Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI).

METHODS

Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence.

CONCLUSIONS

Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group

Osteoporosis causes an elevated fracture risk. We propose the continued use of T-scores as one means for diagnosis but recommend that, alternatively, hip fracture; osteopenia-associated vertebral, proximal humerus, pelvis, or some wrist fractures; or FRAX scores with ≥3% (hip) or 20% (major) 10-year fracture risk also confer an osteoporosis diagnosis.

INTRODUCTION

Osteoporosis is a common disorder of reduced bone strength that predisposes to an increased risk for fractures in older individuals. In the USA, the standard criterion for the diagnosis of osteoporosis in postmenopausal women and older men is a T-score of  ≤ -2.5 at the lumbar spine, femur neck, or total hip by bone mineral density testing.

METHODS

Under the direction of the National Bone Health Alliance, 17 clinicians and clinical scientists were appointed to a working group charged to determine the appropriate expansion of the criteria by which osteoporosis can be diagnosed.

RESULTS

The group recommends that postmenopausal women and men aged 50 years should be diagnosed with osteoporosis if they have a demonstrable elevated risk for future fractures. This includes having a T-score of less than or equal to -2.5 at the spine or hip as one method for diagnosis but also permits a diagnosis for individuals in this population who have experienced a hip fracture with or without bone mineral density (BMD) testing and for those who have osteopenia by BMD who sustain a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture. Finally, the term osteoporosis should be used to diagnose individuals with an elevated fracture risk based on the World Health Organization Fracture Risk Algorithm, FRAX.

CONCLUSIONS

As new ICD-10 codes become available, it is our hope that this new understanding of what osteoporosis represents will allow for an appropriate diagnosis when older individuals are recognized as being at an elevated risk for fracture.

Dermal irritation of petrolatum in rabbits but not in mice, rats or minipigs

Petrolatum is widely used in cosmetics, topical pharmaceuticals and also as a vehicle in dermal toxicity studies. New Zealand white rabbits treated with white petrolatum (vehicle control) in a 2-week dermal irritation study exhibited moderate to severe erythema starting on Day 7 that subsided towards the end of the study. Histological examination of abraded and non-abraded petrolatum-treated skin obtained at termination (Day 15) revealed mild acanthosis, hyperkeratosis, dermal edema with mixed inflammatory cells in the dermis. Macroscopic and microscopic features noted in rabbits were consistent with dermal irritation to petrolatum. Wistar-Han rats, CD1 mice, C57/Bl/6J mice and Göttingen minipigs treated topically with white petrolatum did not exhibit clinical or histologic evidence of dermal irritation. Therapeutic agents developed for topical application are generally tested in rabbits during some point in development. Interpretation of skin irritation data from a single species can impact risk assessment for humans and on product labeling.

Acute inflammation with induction of anaphylatoxin C5a and terminal complement complex C5b-9 associated with multiple intra-articular injections of hylan G-F 20: a case report

OBJECTIVE

The purpose of this case report was to investigate local immune mechanisms present during an acute inflammatory flare initiated by viscosupplementation with hylan G-F 20 in a patient with osteoarthritis (OA) and past meniscectomy.

EXPERIMENTAL DESIGN

A patient with a history of bilateral OA and partial left knee meniscectomy, who had received three injections of hylan G-F 20, was diagnosed with an acute flare reaction in the left knee. Her chart was evaluated for clinical, radiological, and laboratory findings and for clinical follow-up. Histopathological synovial examination and real-time polymerase chain reaction (RT-PCR) for genes with major roles in local inflammation and enzyme-linked immunosorbent assays (ELISAs) for markers of complement activation and cytokines were performed. To study the impact of the inflammatory and immune features we compared the case patient with groups of three representative OA and three rheumatoid arthritis (RA) patients.

