Structural comparison of the finger proximal interphalangeal joint surfaces and those of the third toe: suitability for joint reconstruction

PURPOSE

This study compared the degree of surface structural similarity between finger proximal interphalangeal joints and third toe articular surfaces to assess the appropriateness of using partial toe articular osteochondral grafts for finger joint reconstruction.

METHODS

Computer models were generated from 4 paired cadaver hands and feet and compared the radius of curvature of toe and finger articular surfaces. The angle created by the palmar divergence of adjacent condyles of the same phalanx was also compared and described as the angular difference. The distal articular surfaces of the third toe proximal and middle phalanx were compared to distal articular surfaces of all 4 finger proximal phalanges. The radius of curvature was also compared between the third toe middle phalanx base and those of all 4 fingers.

RESULTS

The toe middle phalanx medial and lateral condyles were 66% and 60% the size of the respective finger condyles. The mean angular difference between adjacent condyles of the toe middle phalanx compared to the finger was 20°. The toe proximal phalanx medial and lateral condyles were 75% and 70% the size of the respective finger condyles, with a mean angular difference between adjacent condyles of 6°. The toe middle phalanx medial base was closer in size to that of the finger (95% to 178%) compared to the toe middle phalanx lateral base (205% to 254%).

CONCLUSIONS

This study revealed that the third toe proximal phalanx distal articular surface more closely matched the geometric characteristics of the finger proximal phalanx distal articular surface than did the toe middle phalanx distal articular surface. The medial base of the toe middle phalanx more closely approximated the size of the finger middle phalanx base than did the lateral toe middle phalanx base.

CLINICAL RELEVANCE

Quantitative data have been provided to help guide third toe osteochondral donor site selection when reconstructing traumatic finger proximal interphalangeal joint defects.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Why are patients with progressive nonfluent aphasia nonfluent?

OBJECTIVE

To investigate the cognitive and neural basis for nonfluent speech in progressive nonfluent aphasia (PNFA).

BACKGROUND

Nonfluent speech is the hallmark feature of PNFA, and this has been attributed to impairments in syntactic processing, motor-speech planning, and executive functioning that also occur in these patients. Patients with PNFA have left inferior frontal atrophy.

METHODS

A large semi-structured speech sample and neuropsychological measures of language and executive functioning were examined in 16 patients with PNFA, 12 patients with behavioral-variant frontotemporal dementia (bvFTD), and 13 age-matched controls. Speech fluency was quantified as words per minute (WPM) in the semi-structured speech sample. Stepwise linear regression analyses were used to relate WPM to grammatic, motor-speech planning, and executive aspects of patient functioning. These measures were then related to cortical thickness in 8 patients with PNFA and 7 patients with bvFTD using structural MRI.

RESULTS

WPM was significantly reduced in patients with PNFA relative to controls and patients with bvFTD. Regression analyses revealed that only grammatic measures predicted WPM in PNFA, whereas executive measures were the only significant predictor of WPM in bvFTD. Cortical thinning was significant in PNFA relative to controls in left inferior frontal and anterior-superior temporal regions, and a regression analysis related this area to reduced WPM in PNFA. Significant cortical thinning associated with limited grammatic processing also was seen in the left inferior frontal-superior temporal region in PNFA, and this overlapped with the area of frontal-temporal thinning related to reduced WPM.

CONCLUSION

Nonfluent speech in PNFA may be due in part to difficulty with grammatic processing associated with left inferior frontal and anterior-superior temporal disease.

Multimodal predictors for Alzheimer disease in nonfluent primary progressive aphasia

OBJECTIVE

Alzheimer disease (AD) and frontotemporal lobar degeneration (FTLD) are hypothesized to cause clinically distinct forms of primary progressive aphasia (PPA) that predominantly affect expressive speech. AD is thought to cause logopenic progressive aphasia (LPA), and FTLD may cause progressive nonfluent aphasia (PNFA). We sought to determine the value of clinical characterization, neuropsychological analysis, and MRI atrophy in predicting pathology of LPA and PNFA.

