DNA-based diagnosis of Angelman syndrome and Prader-Willi syndrome

An endoscopically assisted technique for internally dividing the palmar or plantar annular ligament was developed in six cadaver limb specimens and two anesthetized horses. Under arthroscopic view, a slotted cannula was inserted into the digital sheath through a stab wound proximal to the annular ligament and advanced through the fetlock canal superficial to the flexor tendons with the slot oriented toward the fibers of the annular ligament. Division of the annular ligament by 90-degree tipped open and guarded blades was observed and verified by direct arthroscopic view. At necropsy, complete division of the annular ligament without iatrogenic damage to the neurovascular structures was confirmed by dissection. Annular ligament division was performed in seven horses with complex tenosynovitis conditions. Tenoscopic examination and removal of tendon and digital sheath adhesions, masses, and bands was followed by endoscopically assisted annular ligament transection. At follow-up, five horses were sound athletes without recurrent digital sheath problems, one horse had residual lameness, and one horse was still convalescing.     

Gas-liquid chromatographic analysis of synovial fluid. Succinic acid and lactic acid as markers for septic arthritis

Nonvolatile short-chain fatty acids from 80 synovial fluids were quantified by gas-liquid chromatography. Succinic acid was detectable in all 23 septic synovial fluids infected with either gram-positive or gram-negative organisms and in only 5 of 57 nonseptic synovial fluids. Lactic acid was present in all of the effusions but was correlated with septic arthritis only when present in concentrations greater than 250 mg%. Neither short-chain fatty acid was more sensitive than high white blood cell counts (greater than 50,000 mm3) or depressed glucose concentration (less than 40 mg/dl) in diagnosing septic arthritis before antibiotic therapy; however, the detection of succinic acid was helpful in identifying patients with septic arthritis who had been given antibiotic treatment before arthrocentesis. Thus, gas-liquid chromatography, a rapid and sensitive method for the detection of short-chain fatty acids, may complement the currently available methods used to diagnose septic arthritis.     

Hemangioma of the synovial membrane of the knee joint

The data on 15 patients with hemangioma of the synovial sheath of the knee joint are reported. It is the author's opinion that surgical removal of the tumor is the most radical method of treatment for hemangiomas. Among 15 patients such procedure was accomplished in 6, in the remainder biopsy or partial removal of the tumor followed by radiotherapy were performed. Late results were followed up in 9 patients.     

Binding of properdin to solid-phase immune complexes: critical role of the classical activation pathway of complement

OBJECTIVE: Our objectives were to assess the clinical and microbiological aspects of septic osteoarthritis in children admitted to our center from 1987 until July 1997 and to determine the sensitivity of ultrasound in this age group. PATIENTS AND METHODS: The medical records of 36 children diagnosed as having septic osteoarthritis of the hip were reviewed retrospectively. The diagnosis had been based on clinical criteria, along with synovectomy and drainage of purulent material from the affected joint. An X-ray and/or ultrasound had been performed when the diagnosis was suspected. RESULTS: Nineteen children were diagnosed during the neonatal period, 8 between the ages of 1 and 12 months and 9 older than one year of age. Mean age at diagnosis was 16.8 +/- 6.2 months (median 29 days, range 6 days to 13 years). The hip was involved in 32 children, the ankle in 3 and the elbow in 1. A microbiological diagnosis was achieved in 22 cases (61%) by culture from blood, CSF, and/or synovial fluid. The most common isolates were Gram positive cocci (S. aureus in 9 cases and coagulase negative Staphylococcus in 3). The diagnostic value of the X-rays was very low (18%). The ultrasound was initially considered abnormal in 64.5% of the patients, with a lower sensitivity in the neonatal period. After a mean follow-up period of 36 months, the outcome was good in 86% of the cases, although three children continue with sequelae. Two preterm infants died due to sepsis associated with the osteoarthritis. CONCLUSIONS: At the time of diagnosis of septic arthritis of the hip, the ultrasound is frequently normal. Due to the poor outcome when there is a delay in surgery, we suggest immediate synovectomy and drainage when there is clinical suspicion of septic arthritis despite an apparently normal ultrasound.     