RESULTS

The patient exhibited evidence of highly increased acute phase reactant C-reactive protein (CRP) in the blood. The pathological examination of the synovial membrane identified abundant fibrinous exudate with numerous particles of hyaluronan surrounded by a dense infiltrate of neutrophils and eosinophils. The synovium had moderate hypertrophy and sclerosis as well as an inflammatory infiltrate predominantly composed of T lymphocytes and macrophages with scattered perivascular eosinophils and neutrophils. Immunoperoxidase staining identified numerous deposits of C5b-9 in the fibrinous exudates and the synovial membrane of the patient. Similar findings were observed in the RA patients, whereas deposits were rare in OA synovial samples. In addition, both anaphylatoxin C5a and the terminal complement complex C5b-9 were present at high levels, comparable to those in RA patients. The levels of mRNA for interleukin-1 beta (IL-1β), IL-6, and the neutrophil marker myeloperoxidase (MPO) were markedly increased compared to those in the RA and OA patients.

CONCLUSIONS

This present study is indicative of a pseudo-septic acute inflammatory reaction in response to local accumulation of hylan G-F 20 with the activation of complement and local invasion of pro-inflammatory cells.

[Critical reflexion on quality improvement and networking]

Qualitiy-control and networking are two issues of debate in modern medicine. The origin of these terms is not to be found in medicine, but rather in industry. However their naive transfer to the field of medicine causes damage. It is relatively easy to test industrial products for their quality. Dealing with meaningful medical problems is far too complex. Simple data such as blood pressure, HbA1c, etc. may be assessed. The only means of quality-control of complex medical situations and actions are ward rounds by attending physicians, case presentations at staff meetings, etc. Issues of clinical quality-control are discussed on the basis of the history of an aged couple. Furthermore a personal clinical experience illustrates how doctors create a useful network with other physicians and how they eliminate "useless" colleagues from their network. Economists should have no influence or impact whatsoever on the quality-control and networking of physicians.

Application of an impedance matching transformer to a plasma focus

A plasma focus was constructed using an impedance matching transformer to improve power transfer between the pulse power and the dynamic plasma load. The system relied on two switches and twelve transformer cores to produce a 100 kA pulse in short circuit on the secondary at 27 kV on the primary with 110 J stored. With the two transformer systems in parallel, the Thevenin equivalent circuit parameters on the secondary side of the driver are: C = 10.9 μF, V(0) = 4.5 kV, L = 17 nH, and R = 5 mΩ. An equivalent direct drive circuit would require a large number of switches in parallel, to achieve the same Thevenin equivalent. The benefits of this approach are replacement of consumable switches with non-consumable transformer cores, reduction of the driver inductance and resistance as viewed by the dynamic load, and reduction of the stored energy to produce a given peak current. The system is designed to operate at 100 Hz, so minimizing the stored energy results in less load on the thermal management system. When operated at 1 Hz, the neutron yield from the transformer matched plasma focus was similar to the neutron yield from a conventional (directly driven) plasma focus at the same peak current.

Oleic acid-associated bronchiolitis obliterans-organizing pneumonia in beagle dogs

Accidental intra-airway exposure of dogs with pure oleic acid produced bronchiolitis obliterans and bronchopneumonia. Pulmonary changes included multifocal to coalescing necrosis of bronchioles and adjacent alveoli, hemorrhage, inflammation, and exudation of fibrin. Hyperplasia of bronchiolar and alveolar epithelial cells and proliferation of loose fibrovascular connective tissue formed polyps or plugs of variable size and shape. Polyps in the airways primarily consisted of fibroblasts with loose or myxoid stroma and were variably covered with attenuated epithelial cells. Some polyps had prominent vasculature, mixed inflammatory cell infiltration, and/or necrosis. Polyps or plugs variably effaced bronchioles and adjacent alveoli. The changes closely resembled human bronchiolitis obliterans-organizing pneumonia (BOOP). Controlled intra-airway delivery of oleic acid in dogs may be a potential animal model of obstructive pulmonary diseases such as BOOP or bronchiolitis obliterans.

[Reduction of radiation exposure by using storage phosphor radiography on pelvis and lumbar spine]

PURPOSE

To examine the reduction of radiation dose for radiography of the pelvis and lumbar spine (LS) by using storage phosphor radiography (SPR)?

