Impact of omitting post-transplant minidose-methotrexate doses in allogeneic hematopoietic cell transplantation

Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1-3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3-4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p = .024) and decreased overall survival (HR 1.61; p = .024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival.

Preoperative sizing of meniscal allografts in meniscus transplantation

The purpose of this study was to determine the accuracy of radiographic and magnetic resonance imaging techniques in preoperative sizing for allograft meniscus transplantation. Twelve cadaveric knee specimens underwent sequential radiographs, magnetic resonance imaging scans, and arthrotomy. Meniscus dimensions were measured in multiple planes for the purpose of determining accuracy of imaging studies in comparison with actual meniscus dimensions. Overall, magnetic resonance imaging proved only slightly more accurate than conventional radiography. The mean difference between magnetic resonance imaging measurements and actual meniscus dimensions was 2.25 +/- 2.04 mm. The mean difference between radiographic measurements and actual meniscus dimensions was 2.35 +/- 1.79 mm. Neither imaging technique was accurate for measuring individual meniscus dimensions, with only 35% of images measuring within 2 mm of actual meniscus dimensions. Using less stringent criteria for accuracy (within 5 mm), radiography and magnetic resonance imaging were 79% and 83% reliable, respectively. Failure to obtain true anteroposterior or lateral images (15 degrees of external and internal rotation) increased measurement inaccuracy. Intraobserver agreement was significantly higher for magnetic resonance imaging than for radiography. Further research into the development of alternative techniques for more reliable meniscus sizing and better understanding of the tolerance for meniscus size mismatch is necessary.

Win-win mentoring

This article describes strategies to build and enhance mentor/protégé relationships, expand nurses' experience, and help new nurses develop.

Win-win mentoring

Learn strategies to build and enhance mentor-protégé relationships, expand your experience, and help new nurses develop.

Spondylolisthesis in the elite football player: an epidemiologic study in the NCAA and NFL

Although spondylolisthesis in and of itself is not a contraindication to participation or successful performance in football, having spondylolisthesis may well predispose to symptoms and be associated with a worse prognosis. The purpose of this study was to determine the reported prevalence, treatment approach, outcomes, and perceptions regarding prognosis of elite football players with spondylolisthesis by their National Collegiate Athletic Association (NCAA) and National Football League (NFL) team physicians. A questionnaire regarding the prevalence, treatment, results, and perceptions regarding prognosis related to spondylolisthesis in football players was submitted to each team orthopaedic surgeon of the 28 NFL and the Final Associated Press ranked top-25 NCAA Division I teams at the conclusion of the 1993-1994 season. All questionnaires were returned for review. The prevalence of players with known spondylolisthesis currently participating in elite football was 1% in both the NCAA and NFL. Fifty-two percent of NCAA and 43% of NFL team physicians were aware of at least one athlete with spondylolisthesis currently playing. Only six college and two NFL team physicians were aware of athletes surgically treated for spondylolisthesis. Sixty-four percent of NFL team physicians and 36% of college team physicians believed that the presence of spondylolisthesis implies a poor prognosis. Ninety-six percent of professional team physicians downgraded the rating of players with known spondylolisthesis before the NFL draft.

Release and reattachment of the coracoacromial ligament: a cadaveric study

The purpose of this study was to examine the anatomy and ability to reattach the coracoacromial ligament (CAL) after acromioplasty. Twenty-eight fresh cadaveric shoulder specimens were dissected, and the CAL dimensions and pattern of attachment were examined. The ability to reattach the CAL to the anterior acromion after acromioplasty was investigated, comparing release along the anterior acromion (traditional anterior acromioplasty) versus subperiosteal elevation from the acromial undersurface. The influence of CAL length, acromial "type," and amount of acromioplasty on reattachment were examined. In 96% of the specimens (27 of 28) confluent medial and lateral bands of the CAL insertion along the acromion precluded "selective" release. The ability to anatomically reattach the CAL was directly related to the method of ligament release (anterior release versus subperiosteal elevation) (p < 0.0001). When directly released from along the anterior acromion, the CAL could not be anatomically reattached in any specimen. Nonanatomic reattachment to a more medial anterior acromial insertion site, however, was possible in 22 (79%) of 28 specimens. Reattachment required an average medial positioning of 60% (range 16% to 88%) along the anterior acromion from the anterolateral tip. Six (21%) specimens could not be reattached despite attempted medial positioning. In contrast, when subperiosteally elevated from the anterior inferior acromion, the CAL was reattachable in all specimens, anatomically in 26 (93%) of 28. The two nonanatomic reattachments required medially reattaching the ligament's normal acromial insertion by an average of 30%. There was no relationship between specimen sex, age, presence of rotator cuff tear, type of acromion, and CAL reattachment. The confluent anatomy of the CAL does not permit "selective" release of discretely identifiable portions of the CAL (i.e., the lateral band). In cases in which CAL restoration is important, careful subperiosteal elevation from the acromial undersurface will facilitate anatomic reattachment. Standard release of the CAL from the anterior acromion precludes anatomic, and in some cases any, reattachment of the CAL.

