Operative management of Haglund's deformity in the nonathlete: a retrospective study

Haglund's deformity, or "pump bump," is a common cause of posterior heel pain. Management of the condition usually consists of nonoperative therapy. This study presents a retrospective study of 65 cases (53 patients), with symptomatic Haglund's deformity in nonathletes (13 male and 40 female), who presented during a 4-year period (1989-1994). Sixty-five percent (39 heels) of these patients failed to respond to nonoperative therapy for an average of 62 weeks, (range, 4-260 weeks). This group of patients went on to operative treatment. Surgical management consisted of excision of the posterior calcaneal tuberosity through a medial longitudinal incision with debridement, reattachment of the Achilles tendon using bone anchors, and 4 weeks of postoperative immobilization. Thirty-nine patients (74%) were contacted for follow-up. The average follow-up period for these patients was 155 weeks, (range, 92-335 weeks). There were 50% excellent results, 47% good results, 3% fair results (1 patient), and no poor results. The Maryland Foot Score for operated heels was an average of 67/100 preoperative and an average of 92/100 postoperative. On unoperated heels the score was an average of 81/100 at first evaluation and an average of 86/100 at final evaluation. Complications included one recurrence of painful prominence, one wound infection, and one incisional neuroma. The outcome of these cases demonstrated that in those patients who fail nonoperative treatment, surgical treatment of Haglund's deformity produces a predictably good surgical result when performed using the technique described.     

Eucapnic voluntary hyperventilation as a bronchoprovocation technique: development of a standarized dosing schedule in asthmatics

A variety of dosing schedules have been reported for the hyperventilation method of broncho-provocation testing. To evaluate the effect of challenge technique on the bronchoconstrictive response, we had 16 subjects perform eucapnic voluntary hyperventilation (EVH) with dry, room temperature gas using four different dosing schedules. The hyperventilation challenge dosages included the following: (1) a target minute ventilation (VE) of 20 x FEV1 for 6 min; (2) a target VE of 15 x FEV1 for 12 min; (3) an interrupted challenge with a target VE of 30 x FEV1 for 2 min repeated 3 times; and (4) a target VE of 30 x FEV1 for 6 min. Challenges 2, 3, and 4 gave identical absolute ventilatory challenges (identical factor FEV1 x minutes) but at different VE dosages or time. Challenges 1 and 4 were of identical length, but different target VE. The mean postchallenge fall in FEV1 was 16.6 +/- 10.9%, 11.0 +/- 8.1%, 19.6 +/- 9.9%, and 26.7 +/- 11.3% for challenges 1, 2, 3, and 4, respectively. The response to an identical EVH challenge (FEV1 x 30 for 6 min) was reproducible when performed on separate days. We conclude that the challenge technique used for hyperventilation testing will have a significant impact on the bronchoconstrictive response and must be taken into account when interpreting study results. Tests may be quantitatively comparable over a narrow range of challenge time and VE. We recommend that a 6-min uninterrupted EVH challenge using dry, room temperature gas at a target VE of 30 x FEV1 be adopted as the "standard" challenge.     

Analysis of factors contributing to success in a program of micromanipulation-assisted fertilization

OBJECTIVE: To determine factors important to clinical success in micromanipulation-assisted in vitro fertilization (IVF). DESIGN: Procedures invoked in two separate series of micromanipulation-assisted IVF cycles, one unsuccessful (series I) and the other successful (series II), were compared in an effort to identify changes that led to clinical success. SETTING: University-based IVF clinic. PATIENTS: In both IVF series involving micromanipulation, patients consisted of infertile couples who fit any of five categories of male-factor related infertility. The female patients underwent controlled hyperstimulation for oocyte retrieval and the oocytes were inseminated normally or were subjected either to partial zona dissection or subzonal sperm insertion to assist fertilization. Results in all groups were compared between the two patient series. RESULTS: In the successful series II, a noticeable improvement in fertilization rate and embryo quality was observed compared with series I. A significant increase in the percentage of patients reaching embryo transfer, the pregnancy rate per transfer, and the pregnancy rate per retrieval were noted in series II; a 25% ongoing pregnancy rate per retrieval was observed overall in this successful group, with "ongoing" defined as manifestation of at least a fetal sac on ultrasound with no detectable problems. Patients with a mixed transfer of embryos derived from manipulated and normally inseminated oocytes had a 75% rate of pregnancy per transfer in series II. Differences between the two series could not be attributed to patient selection or biases in selection of oocytes relegated to micromanipulation. However, oocyte handling, micromanipulation, and culture protocols differed significantly between the two series in that temperature and pH of oocytes was better controlled, and micromanipulation time was minimized in series II. CONCLUSION: Success in micromanipulation depends on maintenance of the oocyte in a stable and supportive environment throughout the micromanipulation procedure. It is also important to minimize trauma to the eggs by performing micromanipulation rapidly and with minimal distortion of the egg. Patients with a poor fertilization rate in standard IVF may experience a substantial increase in the likelihood of pregnancy when micromanipulation-assisted fertilization is performed on some eggs.     