MATERIAL AND METHODS

Each pelvis and LS of 2 phantoms (3 M) and 2 corpses were X-raxed digitally in an anterior-posterior orientation using SPR (ADC compact, Agfa). The tube current time product (mAs) was diminished gradually while keeping the voltage constant. The surface entrance dose was measured by a Dosimax (Wellhöfer) sensor. Five investigators evaluated the images for characteristics and critical features and pathological findings.

RESULTS

The images of the 4 various pelvises/LS could be evaluated sufficiently down to an average dose of 34 to 40 %/18 to 35 %. For the assessment of hip joint, region typical corticalis and calcifications (pelvis/LS) 9 to 18 %/8 to 23 % of the initial dose (initial dose is equivalent to a conventional screen film system with a speed class of 400) are enough, spongiosa typical for the region and the sacrum 30 to 56 %/19 to 36 % on average among the readers.

CONCLUSION

For the sufficient exclusion of a fracture the dose can be reduced on pelvis/LS to at least 39 %/28 % ( 23 %/17 %), for the assessment of sacroiliitis/osteolyses/demineralisation to at least 78 %/44 % ( 34 to 36 %/22 to 26 %), to position check after fracture to at least 15 %/25 % ( 9 %/10 %). Question-related tube current time products of the pelvis and LS can be deduced for various objects.

Hepatitis c virus infection in employees of a large university hospital in Israel

OBJECTIVE

To assess whether hospital work constitutes a risk factor for hepatitis C virus (HCV) infection among employees of a large hospital in Israel.

DESIGN

Seroprevalence survey.

SETTING

A 1,006-bed, tertiary-care university hospital in Jerusalem.

PARTICIPANTS

All 5,444 employees (18-65 years old) were eligible; 4,287 (79%) participated in the survey.

METHODS

Sera were tested for antibodies to HCV (anti-HCV) using a third-generation enzyme immunoassay. A third-generation strip immunoblot assay was used for confirmation. Participants were interviewed regarding their occupational history, and they completed a self-administered questionnaire covering history of non-occupational exposure to blood and country of birth. Other demographic information was obtained from the personnel department. Rates and odds ratios (ORs) were calculated, and multivariate logistic-regression analyses were performed to adjust for potential confounding variables.

RESULTS

Anti-HCV was found in 0.9% of employees (37/4,287; 95% confidence interval, 0.6-1.1), ranging from 0.1% among those born in Israel to 5.7% among those born in Central Asia. After age, gender, social status, country of birth, and history of blood transfusion were controlled for in a logistic regression, occupational exposure to blood > or = 10 years was significantly associated with the presence of antibodies (OR, 2.6; P=.01). Presence of anti-HCV also was associated with country of birth (range: Israel OR, 1; West OR, 3.8 [P=.1]; Central Asia OR, 48.6 [P<.0001]) and history of blood transfusion (OR, 2.7; P=.01). No significant associations were found between anti-HCV and age, gender, social status, history of tattoo, acupuncture, current occupation, department, exposure to blood in current occupation, adherence to safety precautions, or history of percutaneous injury. The association with length of exposure was stronger (OR, 3.6; P=.01) when the same logistic regression was run excluding the outlier ethnic group of Central Asia.

CONCLUSIONS

Hospital work does not seem to constitute a major risk factor for HCV infection in Israel today. A higher prevalence of anti-HCV among employees with longer versus shorter lengths of occupational exposure may be due to a cumulative effect of exposure over the years. Infection control efforts in recent years may have contributed to this association.

