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This multicenter trial examined the efficacy and safety of oxcarbazepine in the treatment of bipolar disorder in children and adolescents.A total of 116 outpatients 7 to 18 years of age with bipolar I disorder, manic or mixed, were recruited at 20 centers in the United States and randomly assigned to receive 7 weeks of double-blinded, flexibly dosed treatment with oxcarbazepine (maximum dose 900-2400 mg/day) or placebo. The primary efficacy measure was the mean change from baseline to endpoint in the Young Mania Rating Scale (YMRS), using the last-observation-carried-forward method.Oxcarbazepine (mean dose=1515 mg/day) did not significantly improve YMRS scores at endpoint compared with placebo [adjusted mean change: oxcarbazepine, -10.90 (N=55); placebo, -9.79 (N=55)]. Dizziness, nausea, somnolence, diplopia, fatigue, and rash were each reported in at least 5% of the patients in the oxcarbazepine group with an incidence at least twice that of the placebo group. The majority of adverse events were mild to moderate and occurred during the titration period. Eleven patients (19%) in the oxcarbazepine group discontinued the study because of adverse events, compared with two (4%) in the placebo group.Oxcarbazepine is not significantly superior to placebo in the treatment of bipolar disorder in youths. While the overall adverse event profile was similar to that reported for patients with epilepsy, the incidence of psychiatric adverse events for both the oxcarbazepine and placebo groups was higher than that reported for the epilepsy population.

Follow-up after treatment with the Ponseti method is important because of the known association be- tween lack of brace wear and recurrence. This study was designed to ascertain factors associated with patients who did not return for the recommended follow-up versus those who did.Between January 1, 2000, and December 31, 2009, 222 patients were treated for idiopathic clubfoot at the New York Ponseti Clubfoot Center at NYU Hospital for Joint Diseases, of which 93 patients (143 feet) were potentially available for follow-up (i.e., ≤ 7 years of age, had not moved, or transferred care to another institution). Attempts were made to contact all patients' parents or guardians by telephone to respond to a survey, which included questions from the Disease Specific Instrument and the Oxford Ankle Foot Questionnaire. Forty-two of the 93 patients (45%) responded. The responder group, those who answered the survey, was compared to the group of non-responders. The responder group was further divided into a returning group (35 out of 42, 83%) and a lost to follow-up group (17%, not followed-up in over a year). A chart review was performed for demographics, Dimeglio/Bensahel and Catterall/Pirani scores, and treatment.When comparing the responder and non- responder groups, the responder group had significantly lower (p0.05) Catterall/Pirani scores at initial visit than the non-responder group (5.0 versus 5.5), but otherwise these two groups were similar. Among the responders, 91% or more were very satisfied/satisfied with status and appearance of foot in both lost to follow-up and returning groups. The lost to follow-up group was significantly (p0.05) older at the time of the survey (5 years versus 3.7 years), required significantly fewer casts (4.4 versus 5.5), had significantly lower Dimeglio/Bensahel scores at time of the start of foot adbuction orthoses (FAO) (0.0 versus 2.0), and trended toward greater footwear limitations (p = 0.051) compared with the returning group.Number of casts, severity scores at the start of FAO, and footwear limitations are possible factors to differentiate between lost to follow-up and returning patients. This information may help other clubfoot centers provide vigilant outreach and therefore decrease recurrence rate.

This paper presents methods to accurately predict loop gains in dc-dc converters when arbitrary impedance is added to the input of a dc-dc converter. A step-by-step procedure is presented to implement the methods, which can also be developed in a CAD tool. Online evaluation is also presented. Experimental data verify the proposed approach.

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

Operative correction for infantile and adolescent tibia vara has been described using both external and internal fixation. Gradual correction using a circular fixator offers the advantage of accurate coronal, sagittal, and axial plane correction without significant soft tissue dissection. This study evaluated the use of six-axis deformity analysis and the Taylor Spatial Frame (TSF) for the correction of tibia vara. Nineteen patients (22 tibias), 6 with infantile and 13 with adolescent tibia vara, underwent correction with TSF. On the basis of mechanical axis correction, 21 of 22 tibias were corrected within 3 degrees of normal. Using Schoenecker's criteria, all patients achieved good results (no pain

Cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy with mitomycin C for peritoneal carcinomatosis is used as a palliative treatment for a variety of malignancies. The purpose of this study was to measure the quality of life (QOL) of survivors (3 years) after treatment.Patients were interviewed by telephone with the following tools: (1) the Functional Assessment of Cancer Therapy-Colon (FACT-C), (2) the Short Form of the Medical Outcomes Study Questionnaire, (3) the Center for Epidemiologic Studies-Depression scale, (4) the Life Appreciation scale, (5) the Psychosocial Concerns Questionnaire, and (6) performance status rating.Seventeen (10 appendix, 5 large intestine, 1 ovarian, and 1 peritoneum) of 109 patients were interviewed from 3.1 to 8.0 years after treatment. Ten patients (62.5%) described their health as excellent or very good. No limitations on moderate activity were reported in 94% of cases. Paired t-tests were used to compare 10 patients who had baseline QOL data. FACT mean difference scores and P values (positive difference scores indicate improved QOL) were functional well-being: 4.9, P =.01; physical well-being: 3.3, P =.05; and FACT total: 14.3, P =.02.Long-term survival with good QOL is possible for selected patients with peritoneal carcinomatosis after cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy.

Twenty patients with Type II clubfeet were evaluated an average of 3.1 years after complete surgical soft tissue release. A pinned group had fixation of the talonavicular and calcaneocuboid joints and a non-pinned group had no fixation. The control group consisted of 10 children without foot ailments. Radiographic measurements of talocalcaneal and talus-first metatarsal angles and frequencies of dorsal and medial navicular subluxation were not different for the two treatment groups. Foot progression angle was not significantly different for the two treatment groups, but was significantly different between all clubfoot patients (3.6 degrees of in-toeing) and the control group (5.0 degrees of out-toeing). Tourniquet time was significantly greater for the pinned than for the non-pinned group, but the duration of surgery was similar. Similar radiographic and gait measurement findings suggest that clubfoot surgery with and without percutaneous fixation have comparable outcomes.

The purpose of this study was to determine the early factors associated with the need for surgical interventions in patients with idiopathic clubfoot treated with the Ponseti method.All patients with idiopathic clubfoot treated with Ponseti method at our institution with3 years of follow-up were evaluated. Age at presentation, history of previous treatment, number of casts used, need for percutaneous Achilles tenotomy (PAT), age of initiation of foot abduction orthosis (FAO), compliance with FAO, and need for additional casts were recorded. Dimeglio/Bensahel and Catterall/Piriani scores were recorded at initial presentation, at initiation of FAO, at 1, 2, 3 years of follow-up, and at the most recent follow-up.Since 2000, 86 patients (134 feet) had3 years of follow-up from time of initial presentation, and 43 of these feet (32%) had undergone surgery beyond a PAT. Patients who were noncompliant with the FAO were 7.9 times more likely to need surgery than those who were compliant [confidence interval (CI), 2.8-22.0; P0.001]. Female patients were 5.4 times more likely to need surgery than male patients (CI, 1.8-16.6; P=0.003). For every 1 point increase in Dimeglio/Bensahel score at presentation, patients were 1.3 times more likely to need surgery (CI, 1.0-1.5; P=0.033). For every 1 point increase in Dimeglio/Bensahel score at initiation of the FAO, patients were 1.5 times more likely to need surgery (1.1-2.0, P=0.005). Moreover, for each additional cast required before the initiation of the FAO, patients were 1.5 times less likely to need surgery (CI, 1.1-2.7; P=0.030). No other variable significantly contributed to predicting the need for surgery.There are early factors that can be used to predict increased risk for surgical intervention in patients undergoing treatment for idiopathic clubfoot. Female patients and those patients with higher Dimeglio/Bensahel scores at presentation and at initiation of the FAO are at increased risk for needing surgical intervention. Noncompliance with the FAO is associated with the highest risk for surgical intervention.Level III.