Unusual problems of the athlete's elbow, forearm, and wrist

Early in their medical training physicians often are told, "When you hear hoofbeats, don't think of zebras." Such sage advice is helpful when facing the formidable challenges of information acquisition early on. Later, however, we must be familiar and consider these uncommon conditions when entrusted with the responsibility of properly caring for our patient athletes. This is particularly true in the athlete presenting with symptoms or findings disproportionate to his or her injury, or when symptoms persist despite seemingly appropriate treatment. A high index of suspicion and attention to radiographs and further appropriate work-ups result in detection of most occult unexpected lesions.

Nutrition support team management of enterally fed patients in a community hospital is cost-beneficial

OBJECTIVE

To determine whether nutrition support team (NST) management of enterally fed patients is cost-beneficial and to compare primary outcomes of care between team and nonteam management.

DESIGN

A quasi-experimental study was conducted over a 7-month period.

SETTING

A 400-bed community hospital.

SUBJECTS

A convenience sample of 136 subjects who had received enteral nutrition support for at least 24 hours. Forty-two patients died; only their mortality data were used. Ninety-six patients completed the study.

INTERVENTION

Outcomes, including cost, for enterally fed patients in two treatment groups--those managed by the nutrition support team and those managed by nonteam staff--were compared.

MAIN OUTCOME MEASURES

Severity of illness level was determined for patients managed by the nutrition support team and those managed by nonteam staff. For each group, the following measures were adjusted to reflect a significant difference in average severity of illness and then compared: length of hospital stay, readmission rates, and mortality rates. Complication rates between the groups were also compared. The cost benefit was determined based on savings from the reduction in adjusted length of hospital stay.

STATISTICAL ANALYSES PERFORMED

Parametric and nonparametric statistics were used to evaluate outcomes between the two groups.

RESULTS

Differences were statistically significant for both severity of illness, which was at a higher level in the nutrition support team group (P < .001), and complication rate, which was greater in the nonteam group (P < .001). In the nutrition support team-managed group, there was a 23% reduction in adjusted mortality rate, an 11.6% reduction in the adjusted length of hospital stay, and a 43% reduction in adjusted readmission rate. Cost-benefit analysis revealed that for every $1 invested in nutrition support team management, a benefit of $4.20 was realized.

APPLICATIONS

Financial and humanitarian benefits are associated with nutrition support team management of enterally fed hospitalized patients.

Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction: a new technique of intraarticular measurement and modified graft harvesting

The purpose of this study was to determine the incidence of bitunnel interference fixation and accurate femoral insertion site targeting using a modified technique of endoscopic anterior cruciate ligament (ACL) reconstruction. Thirty-four consecutive central-third bone-patellar tendon-bone autograft modified endoscopic ACL reconstructions were prospectively studied. A new technique was used intraoperatively to directly measure (a) intraarticular (graft) distance (IAD) and (b) patellar tendon graft length, thereby allowing calculation of optimal tibial tunnel length for each case. Accuracy of guide pin placement through this tibial tunnel into the proposed femoral insertion site was assessed, as was the ability to achieve interference fixation in both tunnels (minimum of 20 mm bone interference fixation within the tibial tunnel). A new technique for patellar tendon-bone harvesting and proximal graft fixation to address graft mismatch is described. The average IAD from tibial origin to femoral ACL insertion measured 26.3 +/- 3.0 mm (range 21-33). The average patellar tendon length (LP) was 48.4 +/- 6.0 mm (range 40-63). The average calculated tibial tunnel length (TT) necessary to achieve bitunnel fixation (TT > or = LP + 20 - IAD) was 42.1 +/- 5.3 mm (range 36-57). Establishment of the calculated tibial tunnel length was achieved in 25 cases (74%) (no graft-tunnel mismatch). Graft-tunnel mismatch, in which the tibial tunnel could not be established to the length calculated necessary to accommodate a minimum of 20 mm of bone graft, occurred in nine cases (26%). Graft-tunnel mismatch occurred more frequently in patients whose patellar lengths were > or = 50 mm (p < 0.005), but was not found to correlate specifically to IAD. Recession of the graft up into the femoral tunnel allowed accommodation of the mismatched graft (bitunnel interference screw fixation) in these nine cases, averaging 22.0 +/- 2.98 mm (range 16-29 mm) of available distal bone block fixation. Tibial tunnel fixation of > or = 20 mm was achieved in 30 patients (88%), 18 mm in two, 17 mm in one, and 16 mm in one. Measurement error resulted in inadequate distal graft accommodation in four patients in whom error averaged 3 mm. Targeting of the femoral insertion site guide pin was achieved without requiring any knee manipulation for all cases. Patellar tendon graft protrusion through the tibial tunnel and potentially suboptimal graft fixation poses a frequent problem during endoscopic ACL reconstruction.(ABSTRACT TRUNCATED AT 400 WORDS)