Evaluation of sodium hyaluronate therapy in induced septic arthritis in the horse

This study was conducted to determine the efficacy of sodium hyaluronate (SH) with antibiotic therapy and joint lavage for reducing acute inflammatory and degenerative changes induced by septic arthritis. Septic arthritis was induced in six adult horses by inoculating the tarsocrural joints with 1 x 10(4) colony-forming units of Staphylococcus aureus. When clinical signs appeared, trimethoprim-sulphamethoxazole (30 mg/kg bodyweight [bwt] daily) and phenylbutazone (4.4 mg/kg bwt sid) were administered and continued until termination of the study (Treatment Day 18). Twenty-four hours post inoculation, all joints were lavaged with sterile lactated Ringer's solution. Following lavage, one joint of each horse was injected with 10 mg of SH, and the contralateral joint served as the control. Sodium hyaluronate treated joints showed significant reductions in lameness, tarsal circumference and synovial fluid protein and WBC concentrations. The synovial membrane of the SH-treated joints contained less cellular infiltrate, less granulation tissue formation and retained a more normal villous structure compared with controls. The total glycosaminoglycan loss from the articular cartilage in the SH treated joints was consistently less than that from the control joints; however, this difference was not statistically significant. Sodium hyaluronate with joint lavage appears to be more beneficial than lavage alone for treatment of septic arthritis.     

Thrombophlebitis in the elderly

Treatment of the elderly patient can be significantly compromised by complications which are less troublesome in younger individuals. In the authors' experience this has been the case with septic thrombophlebitis secondary to intravenous infusion. Thirteen patients over 65 years of age presented with septic thrombophlebitis during the course of hospitalization for a variety of diseases. All infections occurred in an upper extremity site of polyethylene catheter insertion. Twenty-five per cent of patients had proven bacteremia and clinically recorded septicemia, with Staphylococcus aureus as the most common organism. Treatment consisted of either a full course of intravenous antibiotics or more commonly surgical therapy (either incision and drainage or resection of the involved vein). Three patients required extensive procedures including muscle debridement and fasciotomy. The mean hospital stay of 19 days was largely related to thrombophlebitis and not primary disease. There was one mortality. Prevention of this condition by meticulous attention to sites of intravenous infusion and frequent changing of these sites rather than treatment after the fact provides the safest mode of patient care.     

Granzyme B: an essential protease for the inflammatory response

BACKGROUND: The study reported here was performed to investigate morphologic intraocular reactions on the surface of metallic intraocular foreign bodies (IOFB) with scanning electron microscopy. METHODS: Twenty-seven extracted IOFB were investigated. Of these, 22 were situated in the vitreous body; 19 had contact with the retina. Five IOFB had been removed from the anterior segment (control group). The duration of intraocular retention was 6 h to 24 days. Immediately after microsurgical removal the IOFB were fixed, dehydrated, dried, sputter-coated and investigated with a scanning electron microscope. Two IOFB from the vitreous were treated for collagen preservation. RESULTS: Eighteen of 20 intravitreal IOFB showed fibers of fibrin on its surface; 11 of 20 were covered with a homogeneous layer. Within this layer a net of collagen fibers was detectable. A major cellular reaction was observed only on IOFB that injured the retina, pigment epithelium and choroid. CONCLUSIONS: This morphologic study shows that: (1) a fibrin net develops in the vitreous around intravitreal IOFB; (2) depositions of amorphous material into the spaces of this net lead to dense coverage of the IOFB; (3) cellular reactions are not condition for the development of this coverage; (4) laceration of the retina induces a fibrocellular response.     