There is limited information about colorectal cancer (CRC) screening trends in high-risk groups, including the black, obese, diabetic, and smoking populations. For this study, the authors evaluated national CRC screening trends in these high-risk groups to provide insights into whether screening resources are being appropriately used.This was a nationally representative, population-based study using the Behavioral Risk Factor Surveillance System from the Centers for Disease Control. Data analysis was performed using bivariate analyses with weighted logistic regression.In the general population, CRC screening increased significantly from 59% to 65% during the years 2006 to 2010. The screening prevalence in non-Hispanic blacks was 58% in 2006 and 65% in 2010. Among obese individuals, the prevalence of up-to-date CRC screening increased significantly from 59% in 2006 to 66% in 2010. Screening prevalence in individuals with diabetes was 63% in 2006 and 69% in 2010. The CRC screening prevalence in current smokers was 45% in 2006 and 50% in 2010. The odds of CRC screening in the non-Hispanic black population, the obese population, and the diabetic population were higher than in non-Hispanic whites, normal weight individuals, and the population without diabetes, respectively. Current smokers had significantly lower odds of CRC screening than never-smokers in the years studied (2006: odds ratio [OR], 0.71; 95% confidence interval [CI], 0.66-0.76; 2008: OR, 0.67; 95% CI, 0.63-0.71; 2010: OR, 0.69; 95% CI, 0.66-0.73).The prevalence of CRC screening in high-risk groups is trending upward. Despite this, current smokers have significantly lower odds of CRC screening compared with the general population.

Between 1994 and 1998, seven adolescents underwent hip arthrodesis with the use of an external fixator. Mean time of follow-up was 24.0 months after surgery. The duration of fixation and time to fusion were 6.6 months (range, 5-9.5 months) and 8.0 months (range, 5.2-15 months), respectively. At most recent follow-up, there was a significant improvement in the mean modified Harris hip score, in which the maximum score is 91 points after omitting 9 points for hip range of motion and deformity, from 25.7 before surgery to 66.7 after surgery (p < 0.01). The advantages of this procedure include (i) the ease and accuracy of obtaining the proper position for fusion, (ii) the ability to lengthen the affected leg at the same time, (iii) the diminished likelihood of compromising future hip operations, and (iv) the ability to ambulate and bear weight throughout the treatment course. We recommend this method of hip arthrodesis with external fixation for patients with intractable hip pain necessitating this procedure.

Purpose: The purpose of the study was to identify those characteristics of congenital tibial dysplasia (CTD) that portend the worst prognosis, including the probable failure of all surgical attempts to achieve union. Clear identification/ classification of this select population of cases could add earlier consideration of relevant treatment options. Method: While several classification systems for CTD exist, the Crawford classification was used to review the literature and our hospital cases (6) to examine the relationship between case characteristics, treatment, and outcome. Results: An atypical variation of Crawford’s type IIC was identified, herein referred to as type IID, that was characterized by early onset, frank pseudoarthrosis, and deformity of the distal-one third of the tibia and fibula. As well, these patients underwent failed multiple surgeries and numerous type treatments over time without good functional outcome and with prolonged physical difficulties. Conclusion: The cases that fall into this newly defined category (IID) of the Crawford classification for CTD are best treated with early amputation rather than repeated attempts to gain union. Significance: Amputation for patients with congenital tibial dysplasia (congenital pseudoarthrosis of the tibia) that are identified as type IID cases and carry the characteristics for a bad prognosis, provides better functional results than repeated surgeries, even when union is achieved. The family should be warned from the beginning that a stable union is unlikely in these cases. Amputation should be offered as a primary or an early option to the family with full disclosure of the long-term advantages and disadvantages of all therapeutic paths.

An efficient regenerative life Support system for manned base cannot be conceived without biological processes. Therefore since the 1960's, numerous projects have been initiated to close, as far as possible, the biological loop. Based on the selected concepts (i.e. carbon and/or nitrogen cycles, microbial organisms and/or higher plants) mathermatical models have been studied and built. Unfortunately, to our knowledge these robust models do not take into account the effects of the space environment (i.e. reduced gravity, radiation,…). In the past, a large number of scientific studies has been performed to understand these effects but only a few of them have tried to quantify them. In this paper we present a very simplified concept of an ecosystem. Its objectives, which are compatible with a non-pressurised mission, are on one hand to quantify microbial kinetics and on the other hand to demonstrate the validity of several technologies and technical concepts.

Salter-Harris type III fractures of the proximal humerus are rare injuries. We report a Salter-Harris type III anterior fracture-dislocation of the proximal humerus in a 10-year-old boy that was open reduced and internally stabilized. A bone scan performed during the initial hospitalization and at 2-year follow-up revealed devascularization and subsequent revascularization of the humeral head. At 2-year follow-up, the patient had full motion of the shoulder, no pain, and arm strength equal to that of the contralateral side. Four cases of Salter-Harris type III fractures of the proximal humerus have been previously reported; good early clinical outcomes were obtained in all. Despite devascularization of the epiphyseal fragment, excellent clinical outcomes may result.

