Scapholunate dissociation in the skeletally immature carpus

Scapholunate dissociation is well documented as a condition occurring in adult patients. We report it in a 14-year-old female patient. Persistent wrist pain 9 months after a well healed fracture of the distal radius triggered further investigation. Dynamic clinical and radiological studies demonstrated the instability.     

Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation

Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78 degrees and was corrected to a normal 47 degrees at surgery. The average final scapholunate angle was 72 degrees, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.     

Paresthesias: a practical diagnostic approach

Filarial nematodes are a cause of chronic debilitating diseases in the tropics. A hallmark of filariasis is the marked down-regulation and polarization of host immune responses, yet molecular constituents of parasites causing this state have remained undefined. We describe a 17-kDa antigen (Av17) of the rodent filarial parasite Acanthocheilonema viteae, which shows amino acid homologies to cystatin C, a major cysteine protease inhibitor belonging to family 2 of the cystatin superfamily. Av17 is released by filariae in vitro. Exported molecules of A. viteae worms are shown to markedly suppress mitogen-induced T cell proliferation of mice and jirds. Av17 accounts for 45.5% of this suppressive activity in the murine system. Recombinant Av17 (rAv17), expressed in Escherichia coli, exhibits biological activity as a cysteine protease inhibitor and was used to examine the immunomodulatory effects, rAv17 induces down-regulation of murine T cell responses to mitogens, to T cell receptor cross-linking by anti-CD3 antibodies and to specific antigens, and at the same time up-regulation of interleukin-10. Hence, this filarial cystatin is a likely effector molecule of immunomodulation and a potential target for antifilarial intervention.     

Erectile dysfunction: a practical approach for primary care

Erectile dysfunction has been poorly recognized and managed in the past, due to its taboo aspects and erroneous perceptions of its medical significance. With research, improved understanding has guided a practical approach to its diagnosis and treatment. In most presentations, erectile dysfunction has an organic etiology. Likely causes are often discerned from the clinical history and physical examination. Management may be a simple matter of addressing correctable risk factors, or a direct intervention may need to be pursued. For an individual patient, selection of the "ideal" treatment is based on an understanding of the extent of the problem and consideration of the patient's preferences.     

The emergency physician and patient confidentiality: a review

Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.     

Squamous cell cancer: a practical approach

Cutaneous squamous cell carcinoma (SCC) is the second most common form of skin cancer and is treated frequently by dermatologists. For many years, the level of knowledge regarding treatment of SCC has taken a backseat to the treatment of basal cell carcinoma and malignant melanoma. As dermatologists become more surgically proficient and assume a leading role in the surgical care for cutaneous carcinoma, a thorough knowledge of the appropriate management of SCC is of paramount importance. In particular, it is essential to recognize that, unlike basal cell carcinoma, certain SCC have a significant metastatic potential and require more comprehensive care. This review targets the etiology, pathogenesis, clinical presentation, histopathology, and treatment of SCC. Particular attention is focused on providing appropriate care for SCC and recognizing and arranging appropriate management for high risk SCC.     

Secondary hypertension: a practical diagnostic approach

Secondary hypertension is a relatively uncommon, potentially reversible condition for which physicians should maintain a high index of suspicion. When a patient is found to have elevated blood pressure, a through history should be obtained and a complete physical examination should be performed. Depending on the findings, additional screening and diagnostic studies may be necessary. The most common causes of secondary hypertension are renal parenchymal disease, renovascular disease, coarctation of the aorta, pheochromocytoma, primary hyperaldosteronism, thyroid dysfunction and Cushing's syndrome.     

Anaemia in malaria control: a practical approach

Mortality from malarial anaemia and malarial infection in those who are already anaemic yet have some degree of compensation is now beginning to receive the attention it deserves. It is of particular concern in Africa and especially in young children and pregnant women. The asymptomatic parasitaemia remaining after poor response to full antimalarial treatment may lead to life-threatening anaemia; as drug-resistant strains of the malarial parasite proliferate this is becoming increasingly important. It is now possible to estimate haemoglobin levels, simply, cheaply, easily and safely, using a haemoglobin colour scale which is being developed by the World Health Organization. The potential and practical value of this scale in malaria-control programmes was demonstrated in a small, preliminary trial in 1995. Estimation of anaemia should become an additional parameter in the traditional malariometric survey. Haemoglobin concentrations should also be taken into consideration in the management of malaria patients at the primary-care level, particularly in deciding whether a patient should be referred to an appropriate treatment centre. The accurate prediction of clinical outcome of malaria and anaemia, and indication of the appropriate action (determined by a case-based reasoning device) should be possible in the near future.     

