have undergone modified radical mastectomies. A questionnaire was sent to 175 general surgeons to determine the reasons for the high number of modified radical mastectomies still being performed. The results indicate that one group of surgeons (34% of those responding) believes each type of surgery has equal survival rates but unknowingly influences the patient to choose modified radical mastectomy, with a subtly biased presentation. Education of both surgeons and patients is needed to increase the number of patients with T1 breast lesions who can benefit from breast-conserving therapy.


Risk of major elective operation after myocardial revascularization.

Although an increased surgical risk of ischemic myocardial disease is widely accepted, amelioration of this risk after coronary artery bypass is poorly defined. We compared the outcomes of major elective general and peripheral vascular operations in 181 patients with prior coronary artery bypass grafting (CABG) with outcomes in an age-, gender-, and procedure-matched group without prior CABG (NOCABG). Despite the perception of a greater operative risk in the CABG patients (more CABG patients in American Society of Anesthesiologists [ASA] class III and fewer in ASA class I, p < 0.001), mortality (1.1% CABG versus 2.8% NOCABG) and morbidity (18.8% CABG versus 18.5% NOCABG) rates in the two groups were not significantly different. For patients who have undergone successful CABG, it appears that: (1) the risk of subsequent elective major general and vascular surgical operations is similar to that of an age-, gender-, and procedure-matched cohort, and (2) the mortality rate after elective operations is low.


Advantages of the Papillon protocol in the preoperative treatment of rectal carcinoma.

Standard treatment for advanced rectal carcinoma currently includes surgery, radiotherapy, and chemotherapy. Although there are theoretic advantages to preoperative irradiation, it is often not performed because of the prolonged delay of surgery and the purported increase in perioperative complications. A pilot study was undertaken at our institution to evaluate a treatment protocol advocated by Dr. Papillon that offers a shorter treatment time and less patient morbidity than conventional preoperative therapy for rectal carcinoma. Twenty patients with rectal cancer underwent the preoperative regimen that consisted of 3,000 cGy delivered in 10 fractions over 12 days with concomitant 5-fluorouracil and mitomycin-C. Complications were acceptable. Local recurrence was lower than in most reported trials, and survival rates were comparable. Additional benefits of the protocol include lower radiation morbidity to the patient and a decreased delay between diagnosis and surgery.


Virulent diverticular disease in young obese men.

Recent treatment of young patients (aged 40 years or less) with complicated diverticulitis prompted us to review our experience. During a 9-year period ending in December 1990, 61 of 238 patients treated for acute diverticulitis were 40 years of age or younger. The younger patients were primarily obese Hispanic males in whom the correct diagnosis was frequently missed. Younger patients more frequently required an operation on an urgent basis for complications of diverticulitis during the initial hospitalization. The most common indication for operation in young patients was perforation compared with recurrent disease for the older age group. The younger group had a sevenfold incidence of enteric fistulas complicating their acute episode of diverticulitis. Our data suggest that diverticular disease in young patients is more common and more likely to require early surgical intervention than previously noted. In addition, obesity may represent an important etiologic factor in the development of diverticular disease.