Neurotrophic signaling in normal and degenerating rodent retinas

Several types of insult cause up-regulation of neurotrophic factors and their receptors in the retina resulting in decreased photoreceptor cell death from subsequent injury. This phenomenon is more prominent in rats than in mice and neurotrophic factors are more efficacious in rats than mice. If up-regulation of neurotrophic factor receptors on photoreceptor cells early in the course of degenerations contributes to neurotrophic factor survival-promoting activity, it may also increase the ability to detect neurotrophic factor-induced signaling in photoreceptors, particularly in rats. In this study, these hypotheses were investigated by performing immunohistochemical staining for the phosphorylated form of extracellular receptor kinase (pERK) or c-fos after intravitreous injection of neurotrophic factors in wild type rats or mice, or those with inherited retinal degenerations. In both rats and mice either early or late in the course of degeneration, or in wild type animals, intravitreous injection of brain-derived neurotrophic factor, ciliary neurotrophic factor, or fibroblast growth factor-2 caused immunostaining for pERK and c-fos in cells of the inner retina, particularly Müller cells, but not in photoreceptors. These data add to the mounting evidence suggesting that neurotrophic factors act indirectly through Müller cells to promote photoreceptor survival.

Microenvironmental regulation of visual pigment expression in the chick retina

Visual pigment (VP) expression in the chick embryo retina was investigated in ovo, in dissociated and explant cultures, and in cDNAs from individual cells. While VP mRNA is not detectable by in situ hybridization until embryonic day (ED) 14-16 in ovo, analysis of VP expression by RT-PCR showed that VP messages are present in the retina as many as 7-10 days before they become detectable by in situ hybridization, and are also detected in other regions of the embryonic CNS. On the other hand, red opsin expression is markedly accelerated when cells are isolated from their intraocular microenvironment at ED 6, and placed in pigment epithelium-free dissociated or explant cultures. This acceleration occurs regardless of cell density, birth date, or serum presence in the medium, suggesting that many photoreceptors are already programmed to express red opsin on or before ED 6, and that microenvironmental inhibitory factors prevent implementation of this program until ED 14 in ovo. The selectivity of this phenomenon is suggested by the finding that other VPs are not observed by in situ hybridization in ED 6 cultures, although they are detectable in cultures of older retinas. Taken together, these findings suggest that red opsin expression may be constitutive for many developing photoreceptor cells in the chick.

Combined use of power Doppler and gray-scale sonography: a new technique for the assessment of inflammatory myopathy

OBJECTIVE

Ultrasonography (US) is a utilitarian approach to the assessment of inflammatory myopathy (IM). Power Doppler sonography (PDS), a newer technique, enables detection of muscle vascularity and inflammation. We describe the combined use of PDS and gray-scale US in patients with IM.

METHODS

We studied 37 IM subjects and 6 control subjects. Clinical scores of muscle strength and function were obtained. The maximum score, 31, represented normal function and strength. Ultrasonographic gray-scale and vascularity results were scored 0-4. Nine subjects had serial assessments.

RESULTS

Subjects ranged from 16 to 83 years of age and were predominantly female. IM subjects had significantly abnormal lower clinical scores than controls, 23.0 +/- 5.8 vs 29.8 +/- 2.0 (p < 0.001). Mean peak gray-scale score was 2.1 +/- 0.96 compared to 0.5 +/- 0.84 for controls (p = 0.001), indicating atrophy in the IM group. Similar results were found for average gray-scale scores. Peak vascularity scores were higher in IM, 2.7 +/- 0.8 vs 2.2 +/- 0.3 (p = 0.007). Disease of longer duration was significantly associated with more abnormal gray-scale scores and lower creatine phosphokinase (CPK) levels. PDS scores were more abnormal in disease of shorter duration. There was a negative association between functional scores and inflammatory scores on serial assessment.

CONCLUSION

Sonography is a valuable tool in the assessment of IM. Gray-scale and PDS findings were significantly different between IM and control subjects. Abnormal gray-scale US scores were associated with disease of longer duration and lower CPK levels. In contrast, increased vascularity on PDS detected disease of shorter duration and varied with the clinical course more than did gray-scale findings.

Liver transplantation and nursing care in Israel

The Liver Unit in Hadassah Medical Center has been following patients before and after transplantation in a process combining medical and nurse care. Since 1991, 145 patients have been studied. This article reviews the study methods associated with the liver transplantation process, including etiology of basic liver disease, drug adverse effects, complications, and survival rates. The value of the nursing coordinator in liver transplantation is discussed.