Baseball batting. An electromyographic study

The muscle firing pattern in 12 muscles throughout the lower extremity, trunk, and upper extremity during the batting swing is described in this study. The two hamstring muscles studied and the gluteal muscle had a similar pattern of high muscle activity during pre-swing and early swing, and then rapidly diminished. The vastus medialis demonstrated peak activity between 95 and 110% maximum muscle test (MMT) throughout the swing phases and follow-through. The erector spinae demonstrated activity from 85 to 185% MMT during the swing phases. The abdominal obliques showed greater than 100% MMT during the swing phases and follow-through. The supraspinatus and serratus anterior showed relatively low muscle activity (less than 40% MMT). These results show that batting is a sequence of coordinated muscle activity, beginning with the hip, followed by the trunk, and terminating with the arms. Power in the swing is initiated in the hip, and therefore exercises that emphasize such strength development are indicated. The maintained, high muscle activity in the trunk muscles indicates a need for back and abdominal stabilization and rotation exercises. The relatively low level of activity in the four scapulohumeral muscles tested indicated that emphasis should be placed on the trunk and hip muscles for a batter's strengthening program.

Frozen shoulder. A long-term follow-up

Sixty-two patients (sixty-eight shoulders) who had been treated non-operatively for idiopathic frozen shoulder were evaluated subjectively and objectively at two years and two months to eleven years and nine months of follow-up (average, seven years). Thirty-one (50 per cent) of these patients still had either mild pain or stiffness of the shoulder, or both. The range of motion averaged 161 degrees of forward flexion, 157 degrees of forward elevation, 149 degrees of abduction, 65 degrees of external rotation, and internal rotation to the level of the fifth thoracic spinous process. Thirty-seven (60 per cent) of the sixty-two patients still demonstrated some restriction of motion as compared with study-generated control values (calculated as the average motion, in each plane, for the thirty-seven unaffected shoulders of the patients who had unilateral disease). Ten patients had restriction of forward flexion; eight, of forward elevation; seventeen, of abduction; twenty-nine, of external rotation; and ten, of internal rotation. However, when the motion of each affected shoulder of thirty-seven patients who had unilateral involvement was compared with that of the unaffected contralateral shoulder, eleven (30 per cent) demonstrated some restriction. None of these patients had restriction of forward flexion; two had restriction of forward elevation; two, of abduction; seven, of external rotation; and seven, of internal rotation. The patients who had substantial restriction in three planes or more were thirteen times more likely to be men (p greater than 0.05). Marked restriction, when it was present, was most commonly in external rotation. Only seven patients (11 per cent) reported mild functional limitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic management of pyarthrosis

Sixteen patients (average age, 38 years; range, 20-63 years) with pyarthrosis were treated during a ten-year period by arthroscopic techniques consisting of joint debridement and application of suction drains, combined with appropriate antibiotics. There were 13 knees, two shoulders, and one ankle in the series. At the first visit to the authors' institution, patients typically had fever, leukocytosis, elevated sedimentation rate, and localized joint findings, such as generalized tenderness, swelling, effusion, and painful, limited range of motion in almost every joint involved. Most patients were seen two to five days after the onset of symptoms. After the initial culture and sensitivity were obtained and broad-spectrum antibiotics were administered, all patients were taken to the operating room on an emergency basis. At an average follow-up evaluation of 36 months (range, 14-48 months), the results have been excellent to good, without evidence of recurrence.