BACKGROUND The Ponseti method of idiopathic clubfoot treatment involves a series of weekly casts, a percutaneous Achilles tenotomy if needed, followed by wearing a foot abduction orthosis (FAO). Gross motor development of children with idiopathic clubfoot has not been examined. The purposes of this study were to determine the ages of achievement of gross motor milestones in children with clubfoot treated with Ponseti method and to compare those ages with historical normative developmental data. METHODS In this prospective study, 51 children with idiopathic clubfoot who had their first cast applied when ≤90 days old, were full-term with no other orthopaedic conditions or previous clubfoot treatment, and were compliant with wearing FAO were enrolled. Parents were interviewed repeatedly to acquire the ages of achievement of 8 gross motor milestones. RESULTS Fifteen children were excluded for reasons such as noncompliance with FAO, and not returning for follow-up. Thirty-six children, mean age of 15.2 days at first casting, achieved rolling prone to supine at a mean age of 5.1 months, rolling supine to prone at 5.1 months, sitting without support at 6.6 months, crawling on stomach at 7.1 months, crawling on hands and knees at 8.6 months, pull-to-stand at 9.0 months, cruising at 10.2 months, and ambulating independently at 13.9 months. When compared with previously published values for unaffected children, the mean ages of achievement for 6 of 8 milestones were significantly greater (P

A rare case of a complete fracture-separation of the proximal radial epiphysis is described in a pediatric patient. A further complicating factor is the delay in diagnosis that may worsen prognosis. An emphasis on early detection by physical examination and imaging studies, as well as consideration of treatment options, are presented.

Background Major depressive disorder is a prevalent, disabling, and often chronic or recurrent psychiatric condition. About 35% of patients fail to respond to conventional treatment approaches and are considered to have treatment-resistant depression (TRD). Objective We compared the safety and effectiveness of different stimulation levels of adjunctive vagus nerve stimulation (VNS) therapy for the treatment of TRD. Methods In a multicenter, double blind study, 331 patients with TRD were randomized to one of three dose groups: LOW (0.25 mA current, 130 μs pulse width), MEDIUM (0.5–1.0 mA, 250 μs), or HIGH (1.25–1.5 mA, 250 μs). A highly treatment-resistant population (>97% had failed to respond to ≥6 previous treatments) was enrolled. Response and adverse effects were assessed for 22 weeks (end of acute phase), after which output current could be increased, if clinically warranted. Assessments then continued until Week 50 (end of long-term phase). Results VNS therapy was well tolerated. During the acute phase, all groups showed statistically significant improvement on the primary efficacy endpoint (change in Inventory of Depressive Symptomatology-Clinician Administered Version [IDS-C]), but not for any between-treatment group comparisons. In the long-term phase, mean change in IDS-C scores showed continued improvement. Post-hoc analyses demonstrated a statistically significant correlation between total charge delivered per day and decreasing depressive symptoms; and analysis of acute phase responders demonstrated significantly greater durability of response at MEDIUM and HIGH doses than at the LOW dose. Conclusions TRD patients who received adjunctive VNS showed significant improvement at study endpoint compared with baseline, and the effect was durable over 1 year. Higher electrical dose parameters were associated with response durability.

This article discusses the unique contribution of MR imaging to the evaluation of selected pediatric disorders of the ankle and foot. MR imaging is helping to unravel the complex congenital malformation of talipes equinovarus. It is the study of choice for the examination of intraarticular abnormalities such as Trevor's disease. The MR imaging staging of osteochondritis dissecans and delineation of a tarsal coalition have shown great promise in guiding surgical management of these abnormalities.

The data concerning changes in the characteristics of hypertensive leg ulcers (HLU) were taken from open studies in a small patient cohort. The aim of this study was to describe the epidemiological characteristics and to identify prognostic factors for healing in a prospective cohort of 59 patients presenting HLU.The cohort comprised patients included in a randomized, double-blind, controlled study published elsewhere; the patients were receiving becaplermin gel (Regranex(®)) or Duoderm Hydrogel™ once daily for eight weeks for the most recent wound. Total follow-up was 12 weeks.The epidemiological analysis was performed for 59 consecutive patients randomized in 17 dermatology departments. Mean patient age was 74.5 ± 9 years and 61% were female. Mean wound duration was 11.1 ± 9 weeks and median wound area was 16 cm(2) (q1; q3: 8; 25.5). Among, 94.9% of patients had hypertension and 39.7% were diabetic. A homolateral peripheral pulse was present in 91.5% of patients. At the end of follow-up, complete wound healing was obtained in 30.5% of the patients. In univariate analysis, neither the foregoing criteria nor the treatment group were significantly associated with healing during the study.This study confirms female predominance, old age, prevalence of diabetes and delay in the diagnosis of HLU. The prognosis for healing does not appear to be dependent on wound duration, wound area or the presence of moderate peripheral arterial disease, doubtless because this condition progresses by episodes of flare-up and under specific conditions.