Educated insane: a nineteenth-century psychiatric paradigm

In the 1830s the time-honored notion that excess study could lead to madness underwent a significant change in America. Under the influence of Enlightenment pedagogy and phrenology, influential superintendents like Amariah Brigham and Isaac Ray feared that the "unnatural" overstimulation of children in schools would ruin their development. In the second half of the nineteenth century, as belief in environmental determinism waned and assumptions about what is "natural" changed, this psychiatric etiology was debated; then, overthrown. By the turn of the century, education was thought to aid, not harm, the mentally ill.     

Novel bacterial structures in human blood: cultural isolation

Evidence for the existence of a novel bacteriological system has been obtained from osmotically lysed and filtered human blood (membrane filters with a pore size of 0.22 micronm) placed in special culture media. These blood filtrates gave rise to ordinary bacteria for 71% of the blood specimens processed from diseased humans and for 7% of those from supposedly normal humans. Morphologically, the bacteria resembled streptococcal, staphylococcal, and gram-positive filamentous (cocco-bacillary) forms. Prior to the appearance of bacteria in the media, large and small "dense bodies" were microscopically observed but disappeared when ordinary bacteria were apparent, Cultures of of unlysed blood as conventionally performed were negative. These organisms may represent an adaptation of certain bacteria to life in the blood.     

Fatal G-CSF-induced pulmonary toxicity

Inherited thrombophilia has been suggested as a cause of Legg-Calvé-Perthes disease in up to 75% of patients. This prevalence seems high compared to the prevalence of inherited thrombophilia in other thrombotic disorders (average, 30%). Therefore, we investigated 44 patients with Legg-Calvé-Perthes disease for antithrombin-III, protein-C, and protein-S deficiency and activated protein C (APC) resistance. Three (6.8%) of our patients were positive for APC resistance, and one patient (2.2%) showed deficiency of protein-C activity. Our results suggest that inherited thrombophilia is not associated with avascular necrosis of the femoral head (Legg-Calvé-Perthes disease).     

Enhancement of CsNO3 extraction in 1,2-dichloroethane by tris(2-aminoethyl)amine triamide derivatives via a dual-host strategy

A systematic study of a dual-host system exhibiting pairwise anion/cation separations has been performed for CsNO3 extraction. Tripodal triamides 1-4 and 9 derived from condensation of hexanoic (for 1), octanoic (for 2), decanoic (for 3), lauric (for 4), and p-tert-butylbenzoic (for 9) acid with tris(2-aminoethyl)amine (tren) were used together with tetrabenzo-24-crown-8, a well-known Cs+ cation receptor. By using 5 mM crown ether in the organic phase and 10 mM CsNO3 with 0.1 mM HNO3 in the aqueous phase, tripods 1, 2, and 9 enhance CsNO3 extraction by factors of 2.4, 1.7, and 4.4, respectively (for 50 mM amide concentration), while the corresponding monoamide controls 5-8 derived from n-propylamine (5, 6) or N,N'-dimethylethylenediamine (7, 8) and hexanoic (5, 7) or octanoic (6, 8) acid derivatives gave no significant enhancement under the same conditions. This behavior may be ascribed to nitrate complexation by the triamides, which lowers the overall thermodynamic barrier for the salt transfer to the organic phase. The nitrate binding was confirmed by 1H NMR titration of receptor solutions, using tetrabutylammonium nitrate. Association constants for the formation of the anion-nitrate complexes were found to vary between 33 and 52 M-1 for the more soluble triamides. The synergistic effects for CsNO3 extraction are in reasonable agreement with the values predicted theoretically from the measured association constants. Electrospray ionization mass spectrometry confirmed the predominant formation of 1:1 tripod-nitrate complexes. Monoamide controls gave no evidence of anion complexation.