METHODS

Patients with LPA (n = 19) and patients with PNFA (n = 19) were evaluated with neuropsychological assessments, structural MRI, CSF analysis, and neuropathologic examination.

RESULTS

Twelve of 19 patients with LPA (63%) and 6 of 19 patients with PNFA (32%) had neuropathologic findings or CSF biomarkers consistent with AD. Neuropsychological testing showed that naming was more impaired in patients with AD, and letter-guided fluency was more affected in patients with a non-AD disorder. Voxel-based morphometry analysis revealed that in patients with AD, patients with LPA and PNFA had significant posterior-superior temporal atrophy; in patients with non-AD, patients with LPA had peri-Sylvian atrophy and patients with PNFA had dorsolateral prefrontal and insular atrophy. Receiver operator characteristic curve analysis showed that combining neuropsychological testing with MRI atrophy pattern had 90% specificity for pathology or CSF biomarkers consistent with AD, and combining clinical features with neuropsychological analysis had 100% sensitivity for pathology or CSF biomarkers consistent with AD.

CONCLUSIONS

Neither PPA phenotyping nor imaging alone is a reliable predictor of pathology. Multimodal predictors, such as combining neuropsychological testing with MRI analysis, can improve noninvasive prediction of underlying pathology in nonfluent forms of PPA.

Neurocognitive contributions to verbal fluency deficits in frontotemporal lobar degeneration

OBJECTIVE

To test the hypothesis that different neurocognitive networks underlie verbal fluency deficits in frontotemporal lobar degeneration (FTLD).

METHODS

Letter ("FAS") and semantic ("animal") fluency tests were administered to patients with a behavioral/dysexecutive disorder (bvFTLD; n = 71), semantic dementia (SemD; n = 21), and progressive nonfluent aphasia (PNFA; n = 26). Tests measuring working memory, naming/lexical retrieval, and semantic knowledge were also obtained. MRI voxel-based morphometry (VBM) studies were obtained on a subset of these patients (bvFTLD, n = 51; PNFA, n = 11; SemD, n = 10).

RESULTS

Patients with SemD were disproportionately impaired on the semantic fluency measure. Reduced output on this test was correlated with impaired performance on naming/lexical retrieval tests. VBM analyses related reduced letter and semantic fluency to anterior and inferior left temporal lobe atrophy. Patients with bvFTLD were equally impaired on both fluency tests. Poor performance on both fluency tests was correlated with low scores on working memory and naming/lexical retrieval measures. In this group, MRI-VBM analyses related letter fluency to bilateral frontal atrophy and semantic fluency to left frontal/temporal atrophy. Patients with PNFA were also equally impaired on fluency tests. Reduced semantic fluency output was correlated with reduced performance on naming/lexical retrieval tests. MRI-VBM analyses related semantic fluency to the right frontal lobe and letter fluency to left temporal atrophy.

CONCLUSIONS

Distinct neurocognitive networks underlie impaired performance on letter and semantic fluency tests in frontotemporal lobar degeneration subgroups.

Long-term results of a prospective trial of mantle irradiation alone for early-stage Hodgkin's disease

BACKGROUND

To determine the long-term treatment outcome and late effects of mantle irradiation alone in selected patients with early-stage Hodgkin's disease.

METHODS

Between 1988 and 2000, 87 patients with pathologic stage (Ann Arbor) I-IIA or clinical stage IA Hodgkin's disease were entered on to a prospective trial of mantle irradiation alone. Patients with B symptoms, large mediastinal adenopathy, or subcarinal or hilar involvement were excluded. The median doses to the mantle field and mediastinum were 36 Gy (range 30.3-40) and 38.6 Gy (range 30.6-44), respectively. The actuarial freedom from treatment failure (FFTF) and overall survival (OS) rates were calculated using the Kaplan-Meier technique.

RESULTS

The median follow-up was 107 months (range 23-192). Thirteen of 87 patients (15%) relapsed at a median of 30 months (range 5-62). The 5- and 10-year actuarial FFTF rates were 86% and 84.7%, respectively. All 13 patients who relapsed are alive without evidence of disease at a median of 84 months (range 30-156) post-salvage therapy. Five patients developed a second malignancy at a median of 93 months (range 27-131). The 10-year actuarial risk of a second malignancy was 4.5%. There have been two deaths to date, both due to second malignancies. The 10-year OS rate was 98.2%.