The Ponseti technique involves sequential clubfoot correction by abduction, supination, and finally dorsiflexion. Although shown to be effective, correction progression has not been examined. The Dimeglio/Bensahel classification system was used to analyze heel equinus, varus, midfoot rotation, adduction, posterior crease, medial crease, and cavus initially and after each casting. From 2000 to 2008, 123 patients (185 feet) with idiopathic clubfeet, aged below 60 days, without prior treatment were grouped by number of casts required. Successive castings achieved goals of reducing cavus and medial crease first, then gradually correcting midfoot rotation, adduction, and heel varus. Unexpectedly, heel equinus improved simultaneously with midfoot variables, as well as with final casting.

Web-based interventions for weight control could promote more-widespread dissemination of weight-loss opportunities; however, they remain limited in effectiveness. Incorporating weight-control practices used by individuals with long-term weight-loss success ("positive deviants") may improve the efficacy of web-based weight control interventions.To evaluate the efficacy of AchieveTogether, a web-based weight-loss intervention for adults based on user-generated weight-loss strategies from successful weight losers.In 2009-2010, participants were randomized to either a 12-week web-based intervention, AchieveTogether, or a wait-list control condition.100 overweight or obese adults participated in the study.AchieveTogether was designed to help individuals implement weight control practices used by others who successfully lost and maintained weight.The primary outcome was change in weight. Secondary outcomes included blood pressure, daily caloric intake, quality of life, and use of weight control practices. ANCOVA, with adjustment for baseline values on outcome measures, was used to assess differences between groups in primary and secondary outcomes. Statistical analyses were conducted in 2010-2011.Most participants were women (69.7%) and white (90.8%), with a mean age of 50.3 years and baseline BMI of 33.2; 88% completed post-program assessments. Mean weight loss among intervention participants was -1.4 kg (95% CI= -2.2, -0.5), compared with a mean weight gain of 0.6 kg (95% CI= -0.3, 1.4) in control participants (p0.01).User-generated weight-loss practices from "positive deviants" could promote weight control in web-based interventions; however, further research is needed to improve program efficacy.This study is registered at ClinicalTrials.govNCT00709501.

Trusts are difficult to design in the best of circumstances. They must maneuver through requirements and restrictions from several disciplines and demand great care in their wording and fiduciary management. This article explores the implications of such issues as business judgment and trustee impartiality for the use of trusts by family business owners.

The new technique of leg lengthening and deformity correction with different types of external fixators has given the orthopedic surgeon a tool that allows correction of very difficult deformities and leg length discrepancies of the lower extremity. Dissemination of this knowledge has demonstrated that there are many associated problems with these techniques: one of which is resulting equinus deformity after correcting the tibia. The shortened soleus-gastrocnemius-achilles tendon complex is the cause of this deformity. Several techniques are suggested on avoiding this complication and how to correct it once it has occurred.

Twenty-nine children underwent 36 Ilizarov procedures for a variety of limb deformities. We present the results in 11 patients, six with leg length discrepancies and five with achondroplasia, who underwent lengthening procedures using the Ilizarov method. Lengthening was accomplished in 15 of the 16 procedures (93%). Average increase in femur length was 10 cm (32%), in tibial length 7.5 cm (30%), in humerus length Il cm (40%), Eleven complications occurred. The most common were pin tract infections (4), joint contractures (2), transient nerve injury (4), premature consolidation (5), and three fractures of the regenerated bone. The complication rate was as high as in other methods, but with the Ilizarov apparatus longer segments of bone were lengthened and more complex deformities were treated. The number of complications were lessened as experience was gained.

