Does this patient have deep vein thrombosis?

OBJECTIVE: To review the validity of the clinical assessment and diagnostic tests in patients with suspected deep vein thrombosis (DVT). METHODS: A comprehensive review of the literature was conducted by searching MEDLINE from 1966 to April 1997. RESULTS: Individual symptoms and signs alone do not reliably predict which patients have DVT. Overall, the diagnostic properties of the clinical examination are poor; the sensitivity of the clinical examination ranges from 60% to 96%, and the specificity ranges from 20% to 72%. However, using specific combinations of risk factors, symptoms, and physical signs for DVT, clinicians can reliably stratify patients with suspected DVT into low, moderate, or high pretest probability categories of actually suffering from DVT. This stratification process in combination with noninvasive testing, such as compression ultrasonography, simplifies the management strategies for patients with suspected DVT. CONCLUSIONS: Use of a clinical prediction guide that includes specific factors from both the history and physical examination in combination with noninvasive tests simplifies management strategies for patients with suspected DVT.     

A comparative evaluation of halo pin designs in an immature skull model

To design an improved halo pin for use in pediatric patients, three commonly used halo pins were evaluated with a mechanical testing apparatus and segments of prepared fetal calf skull. The pins were driven through the bone segments while the load at the bone-pin interface was measured. New pins were designed with respect to pin tip and flange width and similarly compared. Mean maximum loads to penetration, normalized for bone segment thickness, were 55.6 N/mm for the PMT Corporation pin, 61.5 N/mm for the Bremer pin, and 73.6 N/mm for the Ace pin. Four new, short tipped pins were designed and compared with the Ace pin, and there was no significant difference. Finally, four new pins were designed with varying flange widths. Mean maximum loads, normalized for bone segment thickness, were 68.9 N/mm for the 4.2 mm flange, 72.2 N/mm for the 4.7 mm flange, 92.9 N/mm for the 5.2 mm flange, and 96.4 N/mm for the 5.7 mm flange. The findings of this investigation are clinically important because they may help to explain the variability in the complication rates seen with the use of different halo systems in children. The three halo pins currently on the market have different pin designs, including tip lengths and flange distances, which contribute to the difference in load to penetration for each pin. The new, wide flanged, short tipped halo pin design might decrease the complication rate of halo use in children by providing an improved capacity to resist penetration despite increased loads of application.     

Central nervous system nitric oxide formation in cerebral systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an inflammatory disease in which up to two thirds of the patients present neurological symptoms. The diagnosis of the disease is based on clinical findings and the presence of autoantibodies, and the pathogenesis is unclear. The purpose of this study was to determine if the pathogenesis was partly mediated via nitric oxide (NO) formation. Cerebrospinal fluid (CSF) samples from 15 patients with cerebral SLE were analyzed for the NO metabolites nitrite and nitrate using capillary electrophoresis. The severity of neurological symptoms was scored by dividing the patients into two groups with either mild or moderate/severe CNS involvement. All patients with cerebral SLE showed increased levels of NO metabolites. In CSF, there was a relationship between signs of NO production and clinical results showing that increased levels of nitrite and nitrate were associated with more severe neurological symptoms. These findings may shed new light on the pathogenesis of cerebral SLE, and analysis of nitrate and nitrate may prove to be of value in monitoring the activity of the disease.     

Therapy of dislocated calcaneus joint fracture with the AO calcaneus plate

From August 1992 to March 1997, 66 patients with 71 displaced intraarticular calcaneal fractures were prospectively examined after an operative treatment using an extended lateral approach and the ASIF calcaneal plate followed by early functional postoperative treatment (mean follow-up 25 months, retrieval rate 96%). To classify the type of fracture and to verify the results of reduction and of retention CT scans in the coronal and transverse plane were performed pre- and postoperatively and on the day of assessment. The Zwipp Score was used for clinical evaluation. After fractures with 5 to 8 points according to the calcaneal fracture scale, 97% of the patients had an anatomical or near anatomical reduction of the posterior facet and the clinical outcome in 82% of the patients was graded as good or excellent. In 70% of patients with a fracture rated 9 to 10 points a good reduction was demonstrated and clinically there were 67% good or excellent results. But in the fractures with 11 to 12 points, despite 40% good reductions, the clinical outcome was graded as good in 10% of the patients only. However, if the post-operative displacement of the posterior facet was more than 2 mm no patient had a good result independent of the type of fracture. Due to restoration of the geometry of the most comminuted fracture types and the immediate partial weight bearing secondary soft tissue problems could be minimized without any loss of articular reduction. Anatomical reduction and stable internal fixation together with adequate physical therapy are apparently preconditions but not a guarantee for a good clinical result after displaced calcaneal fractures.     