Infection after total elbow arthroplasty

The purpose of this study was to review our experience with the treatment of twenty-five infections (in twenty-five patients) after total elbow arthroplasty and to examine indications for salvage of the prosthesis compared with those for resection arthroplasty. The patients were divided into three groups on the basis of treatment. Group I comprised fourteen patients who were managed with multiple, extensive irrigation and debridement procedures with retention of the original components. The primary indication for retention of the prosthesis was evidence that it was well fixed as determined both radiographically and intraoperatively. Group II comprised six patients who had removal of the prosthesis and debridement followed by immediate or staged reimplantation. Group III comprised five patients who were managed with resection arthroplasty. The infection was successfully eradicated in seven of the fourteen elbows that had salvage of the prosthesis with irrigation and debridement. The results were strongly dependent on the causative organism; attempts at debridement failed in the four elbows that were infected with Staphylococcus epidermidis compared with three of the ten that were infected with another organism. Four of the six patients in Group II had successful reimplantation of a prosthesis; in three, the infection had been caused by an organism other than Staphylococcus epidermidis. Only one of the three patients who had a Staphylococcus epidermidis infection had a successful reimplantation. None of the five patients who had a resection arthroplasty had signs of infection at the latest follow-up examination. We concluded that salvage of the prosthesis with extensive irrigation and debridement in the presence of an infection about the elbow can be reasonably successful if the infecting organism is not Staphylococcus epidermidis and if the components are well fixed. When removal of the components is warranted, staged reimplantation can also be highly successful when the infecting organism is not Staphylococcus epidermidis. However, the repeated operations necessary to retain a prosthesis and the high rates of complications seen with this approach--and the relatively good rates of satisfaction obtained with resection arthroplasty--suggest that resection arthroplasty remains the procedure of choice in medically frail patients or in patients for whom function of the elbow is less of a concern.     

Adjunctive use of a neodymium:yttrium-aluminum garnet laser for treatment of pythiosis granulomas in two horses

Pythiosis, caused by Pythium insidiosum, is a common cutaneous granulomatous disease in horses. Surgical removal is the most common treatment; however, high rates of recurrence have been reported. Results of examination of 2 horses with pythiosis granulomas in which a neodymium:yttrium-aluminum-garnet laser was used to photoablate the bed after removal are reported. The mass had not recurred in either horse 1 year after surgery. Photoablation results in collateral thermal necrosis and may kill organisms that have infiltrated surrounding tissues, thus reducing the risk of recurrence.     

Initial results of a new access device for hemodialysis technical note

A new subcutaneous device (Dialock; Biolink Corp., Middleboro, MA) provides vascular access to patients who currently require hemodialysis (HD). The device consists of a port-like valve, implanted subcutaneously below the clavicle, which provides a linear flow passage to two catheters placed in the right atrium via the jugular vein. The valve is accessed percutaneously with needle-cannulas that functionally convert the device to twin catheters for connecting the patient to the HD lines. Interdialytic patency is maintained using a standard heparin lock. The device has been implanted in 10 outpatients under local anesthesia, with almost immediate use for HD (median, 3 days) and has functioned successfully for more than 6 months (mean +/- SD, 4.0 +/- 1.7; > 400 dialysis sessions). Blood flows over 300 ml/min were consistently achieved (average, 320 +/- 50) with venous and arterial pressures of 197 +/- 42 mmHg and -241 +/- 31 mmHg, respectively. After 40 patient-months, condition of the needle puncture sites remains satisfactory. Four systemic infections have occurred in three patients; all have resolved without the need for device removal. There have been no infections at the puncture sites. One patient whose heparin lock was not changed for 23 days (for reasons unrelated to the device) required fibrin sheath stripping of his catheters. Patient and nurse acceptance has been excellent. The device may offer substantial improvement over conventional devices for HD access.     

Treatment of infectious arthritis of the radiocarpal joint of cattle with gentamicin-impregnated collagen sponges

Gentamicin-impregnated collagen sponges were used successfully in the treatment of chronic septic arthritis of the radiocarpal joint in two cattle. Both animals were moderately to severely lame and refractory to systemic antibiotics, and one of them was refractory to joint lavage and local antibiotics. The clinical diagnosis was confirmed by radiography and arthrocentesis. Arthroscopy was performed under general anaesthesia and, after debridement and lavage of the joint, gentamicin-impregnated collagen sponges were placed intra-articularly. Synovial fluid was sampled at 10 and 20 days after surgery and radiographs were taken three months (case 1) and two months (case 2) after surgery. The infection was eliminated from both animals and they recovered without residual lameness.     