Serious central nervous system injuries after lightning strikes are fortunately rare. Optimal neurological and neurosurgical management has not been firmly established. We describe the successful neurological resuscitation and critical care management using intracranial pressure monitoring of an adult who sustained a lightning strike. The role of intracranial pressure monitoring in this setting is discussed.

The authors determined associated cardiac arrest and death rates in cases from Canada and the United States as reported to The North American Malignant Hyperthermia (MH) Registry and analyzed factors associated with a higher risk of poor outcomes.The authors searched the database for AMRA (adverse metabolic/musculoskeletal reaction to anesthesia) reports with inclusion criteria as follows: event date between January 1, 1987, and December 31, 2006; "very likely" or "almost certain" MH as ranked by MH Clinical Grading Scale; location in Canada or the United States; and one or more anesthetic agents given. The exclusion criterion was a pathologic condition other than MH independently judged by the authors. Severe MH outcomes were analyzed as regards clinical history and presentation, using Wilcoxon rank sum tests for continuous variables and Pearson exact chi-square tests for categorical variables. A Bonferroni correction adjusted for multiple comparisons.Of 291 events, 8 (2.7%) resulted in cardiac arrests and 4 (1.4%) resulted in death. The median age in cases of cardiac arrest/death was 20 yr (range, 2-31 yr). Associated factors were muscular build (odds ratio, 18.7; P = 0.0016) and disseminated intravascular coagulation (odds ratio, 49.7; P0.0001). Increased risk of cardiac arrest/death was related to a longer time period between anesthetic induction and maximum end-tidal carbon dioxide (216 vs. 87 min; P = 0.003). Unrelated factors included patient or family history, anesthetic management, and the MH episode.Modern US anesthetic practice did not prevent MH-associated cardiac arrest and death in predominantly young, healthy patients undergoing low- to intermediate-risk surgical procedures.

Four deformed feet in three patients were corrected completely using the new limited intervention technique of Ilizarov. One foot in the younger patient was corrected by soft tissue distraction only. In three feet in the older patients V osteotomies were needed to initiate the distraction. Two complications occurred: herpes simplex infected two of the osteotomy sites, which were treated successfully with local treatment. The detailed method and indications are outlined.

Closed head injuries account for a significant number of catastrophic sports-related injuries. These injuries may result from virtually any contact, competitive, or individual sports activity. Brain lesions ranging in severity from simple concussions to life-threatening intracranial hematomas are all too common. A number of measures are discussed to effect a reduction in the frequency and severity of such injuries.

Idiopathic periosteal hyperostosis with dysproteinemia has been recognized as a separate entity since its description by Goldbloom and colleagues in 1966. Very few cases have been reported to date, and the radiologic literature is very scanty regarding this syndrome. This article reviews the entity and illustrates it with our own example.

One hundred and thirty-seven idiopathic clubfeet were treated by the Ponseti technique and followed for at least 2 years. Nine feet (7%) were not corrected with initial casting and required early surgery. Recurrence after correction was related to compliance with bracing. At latest follow-up, two-thirds of those noncompliant with brace had recurrences with one-third of these recurrences requiring more extensive surgery than Achilles tenotomy and anterior tibial tendon transfer while only 14% of those compliant with brace had recurrences with none requiring more than Achilles tenotomy and anterior tibial tendon transfer. Early failures and recurrences constituted about 20% of our 137 feet by 2 years of follow-up. When the Ponseti method was fully followed, including initial casting, compliance with brace and treatment of recurrences by recasting, Achilles tenotomy and/or anterior tibial tendon transfer, our success rate was 93%.

The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction.

A 17-month-old boy with a toed-out left lower extremity was presented for evaluation. Before coming to the doctor, the mother had applied a zinc oxide lotion to treat a simple diaper rash in the groin. The radiologist did not remove the boy's diaper for the radiographic examination and so did not notice the lotion. The first radiograph showed what looked like multiple soft-tissue calcifications in the groin, but the radiopacities had been produced by the zinc oxide. This case serves as a reminder to be aware that metal-containing substances both on and in the body can produce radiopacities.

