Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons

The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.

Subcortical dementia revisited: similarities and differences in cognitive function between progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and multiple system atrophy (MSA)

To examine the similarities and differences in cognitive function between three predominantly subcortical dementing disorders associated with parkinsonism we compared the profiles of cognitive performance in 39 patients with Progressive Supranuclear Palsy (PSP), 26 patients with Multiple System Atrophy (MSA) and 25 with Corticobasal Degeneration (CBD) with those of 30 patients with classic cortical dementia, Alzheimer's Disease (AD), using two different cognitive screening tests: Dementia Rating Scale (DRS) and Addenbrooke's Cognitive Examination (ACE). The cognitive profile on ACE and DRS subtests distinguished subcortical diseases from each other as well as from AD. All parkinsonian syndromes were characterized by a disproportionate impairment in verbal fluency, particularly letter fluency. The three diseases differed, however, in the degree of language, memory and visuospatial impairment. We conclude that similarities, as well as differences, between PSP, MSA and CBD can be detected using a brief, clinically applicable cognitive screening test. The pattern of cognitive impairment is likely to reflect a different distribution of pathology, in particular a higher degree of cortical involvement in PSP and CBD.

Cognitive bedside assessment in atypical parkinsonian syndromes

BACKGROUND

Despite the growing recognition of the importance of cognitive symptoms for the diagnosis and management of atypical parkinsonian syndromes, the cognitive assessment of the patients in clinical practice often remains very limited.

OBJECTIVES

To examine the ability of a brief and simple cognitive screening test to detect cognitive deficits in atypical parkinsonian syndromes.

METHODS

Addenbrooke's cognitive examination (ACE), the mini-mental state examination (MMSE), and the dementia rating scale (DRS) were applied to 26 patients with multiple system atrophy (MSA), 39 with progressive supranuclear palsy (PSP), and 25 with corticobasal degeneration (CBD). The results were then compared with those obtained in 30 healthy age matched volunteers and 30 patients with Alzheimer's disease.

RESULTS

In all four diseases the rate of detection of cognitive impairment on ACE was higher than on MMSE and comparable with DRS. The severity of cognitive impairment was most pronounced in the CBD group, which showed a similar degree of impairment to the Alzheimer group. In contrast, MSA patients were the least cognitively impaired. The PSP group took an intermediate position.

CONCLUSIONS

Cognitive impairment in atypical parkinsonian syndromes can be detected using a brief and clinically applicable bedside test such as ACE.

Efficacy of insulin pump therapy: mealtime delivery is the key factor

OBJECTIVE

To investigate, in a clinical setting, the effect of implementation of continuous subcutaneous insulin infusion (CSII) on control of plasma glucose and to identify factors associated with improved glycemic control in patients with type 1 diabetes mellitus.

METHODS

Nineteen patients (16 women and 3 men) with type 1 diabetes were studied retrospectively. Their mean age was 42.6 years (range, 30 to 58), and the mean duration of diabetes was 21 years. The subjects underwent follow-up for a mean of 14 months after conversion to CSII therapy. With use of paired t tests, pre-CSII and follow-up data were evaluated relative to changes in weight, insulin dosing, and glycosylated hemoglobin (HbA(1c)).

RESULTS

At follow-up, the total daily dose of insulin had decreased by 18%, from a baseline mean value of 45.2 IU to 37.1 IU (P = 0.02). HbA(1c) was reduced from 8.4% to 7.7% (P<0.01). The total daily insulin-to-weight ratio also significantly decreased from 0.66 IU/kg to 0.53 IU/kg (P<0.05). Before insulin pump use, the regular/NPH insulin ratio was 0.5 IU; at follow-up, the pump bolus/basal insulin ratio was 1.0 IU (P = 0.02). No weight gain was observed; the mean weight of the study patients decreased 0.2 kg, from 69.4 kg at baseline to 69.2 kg at follow-up (not significantly different).

CONCLUSION

In a clinical setting, CSII therapy in patients with type 1 diabetes improves glycemic control and lowers the total daily basal insulin dose without affecting weight. Improved glycemic control was associated with a shift in insulin therapy from a high percentage of intermediate-acting insulin to a greater percentage of insulin administered in a meal-associated bolus form. This study emphasizes the importance of mealtime insulin adjustment for tight glycemic control in patients using CSII therapy. Future studies evaluating the benefits of decreased total insulin and an increased bolus/basal insulin ratio may be important in helping to understand how to avoid long-term complications of diabetes.

Comparison of motility and membrane integrity to assess rat sperm viability

Rat sperm motility and membrane integrity were compared as endpoints for viability. Sperm motility was measured by computer-assisted semen analysis (CASA), whereas membrane integrity was assessed by flow cytometric analysis of sperm stained with two nucleic acid stains, SYBR-14 and propidium iodide. The two techniques were compared in experiments that examined sperm viability over time and by analysis of known mixtures of control and freeze/thaw-killed sperm. Results from the two approaches were quantitatively very similar. Sperm from rats treated with dibromoacetic acid (600 or 1200 mg/kg) or alpha-chlorhyrin (100 mg/kg) were also analyzed. Neither technique detected a treatment-related effect with dibromoacetic acid. CASA identified a significant decrease in sperm motility in alpha-chlorhyrin-treated rats, whereas flow cytometric analysis did not find a measureable change in sperm membrane integrity. Because decreases in sperm motility would be expected to directly affect fertility, CASA may be a more robust endpoint for risk assessment in reproductive toxicology studies than flow cytometric analysis of membrane integrity.

Regulation of animal care and research. The final order on Good Laboratory Practices

On June 20, 1979, the Food and Drug Administration (FDA) enacted all aspects of its Good Laboratory Practices (GLP) program. The program was instituted to ensure the quality and integrity of the safety data submitted to FDA in support of the approval of regulated products, including human and animal drugs, food additives, biologicals, radiation-emitting products and human medical devices. Moreover, these considerations include all safety data submitted to support applications for research and marketing permits. These steps were taken in response to the appalling circumstances uncovered in a limited series of inspections of laboratories that was performed during 1975. FDA found careless experimentation, improperly trained employees, unreviewed data, omitted data, improper laboratory and animal care procedures and improperly monitored contract studies, including the failure of sponsors to validate the data appearing in the final study reports. The Congress responded to this situation by allocating FDA 600 new positions and .$16 million to remedy the problems that were evident. In their final form, the GLP's represent regulations fine tuned to assure proper safety testing with a minimum of increased cost. It is hoped that these regulations will increase public confidence in FDA decision making and will help to ensure that safe products are approved for marketing.