The disappearance of birth: language versus reality in modern childbirth

Knowledge and technology for cardiovascular disease are growing at a rapid rate. Interventional cardiology offers patients several options of therapy, including percutaneous transluminal coronary angioplasty, directional coronary atherectomy, and percutaneous transluminal coronary rotoblator angioplasty procedures. Patients with these procedures require femoral intra-arterial sheath insertion and postprocedure management of these sheaths. The best practice for sheath removal is a controversial issue. This article describes a study conducted at Presbyterian Hospital in Charlotte, North Carolina, comparing the use of manual/mechanical versus mechanical compression technique for sheath removal. Subjects included patients who had one of the previous procedures performed. Subjects were randomly assigned to one of two study groups: manual/ mechanical or mechanical compression. Variables such as size of sheath, anticoagulants, antiplatelets, and flat time after sheath removal were examined. The outcome measure reported was the development of a groin complication. Results indicated no significant difference in groin complication. As a result, practice at Presbyterian Hospital changed to mechanical compression for removing sheaths.     

Clinicopathologic correlation of localized retinal pigment epithelium debridement

PURPOSE: To characterize changes in the retina, retinal pigment epithelium (RPE), and choriocapillaris with fluorescein angiography (FA) and histology after hydraulic or abrasive RPE debridement in 26 domestic short-haired cats. METHODS: Hydraulic debridement was produced by injecting balanced salt solution forcefully into the subretinal space. For abrasive debridement, RPE were removed with a silicone-tipped cannula after creating a localized retinal detachment. The FAs were performed after surgery, and tissue was prepared for light microscopy (LM) and scanning electron microscopy (SEM). RESULTS: Sixty-seven blebs were examined by FA 1 hour after surgery, and RPE debridement was confirmed by SEM or LM in 15 blebs from 10 animals. Hyperfluorescence and variable central fluorescein leakage were seen 1 week after surgery in 52 of 53 blebs (which includes all 27 blebs from the 1-week timepoint and 26 of 29 blebs from the 4-week timepoint that were studied by FA 1 week after surgery). Choriocapillary filling delays were seen in no hydraulic debridements, but in 11 of 14 abrasive blebs, especially in areas showing leakage late in the angiogram. In 1 of 13 hydraulic and 12 of 14 abrasive debridements, areas of late dye leakage had no RPE with outer retinal degeneration. At the 4-week timepoint, 1 of 17 hydraulic and 10 of 12 abrasive debridements had foci of delayed or absent choriocapillary perfusion by FA, with degenerated outer retina, no RPE, and choriocapillary atrophy by histologic analysis. CONCLUSIONS: Abrasive debridement is more commonly associated with abnormal FAs and with incomplete RPE repopulation, choriocapillaris atrophy, and outer retinal degeneration than is hydraulic debridement. This clinicopathologic study may give insight into FA interpretation after choroidal neovascular membrane removal in human patients.     

Primary synovial chondromatosis of the ankle. A case report

A case of primary diffuse synovial chondromatosis of the ankle with long-term follow-up is reported. Trauma is implicated as a precipitating factor. This unusual, distinctive synovial neoplasm presents readily recognizable pathological features (Fig. 2). Specific diagnostic criteria are presented. The differential diagnosis of primary synovial chondromatosis includes secondary reactive synovial chondromatosis and synovial chondrosarcoma. The usual sources of osteochondritic loose bodies, on the other hand, are traumatic joint disruption, osteoarthritis, and infectious disorders. Acute primary synovial chondromatosis is adequately treated by removal of the loose bodies and synovectomy. Postoperative prognosis is dependent on the stage of the disease at the time of surgery. In this acute case, the patient had minimum impairment, and ankle roentgenograms twenty years after the arthrotomy were normal (Fig. 3).     

Endoscopic treatment of suspected infectious intertubercular bursitis in a horse

A 9-year-old gelding was evaluated because of a 30-day history of mild intermittent left forelimb lameness. The only detectable abnormality was mild atrophy of the musculature of the proximal portion of the left forelimb. The cause of the lameness could not be determined. The horse was discharged from the hospital, but was reexamined 6 weeks later because of worsening of the lameness. At that time, the horse resisted flexion and extension of the left shoulder joint, and results of evaluation of an ultrasound-guided aspirate of fluid from the intertubercular bursa were suggestive of infection. Endoscopic examination of the bicipital bursa revealed synovial hypertrophy, particularly in the distal aspect of the bursa. The bursa was lavaged, and a synovial resector was used to remove inflamed synovium. The horse recovered and was healthy 4 months later. In this horse, endoscopy allowed adequate examination of the intertubercular bursa and was not technically difficult.     