CONCLUSION

In selected patients with early-stage Hodgkin's disease, mantle irradiation alone has an excellent long-term survival rate, comparing favorably with the previous standard treatment of extended-field radiation therapy and the current standard of combined modality therapy.

Inherited myopathy of great Danes

A hereditary, non-inflammatory myopathy occurring in young great Danes with distinctive histological features in muscle biopsy specimens is reviewed. Onset of clinical signs is usually before one year of age and both sexes are affected. Clinical signs are characterised by exercise intolerance, muscle wasting, and an exercise-induced tremor. Although most affected dogs have a severe form of the disease, occasional dogs may have a less pronounced form and survive into adulthood with an acceptable quality of life. Litters containing affected puppies are born to clinically unaffected parents, and an autosomal recessive pattern of inheritance is likely. All recorded cases have had fawn or brindle coat coloration. Elevated serum creatinine kinase concentrations and spontaneous electrical activity in skeletal muscles are frequently found. While originally reported (Targett and others 1994) as a central core myopathy in this breed, the histochemical characteristics of the distinct cytoarchitectural structures differ from those of the well-characterised central core myopathy in human beings. In fact, these structures differ from any known myopathy in human beings and likely represents a unique non-inflammatory myopathy affecting dogs. Until this myopathy is characterised further, the name inherited myopathy in great Danes is suggested.

An exploration of self-reported negative affect by adolescents as a reason for smoking: implications for tobacco prevention and intervention programs

BACKGROUND

Negative affect is related to initiation and maintenance of smoking among youth and understanding its role is important when developing effective prevention and cessation programs. This study investigates the relationship between adolescent negative affect and smoking dependence, behaviors, attitudes, and self-efficacy in order to shed light on differences in adolescent smoking maintenance and cessation.

METHODS

721 smoking youth participated in a cognitive-behavioral smoking cessation program. Reasons for smoking were categorized (alpha = 0.87) and youth were placed into one of two groups based on presence or absence of negative affect. One-way repeated measures ANOVA determined if differences existed between the groups on smoking behaviors, attitudes, and self-efficacy. One-way ANOVA determined if differences existed on Fagerström Nicotine Tolerance Dependence (FTND) scores.

RESULTS

Adolescents indicating negative affect for smoking were significantly more likely to have future smoking intentions and had significantly less self-efficacy to quit smoking than adolescent reporting other reasons.

CONCLUSIONS

This study supports the need to address negative affect among adolescents participating in prevention and cessation programs. An examination of negative affect will provide program developers and facilitators with information to improve their interventions, assist with cessation, and provide an avenue to access other needed health services.

Inherited retinal dysplasia and persistent hyperplastic primary vitreous in Miniature Schnauzer dogs

The objectives of this study were to define the clinical syndrome of retinal dysplasia and persistent primary vitreous in Miniature Schnauzer dogs and determine the etiology. We examined 106 Miniature Schnauzers using a biomicroscope and indirect ophthalmoscope. The anterior and posterior segments of affected dogs were photographed. Four enucleated eyes were examined using routine light microscopy and scanning electron microscopy. A pedigree was constructed and related dogs were test-bred to define the mode of inheritance of this syndrome. Congenital retinal dysplasia was confirmed in 24 of 106 related Miniature Schnauzer dogs. Physical and postmortem examinations revealed that congenital abnormalities were limited to the eyes. Biomicroscopic, indirect ophthalmoscopic, and neuro-ophthalmic examinations confirmed that some of these dogs were blind secondary to bilateral retinal dysplasia and detachment (nonattachment) (n = 13), and the remainder had generalized retinal dysplasia (n = 11). Fifteen of these dogs were also diagnosed with unilateral (n = 9) or bilateral (n = 6) persistent hyperplastic primary vitreous. Nutritional, infectious, or toxic etiologies were not evident on physical, postmortem, light microscopic, or transmitting and scanning electron microscopic examination of four affected Miniature Schnauzers. We examined the pedigree and determined that an autosomal recessive mode of inheritance was most likely. Three test-bred litters including those from affected parents, carrier and affected parents, and carrier parents confirmed this mode of inheritance. This study confirms that retinal dysplasia and persistent hyperplastic primary vitreous is a congenital abnormality that is inherited as an autosomal recessive condition in Miniature Schnauzers.