Children with persistent conduct problems who dropout of treatment

Dropout of treatment is one of the key issues in outcome in a child and adolescent mental health service. We report two studies focusing on the treatment process and the dropout rate of children with persistent conduct problems presenting to a community mental health service, using a prospective design. The first study included 32 children and used a randomised controlled treatment design comparing a CBT approach with conjoint family therapy and an eclectic approach. The overall dropout rate was 36%. Dropout occurred significantly less frequently in the CBT group. The dropout group was associated with mothers who were younger and less educated, a poorer rating by the clinicians at the last meeting, parental dissatisfaction with the treatment service and perception that the treatment was less organised and having less behavioural tasks. In the second study we used a naturalistic follow-up design. Forty-six children were included. The overall dropout rate was 48%. Again, the children who defaulted were rated by clinicians as less likely to have improved and dropout was also significantly associated with parental perception of a less organised treatment. In both studies dropout usually occurred after assessment and at the early phase of treatment.

Developmental expression patterns of bone morphogenetic proteins, receptors, and binding proteins in the chick retina

Bone morphogenetic proteins (BMPs), a large subfamily of the transforming growth factor-beta (TGF-beta) superfamily of growth factors, have been implicated in patterning of the central nervous system, but their role in the retina is much less well known. As an initial step in addressing this issue, we have investigated by in situ hybridization the expression patterns of BMP-2, -4, -5, -6, and -7, BMP receptor kinases (BRKs) -1, -2, and -3, and BMP binding proteins noggin and chordin, in the chick embryonic eye at embryonic day 3 (E3), and in isolated retinas at E6, E8, and E18. Strikingly, all mRNAs examined had spatially restricted patterns of expression in the early eye, with the receptors found primarily in the ventral portion of the retina and in the optic stalk, and the ligands and binding proteins localized to other regions of the retina and/or retinal pigment epithelium. Dorso-ventrally restricted patterns of expression persisted at E8, but were no longer apparent at E18, whereas layer-specific patterns of expression were detectable at both E8 and E18. This distribution of BMP family members, receptors, and binding proteins within the retina appears consistent with a possible role in patterning and/or differentiation of this tissue.

Circumcision: we have heard from the experts; now let's hear from the parents

OBJECTIVE

The current study sought to investigate parental attitudes about circumcision and their satisfaction with the decision.

METHODOLOGY

Parents of boys (6 months to 36 months old) in 3 different practices filled out a questionnaire while waiting for their child's well-child examination.

RESULTS

A total of 149 families were surveyed. Families (68) who did not have their sons circumcised were less satisfied with their decision. Compared with families (81) of circumcised children, parents of uncircumcised boys were less likely to have been asked by their physician about whether they wanted their child circumcised, believed that they did not receive adequate information about the procedure, felt less respected by their medical provider, and were more likely to reconsider their decision.

CONCLUSION

The importance of adequate information and discussion is highlighted by this study.

Rapid seroprotection against hepatitis B following the first dose of a Pre-S1/Pre-S2/S vaccine

BACKGROUND/AIMS

Will immunization with an experimental Pre-S1/Pre-S2/S hepatitis B vaccine (Bio-Hep-B) induce faster seroprotection using fewer doses as compared with a yeast derived S vaccine (Engerix B).

METHODS

Healthy volunteers, n = 36, mean age 23 y, randomized to receive 2 or 3 doses of both vaccines given months 0 and 6, or 0, 1 and 6.

RESULTS

Following primary immunization, seroprotection occurred in 6, 39, 53 and 60% in the Bio-Hep-B group at weeks 1, 2, 3 and 4, compared with 0, 12, 18 and 12.5% in the Engerix-B vaccinees, respectively. Six months following injection of the first dose, seroprotection was 70 and 25% in Pre-S/S and S vaccinees respectively. Area under the curve in vaccinees of Bio-Hep-B; versus Engerix-B showed mean anti-HBs level of 365 +/- 166 and 85 +/- 48 mIU/ml x day respectively (P = 0.012). At month 7, 100% seroprotection was achieved in both groups while anti-HBs rose from 81 to 28,800 mIU/ml and from 12 to 923 mIU/ml in recipients of Bio-Hep-B and Engerix-B respectively (P < 0.025).