Endoscopic fibrin gluing of a pancreatic duct fistula following acute pancreatitis

HISTORY AND CLINICAL FINDINGS: A 45-year-old patient was admitted because of frequent attacks of upper abdominal pain after food intake. The pain episodes had started shortly after a bout of acute pancreatitis. Physical examination was unremarkable except for mild pain on palpation of the left lower abdomen. INVESTIGATIONS: Amylase and gamma-glutamyl transaminase activities as well as inflammatory parameters were slightly raised. Ultrasonography was suggestive of a circumscribed area of necrosis in the tail of the pancreas, a finding confirmed on endoscopic retrograde injection of contrast medium, which passed into the necrotic cavity via a fistula. TREATMENT AND COURSE: The fistula failed to close during 12 days of conservative treatment (total parenteral nutrition; 2 g ceftizoxim twice daily; 1 ampoule somatostatin daily). In three sittings during 6 days, 1-2 ml fibrin glue injections were made by endoscopy retrogradely into the fistular passage resulting in its complete occlusion without any further complications. CONCLUSION: A previously treatment-resistant pancreatic fistula can be successfully occluded by injection of fibrin glue by retrograde endoscopy, obviating surgical intervention with subsequent reduction in glandular capacity.     

Antithrombotic therapy after coronary stent placement

Subacute stent thrombosis and hemorrhagic complications due to intensive anticoagulant therapy limit the clinical benefit of coronary stenting. Antithrombotic therapy after coronary stent placement has not been standardized yet. From January 1994 to December 1995 a total of 338 Palmaz-Schatz stents were implanted in 285 patients. Procedural success rate was 98.8%. In the initial period, after stent placement, patients were treated with acetylsalicylic acid (ASA) and warfarin (135 patients, Group A), while subsequently, according to the results of other studies, patients were treated with ASA plus ticlopidine (146 patients, Group B). Two hours after sheath removal, Group A patients were treated with intravenous heparin until therapeutic INR (2.5-3.5) was reached; warfarin was stopped 3 months later. In Group B patients 2 hours after sheath removal a treatment with subcutaneous heparin 25,000 IU/die plus ticlopidine 500 mg/die was started. Subcutaneous heparin was maintained until hospital discharge, ticlopidine was stopped after 1 month and ASA was maintained indefinitely. There were no significant differences in baseline characteristics between the two groups. Most patients had unstable angina and in the majority of cases the stent was implanted due to intimal dissection after balloon dilation. Eleven patients had subacute thrombosis of the stent (3.9%): 9 patients were in Group A (6%) and 2 patients were in Group B (1.3%; p = 0.04). Seven patients (6 in Group A, 1 in Group B) were treated with emergency coronary angioplasty and 3 (2 in Group A, 1 in Group B) with coronary bypass; nevertheless 7 patients (6 in Group A, 1 in Group B) had an acute myocardial infarction. Eight patients (6 in Group A, 2 in Group B) had major bleeding due to a large groin hematoma requiring blood transfusion or vascular surgery. In conclusion, after coronary stenting antithrombotic therapy with ASA plus ticlopidine, as compared with anticoagulant therapy, reduces the incidence of both cardiac events and hemorrhagic complications.     

New developments and applications in quantitative electron spectroscopic imaging of iron in human liver biopsies

The objective of this study was to determine the effects of intra-articularly administered triamcinolone acetonide (TA) in exercised equine athletes with carpal osteochondral fragmentation. Eighteen horses were randomly assigned to each of 3 groups. An osteochondral chip fragment was created in one randomly chosen intercarpal joint of each horse. Both intercarpal joints in the placebo control group (CNT) horses were injected with intra-articular administration (IA) of polyionic fluid. Both joints in the TA control group (TA CNT) horses were treated with 12 mg of TA in the intercarpal joint without an osteochondral fragment, and the opposite intercarpal joint was injected with a similar volume of polyionic fluid. The TA treated group (TA TX) horses were treated with 12 mg of TA in the joint that contained the osteochondral fragment and the opposite intercarpal joint was injected with a similar volume of polyionic fluid. All horses were treated IA on days 13 and 27 after surgery and exercised on a high speed treadmill for 6 weeks starting on Day 14. Horses in the TA TX group were significantly less lame than horses in the CNT and TA CNT groups. Horses in either TA CNT or TA TX groups had lower total protein, and higher hyaluronan, and glycosaminoglycan concentrations in synovial fluid than did those in the CNT group. Synovial membrane collected from subjects in TA CNT and TA TX groups had significantly less inflammatory cell infiltration, subintimal hyperplasia and subintimal fibrosis compared to the CNT group. Articular cartilage histomorphological parameters were significantly better from the TA CNT and TA TX groups compared to the CNT group. In conclusions, results from this study support favourable effects of TA on degree of clinically detectable lameness, and on synovial fluid, synovial membrane, and articular cartilage morphological parameters, both with direct intra-articular administration and remote site administration as compared to placebo treatment. The clinical use of IA administered TA in horses may be therapeutically beneficial in selected cases of osteochondral fragmentation and osteoarthritis.     