Dissociation of numbers and objects in corticobasal degeneration and semantic dementia

BACKGROUND

Semantic memory is thought to consist of category-specific representations of knowledge that may be selectively compromised in patients with neurodegenerative diseases, but this has been difficult to demonstrate reliably across object categories.

METHODS

The authors evaluated performance on several simple measures requiring number representations (including addition and magnitude judgments of single digits), and on a task that requires object representations (an object naming task) in patients with corticobasal degeneration (CBD; n = 13) and semantic dementia (SD; n = 15). They also examined regional cortical atrophy using voxel-based morphometric analyses of high resolution structural MRI in subgroups of five CBD patients and three SD patients.

RESULTS

CBD patients were consistently more impaired on simple addition and magnitude judgment tasks requiring number representations compared to object representations. Impaired performance with numbers in CBD was associated with cortical atrophy in right parietal cortex. By comparison, SD patients demonstrated a greater impairment on a naming task requiring object representations relative to their performance on measures involving number representations. This was associated with left anterior temporal cortical atrophy.

CONCLUSION

The cognitive and neuroanatomic dissociations between CBD and SD are consistent with the hypothesis that number and object representations constitute distinct domains in semantic memory, and these domains appear to be associated with distinct neural substrates.

Effect of growth hormone (GH) on glycerol and free fatty acid metabolism during exhaustive exercise in GH-deficient adults

GH is an important regulator of fat metabolism at rest, but it is not known whether it regulates fat metabolism during exercise. To determine whether physiologic concentrations of GH influence fat metabolism during exercise, we randomized 16 GH-deficient adults, receiving long-term (mean duration, 5 yr) GH replacement, to either continue GH (n = 8) or receive identical placebo (n = 8) for a 3-month period. Metabolic studies, at rest, during and following exhaustive exercise were carried out at baseline and at the end of the 3 months. The rate of appearance of glycerol (glycerol Ra, an index of lipolysis) and free fatty acids (FFA, FFA Ra) and the rate of disappearance of FFA (FFA Rd) in the plasma were measured using infusions of (2)H(5)-glycerol and 1-(13)C-palmitic acid. Changes in body composition were assessed using dual-energy x-ray absorptiometry scanning and anthropometric measurements. In the baseline studies, exercise resulted in an increase in plasma glycerol and FFA concentrations, glycerol Ra, FFA Ra, and FFA Rd (P < 0.001). Three months of GH withdrawal resulted in reductions in plasma glycerol and FFA, glycerol Ra, FFA Ra, and FFA Rd at rest (P < 0.05 vs. baseline) and during exercise (P < 0.05 vs. baseline and vs. GH treated). Lean body mass decreased after 3 months of GH withdrawal, but total body fat, trunk fat, waist circumference, and the sum of skinfold thicknesses increased after 3 months of GH withdrawal (P < 0.05 vs. baseline and vs. GH treated). Fasting insulin and homeostasis model assessment of insulin resistance decreased after 3 months of GH withdrawal (P < 0.05 vs. baseline and vs. GH treated). In summary, GH withdrawal for 3 months resulted in reductions in release of glycerol and FFA into the circulation and uptake of FFA into the tissues during intense exercise. These changes were accompanied by reduced lean body mass and increased total body and trunk fat. Further studies are required to determine whether reduced mobilization of fat during exercise contributes to reduced exercise capacity and increased body fat in GH-deficient adults.