CONCLUSIONS

Bio-Hep-B induces rapid seroprotection against hepatitis B in 60-70% of vaccinees, within 4-24 weeks after the first dose. Two instead of the conventional three doses of the Pre-S/S vaccine may be sufficient to induce adequate seroprotection.

Lipid-mediated gene transfection into chick embryo retinal cells in ovo and in vitro

Several lipofection reagents were tested on chick embryo retinal cultures using green fluorescent protein (GFP) as a reporter gene; best results were obtained with the GenePORTER (GP) reagent, which yielded approximately 4.4% of the cells with intense GFP fluorescence. Cell survival and structural differentiation appeared normal, but one of the immunocytochemical markers studied (visinin) was less frequently observed in GP-treated cultures. When similar plasmid-GP mixtures were injected into chick embryo eyes in ovo, bright GFP-fluorescent cells were observed in different retinal layers, without detectable detrimental effects on retinal morphology. Particularly extensive reporter gene expression was obtained upon intraocular injection of GP plus naked DNA from a RCAS retrovirus, which resulted in the development of abundant radial columns of alkaline phosphatase-positive cells, separated by columns of negative cells. We conclude that lipid-based transfection offers a quick, simple and fairly innocuous means for gene delivery into proliferating and postmitotic retinal cells, in vitro as well as in the developing eye in ovo, and that transfection of naked retroviral DNA can lead to extensive expression of foreign genes by retinal cells, bypassing the time-consuming steps required for the generation of high-titer virion stocks.

Green cone opsin and rhodopsin regulation by CNTF and staurosporine in cultured chick photoreceptors

PURPOSE

To investigate the regulation of visual pigment expression in chick embryo photoreceptor cells by ciliary neurotrophic factor (CNTF), and by the protein kinase inhibitor staurosporine.

METHODS

Embryonic day (ED) 8 chick embryo retinal cells were dissociated and cultured at low densities for 3 days, either in control medium or in medium supplemented with CNTF or staurosporine. The cultures were analyzed by immunocytochemistry with the monoclonal antibody Rho4D2, which recognizes chicken rhodopsin and green cone pigment, and by reverse transcription-polymerase chain reaction (RT-PCR) and Northern blot analysis to investigate visual pigment expression at the mRNA level.

RESULTS

CNTF increased the number of Rho4D2-immunoreactive photoreceptors in retinal cell cultures, in agreement with previous reports. RT-PCR and Northern blot analysis, however, showed that rhodopsin mRNA was undetectable in both control and CNTF-treated cultures but that CNTF induced significant increases in mRNA levels for the green cone pigment. Staurosporine-treated cultures also had more Rho4D2-immunoreactive cells than control cultures, but this increase was accompanied by induction of rhodopsin expression, with concomitant decreases in levels of green cone pigment mRNA. No significant differences were found between CNTF- or staurosporine-treated cultures and the corresponding control cultures regarding the red cone pigment, which was expressed in all cases, and the blue and violet pigments, which were not detected in any of the samples.

CONCLUSIONS

The results suggest that multiple regulatory systems control visual pigment expression during differentiation of chick embryo photoreceptor cells. CNTF appears to stimulate specifically the differentiation of green cones, without the previously suggested effects on the differentiation of rod photoreceptors in ED 8 chick retinal cultures.

Final report of the FOPE II Financing of Pediatric Education Workgroup

Some of the challenges of financing pediatric medical education are shared with all medical education; others are specific to pediatrics. The general disadvantage that funding of graduate medical education (GME) is linked to reimbursement for clinical care has uniquely negative consequences for freestanding children's hospitals because they therefore receive little Medicare GME support. This represents both a competitive disadvantage for such hospitals and an aggregate federal underinvestment in children's health care that now amounts to billions of dollars. The need to subsidize medical student and subspecialty education with clinical practice revenue jeopardizes both activities in pediatric departments already burdened by inadequate reimbursement for children's health care and the extra costs of ambulatory care. The challenges of funding are complicated by rising costs as curriculum expands and clinical education moves to ambulatory settings. Controversies over prioritization of resources are inevitable. Solutions require specification of costs of education and a durable mechanism for building consensus within the pediatric community. Pediatrics 2000;106(suppl):1256-1269; medical student education, continuing medical education, medical subspecialties, children, pediatrics, health maintenance organizations, managed care, hospital finances, children's hospitals.