Effects of estrogen on tight junctional resistance in cultured human umbilical vein endothelial cells

OBJECTIVE: To study the effects of estrogen on transendothelial paracellular permeability in women. METHODS: Human umbilical vein endothelial cells (HUVEC) obtained from women were grown on filters. The paracellular permeability characteristics were determined in terms of changes in the permeability to the polar acid pyranine (Ppyr) and as changes in the transendothelial electrical resistance (RTE). Tight junctional resistance characteristics were assayed by lowering luminal NaCl and measuring the dilution potential, and were expressed as the ratio of monoion mobility uCl/uNa (cation selectivity). RESULTS: Low extracellular calcium and hyperosmolarity increased Ppyr and decreased RTE. The former but not the latter condition abolished the endothelium-specific cation selectivity. Treatment with 10 nM of estradiol-17 beta had no effect on RTE, but it increased the cation selectivity. The effect of estradiol required 1-6 hours' incubation with the hormone; it was dose dependent and saturable, with a median effective concentration of estradiol of 1 nM. Diethylstilbestrol, but not estriol, could mimic the effect of estradiol, and the estrogen receptor antagonist ICI-182, 780 blocked it. CONCLUSION: Cultured HUVEC cells form patent tight junctions. Estrogens increase the cation selectivity across HUVEC cultures. The effect of estrogen may be mediated by an estrogen receptor. These effects may be important for vasculoprotection in cases of sudden changes in ions levels across the capillary wall, such as ischemia or reperfusion.     

Population structure and physiological changes within a hot spring microbial mat community following disturbance

The influence of disturbance on a hot spring cyanobacterial mat community was investigated by physically removing the top 3.0 mm, which included the entire cyanobacterial layer. Changes in 16S rRNA-defined populations were monitored by denaturing gradient gel electrophoresis analysis of PCR-amplified 16S rRNA gene segments. Some previously absent cyanobacterial populations colonized the disturbed areas, while some populations which were present before the disturbance remained absent for up to 40 days. Changes in physiological activity were measured by oxygen microelectrode analyses and by 14CO2 incorporation into cyanobacterial molecular components. These investigations indicated substantial differences between the disturbed and undisturbed mats, including an unexplained light-induced oxygen consumption in the freshly exposed mat, increased carbon partitioning by phototrophs into growth-related macromolecules, bimodal vertical photosynthesis profiles, and delayed recovery of respiration relative to photosynthesis.     

Comparison of measured sleeping metabolic rate and predicted basal metabolic rate in the first year of life

In infants, sleeping metabolic rate (SMR) is used as a proxy for basal metabolic rate (BMR). BMR can be predicted from anthropometry using published equations. Our study was intended to evaluate the ability of these equations to predict measured SMR in infants aged 6 weeks to 12 months. SMR was measured in a mixed longitudinal study using the Douglas bag technique (n = 105). Measured SMR values were compared with BMR predicted from weight (BMR-1) or weight and length (BMR-2). These equations were not successful in predicting SMR in this age group. Percentage error of predicted BMR was related to infant weight (BMR-1: r = 0.26; p < 0.005; BMR-2: r = 0.18; p < 0.06). Alternative logarithmic equations were derived from this study (R = 0.84-0.87; SEE = 0.159-0.168). We conclude that the new equations, relating to contemporary infants, are more suitable but actual measurements remain preferred.     

Suprasellar osteolipoma: case report

BACKGROUND: Osteolipomas are distinguished from other intracranial lipomas by their arrangement of central adipose and peripheral osseous tissues and by characteristically arising in the suprasellar/interpeduncular region. METHODS: We report computed tomography (CT), magnetic resonance imaging (MRI), and pathology findings from this 34-year-old man who underwent surgical removal of this benign lesion. RESULTS: This case displays the distinctive histopathology that has been reported in 13 of 31 (42%) lipomas in this region. In contrast, ossification of lipomas at other intracranial sites is relatively rare. CONCLUSIONS: Ossification should be expected in many suprasellar/interpeduncular lipomas, and osteolipoma should be included in the radiologic differential diagnosis of fat-intensity masses with calcification in this region.