Differences in evaluations of a tobacco awareness and cessation program by adolescents in four stages of change

This study determined whether adolescents in four stages of change provided significantly different ratings on evaluations of a tobacco awareness and cessation program and the program facilitators. A systematic sample of 639 adolescents in four stages of change (precontemplation, contemplation, preparation, and action) was used for analysis. Analysis of variance revealed significant differences in ratings on 'Cessation Skills,' 'Situation Management,' 'Overall Facilitator,' and 'Facilitator Likeability' evaluations between the groups. Follow-up analysis revealed that adolescent precontemplators provided significantly lower ratings than those in preparation and action, and adolescents in action provided significantly higher ratings than precontemplators and contemplators. This study suggests a need to assess the stage of the adolescent at the beginning of the program in order to provide the facilitator the opportunity to engage and motivate adolescents who are in the precontemplation and contemplation stage of change. This study also provides important information for facilitator training, program planning, and program delivery.

Utilization of health care services by patients with chronic obstructive pulmonary disease

In order to identify healthcare resource use patterns associated with chronic obstructive pulmonary disease (COPD), resource utilization (RU) data collection was integrated into a randomized, double-blind placebo-controlled study of Viozan (sibenadet HCl). This study enrolled patients with symptomatic, smoking-related COPD, randomized to receive sibenadet or placebo for a 52-week treatment period. A questionnaire establishing typical pre-trial, COPD-related RU was completed by each patient. Subsequent data were collected by means of an Interactive Voice Response System (IVRS) at 30-day intervals (14 time points) during the study and in the follow-up period. The IVRS system facilitated data collection and minimized inconvenience to the patient. Compliance with the requirement to record details of the healthcare services during the year-long study was high. No overall trend for lower RU was associated with sibenadet therapy, which correlates with the lack of sustained clinical effect seen in studies conducted concurrently. These data do, however, provide valuable information on RU associated with COPD and insights into adjustments associated with changes in disease course. Physicians were seen to be the most common source of care for patients with COPD and more of the patients with severe COPD (stage III) than mild (stage I) were seen to utilize the most expensive resources (e.g. inpatient hospital care). For those patients who experienced an exacerbation during the trial (irrespective of treatment group), resource use was increased during the periods when an exacerbation was reported when compared with the periods before or after an exacerbation. The proportion of cases attending the physician doubled and with a trip to the Emergency Room (ER) increased approximately ninefold during the reporting period in which the exacerbation occurred compared with the previous month. This study has shown that use of an IVRS, even in elderly patients, is an effective means of gathering RU data over long periods. The study findings suggest that the advent of effective therapeutic interventions, particularly any with the ability to minimize exacerbations and limit disease progression, could impact on the health care services used and potentially reduce associated costs.

Theory-based development and testing of an adolescent tobacco-use awareness program

OBJECTIVE

To develop and disseminate an effective tobacco awareness and cessation program.

METHODS

Self-report data from youth (n=1,601) and implementation data from site facilitators (n=16) provided the basis for the trial program evaluation.

RESULTS

Approximately 146 total classes and 1,601 youth were served. Significantly (p<.01) more participants were in the action stage of change at the end of the program. At follow-up, 40% of the participants indicated they were tobacco free.

CONCLUSION

The multiple iterative steps in program development were described. A theoretically based program, like the ATCP, is well worth exploring as a public health intervention.

Tobacco use and quit behaviors among delinquent youth: a pilot study

With rates of adolescent tobacco use steadily increasing over the past 20 years, assisting youth to quit, particularly those youth most susceptible to tobacco use, has become a national focus. The purpose of this pilot study was to examine and profile the smoking patterns of a small sample (n = 37) of juvenile offenders in Texas. In contrast to anecdotal reports, the sample group from this study did not differ clinically from the general population of adolescent tobacco users. Importantly, the study participants indicated previous attempts to stop smoking. The authors conclude that delinquent youth may be responsive to cognitive behavioral smoking cessation programs that also address the management of peer networks.

Breakthrough pain: assessment and management in cancer patients

This article provides an overview of breakthrough pain in cancer patients, what causes it, current treatment options and the impact it has on individuals. It considers the importance of accurate assessment, the use of assessment tools and the growing role of nurses in managing this challenging pain syndrome. The article aims to open the debate on the need for new choices in pain management. While many advances have been made in the treatment of pain, there is still room for improvement in both the pharmaceutical and general management of the condition. Suggestions are made as to how these may be met.