Gas gangrene. A review

Gas gangrene continues to cause significant morbidity and mortality. This monograph reviews the entire spectrum of clostridial infection, including its etiology, pathophysiology, diagnosis, current recommended treatment, and prophylaxis. The early diagnosis of gas gangrene is paramount, as delay in aggressive combined treatment may result in death.

Disease-associated fractures: detection and management in the elderly

Pathologic fractures in the elderly result from a variety of conditions, including malignancies and Paget's disease. Comprehensive laboratory and radiological evaluation is essential to analyze both the underlying etiology and the extent of the disease. Surgical intervention is critical in stabilizing these fractures so that pain is relieved and function is improved.

Translocation t(X;18) in orofacial synovial sarcoma

Cytogenetic analysis of a synovial sarcoma of the base of the tongue showed a reciprocal translocation involving chromosomes X and 18 [t(X;18)(p11.2;q11.2)]. This is a translocation recently reported to be characteristic of synovial sarcomas of the extremities. The histogenesis of synovial sarcoma is controversial. Our discovery of this translocation in an oral synovial sarcoma confirms the unity of origin of this neoplasm with the far more common synovial sarcomas of the extremity. Karyotypic analysis may prove useful in confirming the diagnosis of this uncommon neoplasm.

Cytogenetic findings in malignant fibrous histiocytoma

The cytogenetic findings of two malignant fibrous histiocytomas from two unrelated patients are discussed. Both tumors were characterized by trisomy 7.

Associative response bias and severity of thought disorder in schizophrenia and mania

Studied severity of thought disorder related to putative, exaggerated tendency of schizophrenics to respond to associative intrusions. Three groups of patients, paranoid schizophrenics, nonparanoid schizophrenics, and manics, participated in the investigation. The findings were: vulnerability to associative distractors is not specific to schizophrenia; performance deficit is more related to severity of thought disorder than to a specific diagnosis; degree of cognitive impairment was found to negatively influence verbal performance; the three groups of patients manifested equivalent levels of cognitive impairment.

Convergent and discriminant validity of the WIST

Tested the ability of the Whitaker Index of Schizophrenic Thinking (WIST): (1) to distinguish schizophrenics from nonschizophrenics (N = 30); (2) to agree with clinically rated severity of thought disorder; and (3) to correlate with a measure of generalized cognitive deficit. The WIST was not found to discriminate accurately schizophrenics from nonschizophrenics, but was found to agree strongly with the Shipley Institute of Living Scale, a measure of generalized cognitive dysfunction. Finally, clinically rated estimates of schizophrenic thinking (i.e., conceptual disorganization, unusual thought content) failed to predict WIST Index. The WIST appears to be primarily a measure of generalized deficit.

Role of procaine and washed red cells in the isolated dog heart perfused at 5 degrees C

Isolated dog hearts were perfused for 24 hours at 5 degrees C with one of three solutions: plain Krebs solution, Krebs solution containing 167 mg/L of procaine hydrochloride, or Krebs-procaine solution with washed red cells (hematocrit 2%). Coronary vascular resistance (CVR) of hearts perfused with Krebs solution alone increased sharply between the eighth and the twelfth hours of perfusion and then stabilized. Increase of myocardial firmness paralleled the increase of CVR. The addition of procaine to Krebs perfusate kept the heart flaccid and suppressed the steplike increase in CVR but failed to improve significantly the preservation of the hearts. The addition of washed red cells to Krebs perfusate kept CVR near baseline level, improved coronary perfusion flow, doubled myocardial oxygen consumption, reduced edema formation, and improved left ventricular stroke work (LVSW) of the preserved heart. This improvement seems mostly related to a mechanical effect of red blood cells on capillary flow distribution of the heart.

Nonsense mutations affecting the his4 enzyme complex of yeast

The his4 region of yeast contains the information necessary for the catalysis of three steps in the histidine biosynthetic pathway. The three activities specified by this region remain physically associated during gel filtration and ultracentrifugation and after extensive purification. Nonsense mutations in the "operator distal" his4C region lower the molecular weight of the two proximal activities. The proximal activities can, therefore, function without the his4C portion of the protein(s). These observations are compatible with the following three possibilities. The his4 region codes for: (1) an aggregate of three proteins forming a multiprotein complex; (2) a single protein with three catalytic activities; and (3) a single protein which is cleaved to form three proteins which remain associated.