Activation of the extrinsic coagulation pathway in patients with severe sepsis and septic shock

OBJECTIVES: To obtain systematic information on the extrinsic coagulation pathway, as well as to investigate the time course of the coagulation abnormalities in sepsis. DESIGN: Prospective observational study. SETTING: General intensive care unit. PATIENTS: Nineteen patients with the diagnosis of severe sepsis or septic shock and nine control patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tissue factor antigen concentration (tissue factor antigen), prothrombin fragment F1+2, thrombin antithrombin III complex, fibrinopeptide A, D-dimer, and antithrombin III concentrations were measured on the day of diagnosis of severe sepsis and septic shock, and on days 1, 2, 3, and 4 after diagnosis. The concentrations of tissue factor antigen, prothrombin fragment F1+2, fibrinopeptide A, and D-dimer were significantly increased in patients with severe sepsis and septic shock compared with control subjects. However, the concentrations of thrombin antithrombin III complex showed no statistical differences between the septic patients and the control subjects. Significantly, low antithrombin III concentrations were observed in the septic patient groups compared with control subjects. With the exception of D-dimer, the concentrations of the hemostatic markers were similar between severe sepsis and septic shock patients. Significant correlations were noted between tissue factor antigen and the disseminated intravascular coagulation score (r2=.236, p< .0001) and the number of dysfunctioning organs (r2=.229, p=.035). CONCLUSIONS: We systematically elucidated coagulation disorders in newly defined sepsis. The extrinsic coagulation pathway is activated in patients with severe sepsis and septic shock. In these patients, enhanced thrombin generation and activation, and fibrin formation were demonstrated when compared with the control subjects. Furthermore, the thrombin generated appears not to be fully neutralized by antithrombin III.     

Effect of fibrin sealant on the integrity of colonic anastomoses in rats with faecal peritonitis

OBJECTIVE: To assess the influence of fibrin adhesive on the healing of colonic anastomoses in rats with and without faecal peritonitis. DESIGN: Controlled study. SETTING: Laboratory for experimental surgery, Erasmus University Rotterdam, The Netherlands. MATERIAL: 120 male Wag/Rij rats. INTERVENTIONS: All rats had a single layer end-to-end anastomosis fashioned with 7/0 polypropylene. Faecal peritonitis was then induced in half of the rats by placement of 200 mg powdered autoclaved rat faeces in the peritoneal cavity near the anastomosis. Rats were allocated to one of four groups (n = 30 in each): 1--control; 2--additional sealing with fibrin glue; 3--peritonitis alone; and 4--peritonitis with fibrin glue. MAIN OUTCOME MEASURES: Body weight, adhesion formation, anastomotic bursting pressure and collagen concentration around the anastomosis on days 2, 4, and 7 in 10 rats from each group. RESULTS: 11 rats died of peritonitis before the experiment was completed. Peritonitis caused increased formation of adhesions and abscesses, with or without fibrin sealant. Bursting pressure at the anastomosis was significantly reduced in peritonitis compared with controls on days 4 and 7, and this was not prevented by fibrin. Sealing of anastomoses resulted in lower bursting pressures on day 4 in control animals. Collagen concentration was significantly reduced in peritonitis with or without fibrin sealant on days 4 and 7, and after fibrin sealing of control anastomoses. CONCLUSION: Faecal peritonitis reduced mechanical strength and collagen concentration of colonic anastomoses, and this was not prevented by additional sealing of the anastomosis with fibrin sealant.