Hereditary benign telangiectasia--first family in Northern Ireland

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Naevus lipomatosus cutaneous superficialis

A young male presenting with cutaneous papules and plaques in a segmental distribution in the pelvic girdle area is reported. The clinical features were suggestive of naevus lipomatosus cutaneous superficialis, but diagnostic biopsy is essential to demonstrate the typical histopathological features and exclude important differential diagnoses such as segmental neurofibromatosis.

Problem drinking in Northern Ireland: results of a community survey using the CAGE questionnaire

A random sample of over 700 adults resident in Northern Ireland answered a questionnaire about their drinking practices. Approximately one-quarter of the men and almost 40% of the women described themselves as non-drinkers. Logistic regression analyses identified religious denomination, marital status, and age as the most important predictors of drinking. Of the drinkers 15.8% of the men and 5.7% of the women obtained a CAGE score of 3 or 4. Further logistic regression analyses identified gender, marital status, and religious denomination as the most important predictors of problem drinking.

Social and behavioural predictors of women's cancer screening practices in Northern Ireland

The aim of this study was to describe the extent of cancer screening practices among women resident in Northern Ireland and to identify the social and behavioural characteristics associated with these practices. The study involved a survey of adults resident in the community in Northern Ireland. Contact was made with a sample of 1162 residents who were asked to complete a questionnaire about preventive health practices and attitudes. This produced a response rate of 65.1 per cent. Of these, 391 were women who were asked questions about breast self-examination (BSE), attendance for cervical screening, and certain social and behavioural factors. Approximately 28 per cent of the women performed BSE regularly, a further 28 per cent performed it occasionally, and the remainder rarely or not at all. Almost 20 per cent of the women had had a smear test once, 48 per cent several times, and the rest never. Performance of BSE and attendance for smear tests and BSE was more common among those women aged 35-54 years, who were married, worked outside the home, and whose religion was Church of Ireland (Anglican). The most frequent reason given for not performing BSE was fear of finding a lump and ignorance of the procedure. The most frequent reason given for non-attendance for a smear test was that it was not thought necessary at their age. Public health strategies designed to promote cancer screening need to consider the value of directing their campaigns at those who are most reluctant to perform these practices.

Health beliefs, locus of control, emotional control and women's cancer screening behaviour

Improvements in women's cancer-screening behaviours can lead to a reduction in the incidence of breast and cervical cancer. This paper considers the utility of three social psychological models as predictors of such behaviours. Almost 400 women throughout Northern Ireland completed a questionnaire designed to measure the extent of their cancer-screening behaviour, their health beliefs about cancer, their health locus of control and their emotional control. It was found that several components of the health belief model and of locus of control were predictors of the behaviours. The most important predictor of breast self-examination was confidence in how to practise BSE while the most important predictor of attendance for cervical smears was lack of fear of the consequences of the investigation. The findings are discussed with reference to attempts to promote these practices.

Neuropsychologic functioning of human immunodeficiency virus-infected children with hemophilia

Efforts to detect subtle but objective neuropsychologic deficits could clarify the early involvement of the central nervous system and the progression of human immunodeficiency virus (HIV) infection in older children and young adolescents. Baseline examinations of 63 children and adolescents with hemophilia were conducted by examiners unaware of HIV status or staging or of our study's major hypotheses. They measured six domains of neuropsychologic functioning (motor, language, memory, attention, visual processing, and problem solving), and no differences between groups of similar age, race, and socioeconomic status defined by HIV seropositivity (n = 25) and HIV seronegativity (n = 38) were revealed. A high incidence of subtle neuropsychologic deficits relative to (1) age norms and (2) individual cognitive potential was found on measures of motor performance, attention, and speeded visual processing within both infected and uninfected groups. On the basis of these baseline data, it seems premature to attribute early, subtle neuropsychologic deficits in seropositive children with hemophilia to the central nervous system effects of HIV infection.