Maintenance of immune memory to the hepatitis B envelope protein following adoptive transfer of immunity in bone marrow transplant recipients

Adoptive transfer of immunity against hepatitis B surface antigen (HBsAg) has been documented in mice and humans. In the present study, we report long-term follow-up of antibodies to HBsAg in humans who received allogeneic bone marrow transplantation (BMT) from donors immunized with HBsAg. BM donors were immunized with recombinant HBsAg. BM or PB cells were transplanted to HLA matched recipients. Recipients were followed for anti-HBs seroconversion. Control groups included non-immunized or rHBsAg immunized healthy adults as well as individuals that had had hepatitis B and recovered spontaneously. PBLs were stimulated in vitro with rHBsAg and stimulation was expressed as stimulation index. Adoptive transfer of immunity to HBsAg was initially documented in 12 recipients of BM from anti-HBc+/anti-HBs+ donors. An almost 4 year follow-up showed detectable protective anti-HBs levels (>10 mIU/ml) in 50% of patients. Immunity to HBV was also documented in 22/35 BMT recipients (62%), who received their bone marrow from actively immunized donors. In 7/9 of these BMT recipients, anti-HBs antibodies levels were documented 25 months following BMT. In 6/8 (75%) of patients who received only PBLs from HBV immune donors, adoptive transfer of immunity to HBV, and seroconversion to HBsAg+, were documented within 2 months of i.v. injection. Evidence for specific cellular immune response with increased SIs was documented for healthy vaccinees, and BMT recipients, and in none of the healthy non-vaccinated controls. These results suggest that adoptive transfer of immunity to HBV is a useful method for providing long-lasting protection for BM recipients.

A model of retinal cell differentiation in the chick embryo

This article presents an overview of retinal cell differentiation in the chick embryo, in the context of a hypothetical model based on information generated during the last several years. The model proposes that: (1) most (if not all) proliferating neuroepithelial cells have the potential to give rise to a progeny comprising two or more different cell types; (2) the time at which cells undergo their terminal mitosis does not determine their differentiated fate; (3) many postmitotic precursor cells remain plastic (i.e., uncommitted) for some time after terminal mitosis, during which they encounter position-dependent signals as they migrate toward their definitive laminar position within the retina; (4) as a consequence of these inductive stimuli, precursor cells that migrate to different retinal layers express different transcriptional regulators; (5) morphologically undifferentiated precursor cells are committed to cell type-specific, complex patterns of differentiation, which they can express even when isolated from their normal microenvironment, and (6) even after precursor cells become committed to a specific identity, additional inductive signals are necessary for the cells to complete the development of a fully mature phenotype. The article presents a summary of the supportive evidence, as well as a critical evaluation of the model, and concludes with an overview of unanswered questions regarding retinal cell differentiation and a brief evaluation of the prospects for further progress in this field.

Herbal vitamins: lead toxicity and developmental delay

A case of lead poisoning from an Indian herbal vitamin is presented. The patient who was developmentally delayed was given an herbal vitamin from India to strengthen his brain. The tablet contained large amounts of lead and mercury, leading to significant lead burden. Vulnerability of families and lack of awareness of health care professionals of dangers of unknown herbal supplementation are discussed.

Thalamic stimulation in patients with multiple sclerosis

OBJECTIVE

To assess tremor control and side effects in patients with multiple sclerosis (MS) treated with chronic thalamic stimulation for relief of upper extremity tremor.

METHODS

Five patients were studied before and after thalamic placement of a deep brain stimulation (DBS) system. Preoperative and postoperative evaluation included magnetic resonance imaging, Extended Disability Status Scale (EDSS), the Bain-Finchley visual analog scale for tremor, video recording and neuropsychological testing. Stereotactic targeting of the Vim nucleus was done using computed tomography; intraoperative testing was done under local anesthesia before permanent implantation.