Background: Sudden weight loss following bariatric operations for morbid obesity, such as the duodenal switch (DS), can result in a concurrent decrease in lean body mass. Several methods for tracking body composition, such as bioelectrical impedance analysis (BIA), are available to monitor these changes. One method to offset the negative effects of sudden weight loss on body mass composition may be exercise. Methods: 100 patients who had undergone the DS operation for morbid obesity were classified as exercisers and non-exercisers based on self-reporting. Their body mass compositions were measured using BIA preoperatively and at 0.75, 1.5, 3, 6, 9, 12, and 18 months postoperatively. Results: At no study interval did postoperative percent changes in weight loss differ between the exercise and non-exercise groups. At 18 months postoperatively, the exercise group showed a 28% higher loss of fat mass and an 8% higher gain in lean body mass than the non-exercise group. Conclusion: Exercise positively influences body mass composition following the DS. BIA can be successfully employed to monitor changes, diagnose deficiencies, and formulate treatment recommendations.

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.

Medical records and radiographs of 17 known cases of slipped capital femoral epiphysis, treated with in-situ pin fixation and complicated by chondrolysis were reviewed. Fourteen of these 17 hips that developed chondrolysis had definite evidence of pin penetration of the femoral head. One hip had intra-articular pin penetration of the femoral neck. In the remaining two hips, the pins were placed within the anterolateral quadrant of the femoral head and within 2 mm of the articular surface. Overall, this is an 88% incidence of definite intra-articular pin penetration on postoperative radiographs, and a 100% rate if the two probable cases are included. This suggests a correlation between pin penetration and the development of chondrolysis following slipped capital femoral epiphysis.

A relatively simple triple pelvic osteotomy using two cosmetically small skin incisions can provide excellent coverage of the femoral head. An adductor approach and a bikini approach are used to do the osteotomy. The 'almost' percutaneous pelvic osteotomy successfully increases femoral head coverage in a concentric hip joint. The VCA angle of Lequesne and the center-edge angle of Wiberg both show significant improvement in the coverage of the femoral head. Three-dimensional computed tomography scanograms may provide a more graphic representation before and after surgery. Preoperatively, this is especially useful in evaluating posterior acetabular coverage of the femoral head. The almost percutaneous pelvic osteotomy is another possible triple pelvic osteotomy for procedures for hip dysplasia. It has a relatively low learning curve in comparison with other triple pelvic osteotomies for hip dysplasia in children aged 6-14 years. With careful patient selection, femoral head coverage can be improved with small incisions that are cosmetically acceptable.

Background: Laparoscopic duodenal switch with gastric reduction (LapDS) is a minimally invasive hybrid operation combining moderate intake restriction with moderate malabsorption for treatment of morbid obesity. In LapDS, both the quantity of food ingested and the efficiency of digestion are reduced. Methods: A cohort of 589 sequential LapDS patients had laboratory studies drawn annually. Serum markers for calcium, iron and protein metabolism and for hepatic function were analyzed using SAS statistical software. Results: There were 95 men and 494 women. Mean age was 44 years, mean BMI 50 kg/m2 and mean preoperative weight 142 kg. Although mean hemoglobin decreased below reference and mean parathyroid hormone (PTH) increased above reference, similar to abnormal values reported after Roux-en-y gastric bypass, both hemoglobin and calcium in LapDS readily returned to within the reference range following supplementation with iron and calcium respectively. Mean iron, corrected calcium, alkaline phosphatase, albumin, total protein, aspartate aminotransferase (AST), alanine transaminase (ALT), and bilirubin remained within the normal range. Conclusion: LapDS is not associated with broad nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavorable trends. In selected patients, additional iron and calcium supplementation are effective when indicated.

Differences in in situ dry matter degradabilities occurred at all incubation times when 22 cultivars of barley gram grown at three locations were examined. Rapidly and slowly degradable fractions ranged from 25 to 40% and from 49 to 65%, respectively. Rates of degradation ranged from 23 to 35% h−1 (P = 0.03). Key words: Barley, cultivars, in situ, degradability, location