The work of the American emergency physician

OBJECTIVE: To compare gestational age (GA) calculated from oocyte retrieval and from ultrasound measurements in pregnancies after in vitro fertilization (IVF). DESIGN: In a retrospective study of 253 women with singleton and 84 women with twin pregnancies conceived from IVF, GA calculated from the day of oocyte retrieval was compared with GA calculated in the second trimester of pregnancy from ultrasound measurements of biparietal diameter (BPD) and femur length (FL). RESULTS: For singletons, the mean GA calculated from ultrasound measurements was significantly shorter than the mean GA estimated from the day of oocyte retrieval. The mean difference was 1.9 days (SD 3.3; 95% CI 1.5-2.4) if only BPD was used and 2.1 days (SD 2.1; 95% CI 1.6-2.5) if BPD and FL were combined. For twins, the mean GA calculated from ultrasound measurements was also significantly shorter than the mean GA calculated from the day of oocyte retrieval. The mean difference was 1.4 days (SD 2.7; 95% CI 1.0-1.8) if BPD was used and 1.6 days (SD 2.5; 95% CI 1.2-2.0) if BPD and FL were combined. CONCLUSIONS: In IVF pregnancies, term prediction using ultrasound in the second trimester is reliable and may reduce the number of pregnancies subsequently classified as post-term, thus avoiding unnecessary obstetric interventions.     

Social competence and head injury: a practical approach

Social competence assessment and training has long focused on specific skills within the clinical setting. In addition, emphasis has been placed on identifying deficits relative to an arbitrary, often idiosyncratic metric. In this article, we discuss the importance of the principles that underlie communication and which are reflected in the range of behaviours described as 'social competence'. We review methods we have found productive in the training of these principles with persons who have suffered traumatic brain injuries.     

A practical approach for lateral meniscectomy

A variant surgical approach to the lateral meniscus is described in an effort to overcome the difficulties encountered in the region of the anterior horn of this meniscus. The knee is braced in 90 degrees of flexion and the incision is made from the lower lateral side of the patella, extending down and back for 4-5 cm.     

Liver CT: a practical approach to dynamic contrast enhancement

The aim of this study was to establish a practical, simple protocol that reliably produces high quality dynamic incremental computed tomography (CT) of the liver. We reviewed 90 patients randomly allocated into six different protocols. All had preliminary unenhanced scans followed by a dynamic incremental CT of the liver. An initial delay of 30 seconds was used from the commencement of the injection of Iopamiro 370. The groups were: 1. Pump infusion (a) 100 mls at 2 mls/sec scanning inferosuperiorly. (b) 100 mls at 2 mls/sec scanning superoinferiorly. (c) 100 mls at 1 ml/sec scanning inferosuperiorly. (d) 50 mls at 1 ml/sec scanning inferosuperiorly. 2. 40 mls hand injected bolus followed immediately by 60 ml pump infusion at 1.3 mls/sec scanning inferosuperiorly. 3. 50 mls hand injected bolus scanning inferosuperiorly. The parameters recorded were the degree of hepatic parenchymal and hepatic venous enhancement and the aortic--IVC difference at the last slice through the liver, all measured in Hounsfield units. The protocols using 100 mls of contrast produced approximately twice the parenchymal and hepatic venous enhancement compared with those using 50 mls. Approximately 60-90% of examinations using 100 mls produced scans through the entire liver during the bolus or nonequilibrium phase, deemed the most sensitive for the detection of focal lesions, compared with 13-33% of those using 50 mls. Equally satisfactory results were obtained using the relatively inexpensive Biotel power injector preceded by a 40 ml hand injected bolus, compared with using an Angiomat angiography infusion pump.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute monoarthritis: a practical approach to assessment and treatment

A basic approach to the patient presenting with acute monoarthritis includes a careful history, a physical examination and a selected battery of laboratory tests and radiographs. Because of the possibility of septic joint, rapid assessment and treatment are required. The most common causes of acute monoarthritis are trauma, crystals (gout and pseudogout) and infection. The most important cause of acute monoarthritis is infection, which must be excluded through the use of diagnostic joint aspiration and culture of synovial fluid.     

Crack cocaine: A practical treatment approach for the chemically dependent.

Review of book: Crack Cocaine: A Practical Treatment Approach for the Chemically Dependent by Barbara C. Wallace, New York: Brunner/Mazel, 1991, 304 pp., ISBN 0-87630-604-0. Reviewed by Arnold M. Washton. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Statistical procedures for evaluating the practical utility of a moderator approach to prediction.

Describes 3 statistical procedures for evaluating the practical utility of a moderator approach. Each procedure gives tests of significance for the comparison of 3 prediction strategies: (a) using the moderator variable as a basis for subgrouping Ss and computing separate regression equations, (b) using the moderator variable as a predictor variable, or (c) excluding the moderator variable from the prediction model. It is concluded that when job performance is measured along a continuum, the average y score of the selected group (Procedure 1) should be considered. However, when 2 levels of job performance are measured, (e.g., pass-fail grades) then either the number of selection errors (Procedure 2) or the number of selection errors when a selection ratio constraint is present (Procedure 3) should be used. (PsycINFO Database Record (c) 2010 APA, all rights reserved)