RESULTS

Functionally useful tremor suppression was obtained in 3/5 patients. Neuropsychological deficits of higher cortical function, memory and visuospatial coordination were observed in all patients before surgery; in 1 patient with improved postoperative visuospatial coordination, worsened memory was found. New brainstem plaque formation was seen several weeks after surgery in 1 patient who had an acute worsening of MS which improved after high-dose intravenous steroids.

CONCLUSIONS

Chronic thalamic stimulation may help selected patients with MS-induced tremor. Given the complexity of their underlying illness, patients must be selected carefully, and long-term follow-up is vital to evaluate the true utility of DBS.

Quantification of mtDNA in single oocytes, polar bodies and subcellular components by real-time rapid cycle fluorescence monitored PCR

Oocytes, in general, are greatly enriched in mitochondria to support higher rates of macromolecular synthesis and critical physiological processes characteristic of early development. An inability of these organelles to amplify and/or to accumulate ATP has been linked to developmental abnormality or arrest. The number of mitochondrial genomes present in mature mouse and human metaphase II oocytes was estimated by fluorescent rapid cycle DNA amplification, which is a highly sensitive technique ideally suited to quantitative mitochondrial DNA (mtDNA) analysis in individual cells. A considerable degree of variability was observed between individual samples. An overall average of 1.59 x 10(5) and 3.14 x 10(5) mtDNA molecules were detected per mouse and human oocyte, respectively. Furthermore, the mtDNA copy number was examined in polar bodies and contrasted with the concentration in their corresponding oocytes. In addition, the density of mtDNA in a cytoplasmic sample was estimated in an attempt to determine the approximate number of mitochondria transferred during clinical cytoplasmic donation procedures as well as to develop a clinical tool for the assessment and selection of oocytes during in vitro fertilisation procedures. However, no correlation was identified between the mtDNA concentration in either polar bodies or cytoplasmic samples and their corresponding oocyte.

Immunization levels and risk factors for low immunization coverage among private practices

OBJECTIVES

Previous studies have indicated that provider characteristics are an important determinant of immunization coverage. The objectives of this study were to: 1) assess immunization coverage levels among 2-year-old children receiving care in private practices in 3 California counties; and 2) evaluate practice and patient risk factors for low immunization coverage.

STUDY DESIGN

Cross-sectional chart review of immunization histories and provider survey of immunization policies.

SETTING

Forty-five randomly selected, private medical practices in 3 counties in California.

PATIENTS

Children 12 to 35 months old, followed by the participating practices.

METHODS

Providers underwent a detailed assessment of their immunization coverage and completed a questionnaire describing their immunization policies and procedures. Immunization data were abstracted from randomly selected medical charts of children 12 to 35 months old. Only patients who met the criteria for active status (>/=2 visits and >/=1 visit during the preceding 18 months) were included in analyses. Immunization coverage levels were calculated and logistic regression was used to estimate the risk of underimmunization associated with different practice and child characteristics.

RESULTS

Of the 72 eligible practices that were contacted, 45 participated in the study, yielding a participation rate of 62%. The median immunization coverage of participating offices was 54% (range: 0%-91%). Multivariate analysis revealed 5 independent risk factors for underimmunization. The strongest predictors were having fewer than 50% active children in the practice and children having fewer than 8 visits to the provider. Other significant predictors were the percentage of patients in the practice on Medicaid, administering diphtheria-tetanus-pertussis 4 at a separate visit from the Haemophilus influenzae type b booster, and practice location.

CONCLUSIONS

These data provide new insights into immunization practices in an important clinical setting that has been poorly characterized previously. Immunization coverage levels were found to be low and significant risk factors for underimmunization were identified. Recommendations are made for immunization policy changes and targeting of immunization improvement interventions at practices that may be at risk for low immunization coverage. immunization, vaccination, immunization programs, primary prevention, private practice, child, preschool, pediatrics, family practice.