Chronic fatigue syndrome (CFS) is a disabling illness of persistent fatigue. Recent studies have shown that patients with CFS have an increased prevalence of nonallergic rhinitis. Inflammation of the nasal passages due to allergic rhinitis can cause nasal congestion resulting in an increased number of sleep disturbances and daytime fatigue. While topical nasal corticosteroids have been shown to alleviate nasal obstruction effectively in patients with rhinitis who do not have CFS, it is unknown whether topical nasal corticosteroids will reduce CFS symptoms.The purpose of this study is to determine whether topical nasal corticosteroids will reduce daytime sleepiness in patients with CFS and rhinitis.Twenty-eight of 31 subjects with rhinitis and a diagnosis of CFS completed the double-blind, randomized, placebo-controlled trial. Two subjects failed screening, and 3 subjects withdrew from the study prior to its completion. Subjects were randomized according to Balaam's crossover design, and one of the following interventions was used for each group in the study: 8-week treatment with a topical nasal corticosteroid, 8-week treatment with a placebo saline spray, 4-week treatment with a topical nasal corticosteroid followed by a 4-week treatment with a placebo saline spray, or a 4-week treatment with a placebo saline spray followed by a 4-week treatment with a topical nasal corticosteroid. Data focusing on rhinitis symptoms, severity of chronic fatigue symptoms, and quality of life were gathered at biweekly office visits and with daily diaries.The results indicated that daytime sleepiness was reduced when patients with rhinitis and CFS were treated with topical nasal corticosteroids. The severity of associated CFS symptoms, specifically fatigue, muscle pain, postexertional fatigue, and daily activity, did not improve with treatment.Treating the symptoms of rhinitis in patients with CFS does not appear to alleviate daytime fatigue or associated nasal, musculoskeletal, or cognitive complaints. Therefore, it is unlikely that aggressive treatment of such symptoms with topical nasal corticosteroids will provide significant benefit to patients with CFS who do not have allergic rhinitis. These results indicate that the nonallergic rhinitis seen in patients with CFS may arise from a mechanism other than chronic inflammation.

Background: The duodenal switch procedure with gastric reduction (DS) is a hybrid procedure for morbid obesity that combines moderate intake restriction with moderate malabsorption. This report describes the laparoscopic hand-assisted technique for the duodenal switch procedure (LapDS). Methods: Restriction is achieved via a greater curvature gastrectomy, reducing gastric capacity to 120 ml. The malabsorptive component is constructed by dividing the duodenum 4 cm distal to the pylorus and anastomosing the proximal duodenum to the distal 250 cm of ileum. The biliopancreatic limb is anastomosed to create a 100 cm common channel. Laparoscopic cholecystectomy, cholangiogram, liver biopsy and appendectomy are performed in conjunction with DS. Results: 345 LapDS procedures (27 lap-assisted; 318 hand-assisted) were performed between September 1999 and February 2002. There were 299 women and 46 men with a mean age of 43 years (range 19-67 years). Mean BMI was 50 (range 36-118 kg/m2). Mean operating time was 201 minutes (range 105-480). The median length of hospital stay was 3.0 days (range 2-22 days, excluding one outlier). There were 7 conversions to open laparotomy, 14 reoperations, and 21 readmissions. There were 3 pulmonary emboli, 2 deep venous thromboses, and 4 perioperative proximal anastomotic strictures. There were no deaths. Mean percent excess weight loss at 6, 18, and 24 months was 51%, 89%, and 91%, respectively. Conclusion: Laparoscopic assisted duodenal switch procedure can be performed safely with acceptable operative times and without excess morbidity or mortality.

Recent data suggested that daytime somnolence in patients with allergic rhinitis was secondary to disrupted sleep caused by nasal congestion. Medications, which decreased congestion, would be expected to improve sleep and daytime somnolence. Previously, we showed that nasal steroids improved all three symptoms. Presently, we have not performed objective sleep testing to determine if there is a correlation between subjective improvement of congestion, sleep, and daytime somnolence. The objective of this 8-week, double-blind, placebo-controlled study was to determine if topical nasal fluticasone is effective at decreasing subjective congestion and daytime somnolence and improving sleep and if this improvement correlated with a change in overnight sleep testing (polysomnography). We recruited 32 subjects with perennial allergic rhinitis and randomized them in a double-blinded, cross-over fashion, to receive placebo or fluticasone (50 micrograms a spray), 2 sprays each side everyday, using Balaam's design. Questionnaires, quality of life instruments, daily diary, Epworth Sleepiness Scale, and an overnight sleep test with polysomnograms were used as tools. The last 2 weeks of each 4-week treatment period were summarized, scored, and compared by PROC MIXED in SAS. Correlations between arousals on sleep tests and subjective tests were performed. Fluticasone improved subjective sleep when compared with placebo (p = 0.04); however, there was no difference in the apnea/hypopnea index in those that were treated. Daytime sleepiness and fatigue were decreased by10% in the treated group; however, this was not statistically significant. However, fluticasone used at approved doses improves subjective sleep in patients with perennial allergic rhinitis without a change in the apnea/hypopnea index.